WELCOME TO THE ACS BEGINNING BILLING SESSION FEBRUARY

1. WELCOME TO THE ACS BEGINNING BILLING SESSIONFEBRUARY/MARCH 2006

2. FEBRUARY/MARCH 2006

3. FEBRUARY/MARCH 2006 We process health care claims for the State of New Mexico’s Medicaid program We process health care claims according to the policies of the New Mexico Medicaid program We issue payment to Medicaid providers

4. FEBRUARY/MARCH 2006 As the Fiscal Agent We Do Not ..…………. Make Medicaid policy Make exceptions to policy

5. FEBRUARY/MARCH 2006 Which State Agency Runs the New Mexico Medicaid Program? The NM Human Services Department (HSD), Medical Assistance Division (MAD)

6. FEBRUARY/MARCH 2006 Some of the agencies or departments ACS Interfaces with are… Department of Health (DOH) Income Support Division (ISD) Social Security Administration (Eligibility) Children, Youth and Family Department (CYFD) State Translator

7. FEBRUARY/MARCH 2006 Other Agencies or Departments ACS Interfaces with… NM Medicaid Utilization Review Agency – Blue Cross/Blue Shield (BC/BS) Once the prior authorizations are approved by UR, they are sent electronically to ACS MEDICARE Carriers and Fiscal Intermediaries Electronic crossovers are sent electronically to ACS from these agencies

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9. FEBRUARY/MARCH 2006 Medicaid Policy Manual There is a Medicaid Policy Manual for each provider type. Each manual contains basic Medicaid policy as well as specific provider type policy and billing instructions. Every billing provider should be familiar with their manual and refer to it.

10. FEBRUARY/MARCH 2006 Medicaid Policy Manual HIPAA-updated Program Policy Manuals and Billing Instructions are available from these HSD web addresses: Program manuals: http://www.state.nm.us/hsd/mad/ProgManIndex.htm Billing instructions: http://www.state.nm.us/hsd/mad/OtherDocs/BillingInstructions.htm

11. FEBRUARY/MARCH 2006 Remittance Advice Newsletter A newsletter listing the most current issues for billing providers is updated weekly and included with the RA. This newsletter contains any changes in claims processing, systems issues, and billing tips for common billing errors.

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13. FEBRUARY/MARCH 2006 HIPAA - PayerPath questions, electronic claims submission questions of any kind, websites for crosswalks, etc. (505) 246-9988 ext. 240, (800) 299-7304 ext. 240 Provider Relations – Billing questions, claim status, etc. (505) 246-0710 ext. 190, (800) 299-7304 ext. 190 Eligibility – Information on client eligibility. (505) 246-2056, (800) 705-4452 ACS Helpdesks

14. FEBRUARY/MARCH 2006 Provider Enrollment – Questions about reverification, license renewal, changes to provider file, which includes: addresses, name changes and putting Medicare numbers on file. (505) 246-9988 ext. 193, (800) 299-7304 ext. 193 TPL – Adding/removing clients’ TPL (Third Party Liability) resource. (505) 246-9988 ext. 195, (800) 299-7304 ext. 195 ACS Helpdesks

15. FEBRUARY/MARCH 2006 The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Review Remittance Advice Resubmit, Void, or Adjust

16. FEBRUARY/MARCH 2006 Date of Service – Make sure client is eligible on DOS Is the Client Fee for Service or SALUD Limited Benefits – Check Category of Eligibility TPL or Medicare – There may be a payer primary to Medicaid The Client may be required to pay a co-pay Eligibility Check List

17. FEBRUARY/MARCH 2006 Ways to Check Eligibility Medicaid Eligibility Verification Services (MEVS) – See handout for list Automatic Voice Response System (AVRS) – (505) 246-2219, (800) 820-6901 Eligibility Help Desk – (505) 246-2056, (800) 705-4452

18. FEBRUARY/MARCH 2006 If you have a client who is seen on a regular basis, you should check the eligibility for that client at the beginning of each month. Eligibility denials are the most common denials for all provider types!

19. FEBRUARY/MARCH 2006 Behavioral Health Eligibility All Behavioral Health claims for DOS beginning July 1, 2005, are covered by ValueOptions, except for Medicare crossovers.

20. FEBRUARY/MARCH 2006 0101 – Service Dates Within Managed Care Enrollment Period The client is in managed care on some or all of the dates of service on the claim. Verify eligibility through our Eligibility Helpdesk (505) 246-2056, (800) 705-4452.

21. FEBRUARY/MARCH 2006 0141– Client ID not on file The client ID was included on the claim, however that ID is not on file. Check the RA against your files to be sure the ID was input correctly. Call Eligibility Helpdesk for correct client ID.

22. FEBRUARY/MARCH 2006 0143 - Client not Eligible The client ID was included on the claim, however, the client does not have Medicaid eligibility for that DOS. Check the RA against your files to be sure the ID was input correctly. Call Eligibility Helpdesk for correct client eligibility.

23. FEBRUARY/MARCH 2006 0265 - Client is Medicare Part B Eligible Client is eligible for Medicare Part B for that DOS, but claim is not being filed as a crossover. Claim must be filed as a Medicare primary claim before being submitted to Medicaid for payment.

24. FEBRUARY/MARCH 2006 0222 – Name/DOB Mismatch Be sure the Medicaid ID number, name, and date of birth you use on your claim matches the information on the client’s Medicaid ID card.

25. FEBRUARY/MARCH 2006 Limited Categories of Eligibility 029 – Family Planning 035 – Pregnancy Related 041, 044 – Qualified Medicare Beneficiary (QMB)

26. FEBRUARY/MARCH 2006 029 – Family Planning Covered Services Counseling services, laboratory tests, medical procedures, and pharmaceutical supplies and devices related to family planning purposes, e.g., birth control pills Sterilizations, i.e., tubal ligations Regular reproductive health exams/screenings, i.e., pap smears and sexually transmitted disease screenings

27. FEBRUARY/MARCH 2006 029 – Family Planning Non-Covered Services Abortions Hysterectomies Treatment services for infertility Inpatient Services Management or treatment of medical conditions/ problems discovered during screenings or caused by or following a family planning procedure: i.e., treatment for STDs, ultrasounds or cervical cancer

28. FEBRUARY/MARCH 2006 0029 – Service not Family Planning This exception will post if the client has COE Family Planning and the service is not a covered family planning service. Call our Eligibility Helpdesk to verify status of eligibility.

29. FEBRUARY/MARCH 2006 035 – Pregnancy Related (non-presumptive) Covered Services Pregnancy related services only: Prenatal care Delivery Two months of postpartum care

30. FEBRUARY/MARCH 2006 035 – Pregnancy Related (non-presumptive) Non-Covered Services Abortions (elective) Vision, Dental, Hearing Psychiatric/Psychological Chiropractic Plastic Surgery (elective) Anything not medically related to the pregnancy

31. FEBRUARY/MARCH 2006 0707 – Procedure not Pregnancy Related This exception will post if the client has a COE for pregnancy related services only and the service is not a pregnancy related service. Call our Eligibility Helpdesk to verify status of eligibility

32. FEBRUARY/MARCH 2006 041, 044 – Qualified Medicare Beneficiary QMB) MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid If service is not covered by Medicare, MEDICAID WILL NOT PAY

33. FEBRUARY/MARCH 2006 0266 – QMB Client/Bill Crossover only Client’s COE is QMB. The claim is a non-crossover claim type and Medicaid will only cover deductible and co-insurance on QMB clients. Call our Eligibility Helpdesk to verify status of eligibility (505) 246-2056, (800) 705-4452.

34. FEBRUARY/MARCH 2006 Categories of Eligibility with Co-pays 071 – SCHIP (State Children’s Health Insurance Program) 074 – WDI (Working Disabled Individuals) Clients with these COEs may owe co-pays for some services.

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36. FEBRUARY/MARCH 2006 CHANGES TO WORKING DISABLED INDIVIDUAL (WDI) CO-PAY AMOUNTS $7.00 outpatient therapy and behavioral health services $20.00 emergency room services $30.00 inpatient hospital services $7.00 doctors visit, urgent care or vision visit $7.00 dentist visit $5.00 prescriptions

37. FEBRUARY/MARCH 2006 TPL – Third Party Liability Medicaid is the payer of last resort, except for clients covered by the Indian Health Service (IHS). TPL is all commercial insurance TPL must be billed primary to Medicaid Medicaid does not consider Medicare TPL

38. FEBRUARY/MARCH 2006 0750 – Client has TPL - Resubmit with TPL EOB When a client has TPL you must submit to the commercial insurance company as primary. Once you have received the EOB, you need to submit to Medicaid as secondary. You have 1 year from the DOS to submit the claim to Medicaid.

39. FEBRUARY/MARCH 2006 0760 – HMO/No TPL Attachment This edit will occur when the recipient has HMO coverage identified on the TPL resource database, but the claim does not have payment information or a TPL EOB attached

40. FEBRUARY/MARCH 2006 The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Review Remittance Advice Resubmit, Void, or Adjust

41. FEBRUARY/MARCH 2006 How do you determine if/when a Prior Authorization (PA) is required? Call Utilization Review/BCBS – 1-800-392-9019. UR can tell you if a PA is required and the procedures for getting a PA Prior Authorization Requirements

42. FEBRUARY/MARCH 2006 Also, consult the Medicaid program and billing manuals for prior authorization requirements. Prior Authorization Requirements

43. FEBRUARY/MARCH 2006 All claims for Children’s Medical Services (CMS) clients must have the CMS prior authorization number entered on the claim. The CMS prior authorization number is 8 digits, so when you include it on the HCFA 1500 form (box 23), you must put 2 zeros in front of the 8 digit PA number to make a 10-digit number. Prior Authorization Requirements

44. FEBRUARY/MARCH 2006 ACS recommends that the paper authorization issued by CMS be attached to the claim form as well. This is either the CMS 309 form or the Healthier Kids Fund card. Prior Authorization Requirements

45. FEBRUARY/MARCH 2006 Prior Authorization Requirements Claims secondary to TPL: PAs issued by Medicaid Utilization Review are always required when TPL is involved, no matter if TPL paid or denied the service.

46. FEBRUARY/MARCH 2006 0436 – PA Required/PA is missing/invalid A PA is required for this service. The PA number was either missing from the claim or not a correct number.

47. FEBRUARY/MARCH 2006 0727 – Prior Authorization Required/No PA on File This edit posts when the claim requires authorization and the authorization number is on the claim, but the authorization number cannot be found on the Prior Authorization database (Omnicaid). Call Provider Helpdesk to verify the information on PA in Omnicaid and/or to see if PA is in our system.

48. FEBRUARY/MARCH 2006 0727 – Prior Authorization Required/No PA on File Check to be sure you entered the PA correctly on the claim. Correct and resubmit. Call Provider Helpdesk to verify there wasn’t a data entry error. Verify the PA number in Omnicaid and/or to see if PA is in our system.

49. FEBRUARY/MARCH 2006 0511 – Authorization/ Service Conflict The procedure code listed on the PA on file does not match the service on the claim. Call the provider help desk to determine what the service on the PA on file is and then determine if you billed the incorrect procedure code or if the PA has the wrong service on it.

50. Spring, 2006 Provider Training Sessions Presented by Blue Cross Blue Shield of New Mexico

51. FEBRUARY/MARCH 2006 Medicaid Utilization Review Blue Cross Blue Shield of New Mexico has been contracted by HSD/MAD to review prior authorization requests for recipients who are not enrolled in managed care. Services reviewed include nursing facility, durable medical equipment, emergency medical services for aliens, and many others.

52. FEBRUARY/MARCH 2006 Medicaid Utilization Review We work closely with other state agencies, including the Department of Health and the Aging and Long-Term Services Department. We also work closely with ACS, the fiscal agent.

53. FEBRUARY/MARCH 2006 Sending Prior Authorization Requests U.S. Mail Medicaid Utilization Review P.O. Box 27950 Albuquerque, NM 87125-7950 Courier Delivery (FedEx, UPS) 4373 Alexander Blvd NE Albuquerque, NM 87107

54. FEBRUARY/MARCH 2006 Sending Prior Authorization Requests

55. FEBRUARY/MARCH 2006 Sending Prior Authorization Requests Drop Box Located at the Alexander Boulevard address. Drop box is available 24 hours a day/seven days a week. Signature is not available at the drop box.

56. FEBRUARY/MARCH 2006 Sending Prior Authorization Requests Fax Server 1-800-746-7292 Fax-driven database that can accept requests for: DME home health hearing aids contact lenses therapy (physical, speech, and occupational)

57. FEBRUARY/MARCH 2006 Eligibility Medicaid Utilization Review does not provide eligibility information. It is the provider’s responsibility to verify eligibility. Refer to Medical Assistance Division Program Policy manual – Section 8.302.1.11.A.

58. FEBRUARY/MARCH 2006 Review Process Abstracts are reviewed by clinical reviewers: Nurses Peer consultants

59. FEBRUARY/MARCH 2006 Clinical Reviewers Nurse reviewers can approve reviews; however, all potential denials must be referred to a peer consultant. Peer consultants include: Medical doctors Physical and speech therapists Audiologists Dentists

60. FEBRUARY/MARCH 2006 Required Documentation for a Successful Review Objective clinical/medical documentation needed to justify services Each review must stand on its own Diagnosis alone does not establish medical necessity “Paint the picture!” Clearly illustrate why the client needs the services

61. FEBRUARY/MARCH 2006 Top Ten Ways to Avoid Buck-Backs Submit mandatory forms and documentation for your request: Completed request form (e.g., ISD-379, ISD-303, ISD-301) Appropriate documentation, based on the review type. This may include a History and Physical, signed physician orders, CIA, etc.

62. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) Fill in all the blanks Be sure that the Medicaid number submitted is correct on ALL forms. Correct procedure/provider codes must be present on ALL forms.

63. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) Ensure all required signatures and dates are submitted: For example, History and Physical must be current; Level of Care orders with dates must be present on the ISD-379 or ISD-378 and relevant to the time frame requested; physician’s signature must be submitted with the ISD-303.

64. FEBRUARY/MARCH 2006 Avoid Buck-Backs(Continued) Re-check entire document and double check any mathematical calculations submitted: For example, Homemaker Assessment score, MAD-046 units/hours, ISD-378 assessment score

65. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) Understand the criteria for the services you are requesting. For example, to be eligible for the Disabled and Elderly Waiver program, the client must meet criteria for placement in a nursing facility. DD Waiver clients must meet criteria for ICF MR placement.

66. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) Submit all supporting documentation Ensure that the information submitted is consistent, sufficient, and relevant to that specific request. Please do not submit unnecessary and excessive documentation; it can cause a delay in the review of your request.

67. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) Clarify your request What are you requesting? Initial Annual reassessment Readmit Revision Re-review Reconsideration

68. FEBRUARY/MARCH 2006 Avoid Buck-Backs(continued) In the event you do receive a buck-back, be sure to return ALL information and documentation with your response. This will avoid a subsequent buck-back.

69. FEBRUARY/MARCH 2006 Buck-BacksLast, But Not Least… If a request is unclear, please call customer service. They will obtain the needed clarification and call you back.

70. FEBRUARY/MARCH 2006 Time Frames The current contract with HSD/MAD requires that reviews be completed by BCBSNM in 14 calendar days. If a review is returned to you for clarification or additional documentation (buck back), the 14-day time frame starts again with our receipt of the complete information.

71. FEBRUARY/MARCH 2006 The Appeal Process Re-review Process Reconsideration Process Fair Hearings Process

72. FEBRUARY/MARCH 2006 Re-Review Process Based on MAD regulations, this request must be received within 10 calendar days from the date of the denial letter. This request must have additional medical/clinical information (that is in addition to the initial information submitted) in order to meet the requirements for the re-review process

73. FEBRUARY/MARCH 2006 Reconsideration Process This request must be received within 30 calendar days from the date of the re-review denial. This request must have additional medical/clinical information (that is in addition to the initial and re-review information submitted) in order to meet the requirements for the reconsideration process

74. FEBRUARY/MARCH 2006 Reconsideration Process (continued) If you are unable to request a re-review within the mandated ten-day time frame, you may request a reconsideration (without benefit of a re-review). Your request must be received within 30 days of the date of the original denial letter; please indicate that your request is for a reconsideration.

75. FEBRUARY/MARCH 2006 The Fair Hearing Process This request is administered through the Administrative Hearings Bureau. This is the appeal process that a recipient may utilize.

76. FEBRUARY/MARCH 2006 Data Entry All reviews are entered into the Medicaid Utilization Review system and transmitted daily to ACS.

77. FEBRUARY/MARCH 2006 Customer Service 1-800 392-9019 (this number is valid both in-state and out-of-state) ACD (Automatic Call Distribution) allows your call to be handled in the order received. Contact us via the Web.

78. FEBRUARY/MARCH 2006 Help Us Help You! Have this information ready: Recipient number Recipient name Date of birth Your provider number Provider name Date request was sent to us Item(s) or service(s) requested

79. FEBRUARY/MARCH 2006 Customer Service (continued) Recipient calls regarding denial/ reduction/modification letters Recipients are encouraged to contact their providers. Providers are encouraged to assist their clients by discussing availability of re-review and reconsideration reviews.

80. FEBRUARY/MARCH 2006 Following up on Submissions If you are calling to see if your review has been completed, please be sure to allow time for mail to reach us. Our imaging system allows Customer Service to see if your review has been received and is in process.

81. FEBRUARY/MARCH 2006 Forms Requests You can call customer service for forms You can download blank forms from the Web site

82. FEBRUARY/MARCH 2006 Medicaid UR Website The Medicaid UR website is located at: http://bcbsnm.com Medicaid UR Website The Medicaid UR website is located at: http://bcbsnm.comMedicaid UR Website The Medicaid UR website is located at: http://bcbsnm.com

83. FEBRUARY/MARCH 2006 Once in the BCBSNM website select Providers. Once in the BCBSNM website select Providers.

84. FEBRUARY/MARCH 2006 Next select Medicaid UR.Next select Medicaid UR.

85. FEBRUARY/MARCH 2006 The opening page is about Medicaid Utilization Review and our Mission Statement.The opening page is about Medicaid Utilization Review and our Mission Statement.

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87. FEBRUARY/MARCH 2006 Once you click on a review type you will see a description of that review and the form number required for submitting the request. You can see the form by either clicking on the form number in the description or click Forms on the menu.Once you click on a review type you will see a description of that review and the form number required for submitting the request. You can see the form by either clicking on the form number in the description or click Forms on the menu.

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89. FEBRUARY/MARCH 2006 For a word doc form you can open the form to view or you can save and download into your computer drive. For a word doc form you can open the form to view or you can save and download into your computer drive.

90. FEBRUARY/MARCH 2006 The downloaded word doc form can be used as a template over and over completing electronically or you can print the form and complete manually. The downloaded word doc form can be used as a template over and over completing electronically or you can print the form and complete manually.

91. FEBRUARY/MARCH 2006 The pdf form can only be printed and completed manually.The pdf form can only be printed and completed manually.

92. FEBRUARY/MARCH 2006 The Frequently Asked Questions section addresses commonly asked questions received by our customer service representatives. The Frequently Asked Questions section addresses commonly asked questions received by our customer service representatives.

93. FEBRUARY/MARCH 2006 The Nurses’ Corner section will have an article once a quarter regarding the review process. As we change the article we will keep previous articles available for viewing.The Nurses’ Corner section will have an article once a quarter regarding the review process. As we change the article we will keep previous articles available for viewing.

94. FEBRUARY/MARCH 2006 If you click on the E-mail hyperlink you will receive this page to contact us.If you click on the E-mail hyperlink you will receive this page to contact us.

95. FEBRUARY/MARCH 2006 Future Enhancements Increased use of phone reviews Several review types are being considered for handling via phone, rather than abstract. Pilot project is currently in development. Enhanced phone system This will allow Customer Service to serve you more quickly and efficiently.

96. FEBRUARY/MARCH 2006 Review Specific Sessions Sessions addressing specific needs and questions for different review types are being held throughout the day – please join us!

97. FEBRUARY/MARCH 2006 Time for Your Questions Thank you for your time and attention!

98. FEBRUARY/MARCH 2006 The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Review Remittance Advice Resubmit, Void, or Adjust

99. FEBRUARY/MARCH 2006 Claim Submission –  Paper vs. Electronic You may submit any claim electronically or on paper within 120 days from the initial date service.

100. FEBRUARY/MARCH 2006 Claim Submission  Paper vs. Electronic Once the claim is more than 120 days past the initial date of service, the claim must be submitted on paper with proof of timely filing attached. Claims for services that require attachments need to be submitted on paper along with the attachment.

101. FEBRUARY/MARCH 2006 Provider has complete control over data entry Provider receives claim status (Paid/Denied/ Suspending) in as little as a week Provider receives payment in as little as a week Provider has a confirmed receipt of the submitted claims Eliminates expense of mailing claims for the provider Advantages to Billing Electronically

102. FEBRUARY/MARCH 2006 Have you Heard how ACS is improving Claims Service?

103. FEBRUARY/MARCH 2006 Optical Character Reader Optical Character Reader (OCR). This technology provides accurate data entry, reduces errors, and allows faster claims processing, without waiting for manual data entry.

104. FEBRUARY/MARCH 2006 Optical Character Reader OCR Do’s: Use an original, standard red-dropout form (HCFA, UB, etc.) Use machine print Use a clean, non-proportional font (such as Courier)

105. FEBRUARY/MARCH 2006 OCR Do’s: Use black ink Print claim data within the defined boxes on the claim form Print only the information asked for on the claim

106. FEBRUARY/MARCH 2006 OCR Do’s: Use all capital letters Use a laser printer for best results Use white correction tape for corrections

107. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t hand print or hand write your forms If you must hand print, use neat block letters that stay within field boundaries Don’t use copies of claim forms

108. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t use stamps, labels, or stickers Don’t use dashes or slashes in date fields. Don’t use fonts smaller than 8 point Don’t use a dot matrix/impact printer, if possible

109. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t use correction fluid Don’t put notes on the top or bottom of the claim form Don’t enter “none” or “NA” if there is no information; just leave the box blank Don’t fold claim forms

110. FEBRUARY/MARCH 2006 Electronic Claims Deadlines If claims are being submitted through PayerPath, claims marked for send are picked up by PayerPath at 8 am. Claims submitted so they are picked up by PayerPath at 8 am on Thursday will appear on the following week’s remittance advice.

111. FEBRUARY/MARCH 2006 Electronic Claims Deadlines All HIPAA formatted electronic claims submitted directly to the translator (i.e. - not submitted using PayerPath) must be transmitted no later than 11 pm Thursday in order to be on the following week’s remittance advice.

112. FEBRUARY/MARCH 2006 HIPAA Electronic Billing Information Claims where Medicaid is not the primary payer cannot yet be submitted as a HIPAA electronic claim. Medicaid accepts electronic crossovers directly from Medicare. If your claim doesn’t crossover, you will have to submit it on paper.

113. FEBRUARY/MARCH 2006 HIPAA Electronic Billing Information IMPORTANT NOTICE ELECTRONIC CLAIMS ARE NO LONGER ACCEPTED IN THE NSF AND ACE$ FORMATS. ONLY HIPAA COMPLIANT CLAIMS IN THE 837 FORMAT SUBMITTED THROUGH THE STATE TRANSLATOR WILL BE ACCEPTED FOR ELECTRONIC CLAIMS, WHICH INCLUDES PAYERPATH.

114. FEBRUARY/MARCH 2006 CMS (Childrens Medical Services) Claims Submission CMS is like billing for a Medicaid client with the following differences: Always use the 14 digit CMS client ID number that begins with 07 Always enter the PA number in box 23 of the HCFA-1500 form (If the PA number is 8 digits, add 2 zeroes in front of it.) Always attach the 309 form or a copy of the healthier kids card

115. FEBRUARY/MARCH 2006 Pharmacy Claim/ CMS PA If a CMS PA for a pharmacy service is not on file, the provider needs to first contact the Point of Sale helpdesk and then fax the CMS PA to them. ACS Point-of-Sale help desk (800) 365-4944

116. FEBRUARY/MARCH 2006 Original Claims - 120 days from the initial date of service. (For DRG hospital inpatient claims ONLY – 120 days from last date of service.) Resubmissions - 6 months from the date of the previous denial (include a copy of the page of the RA(s) where the claim denied and/or other proof of timely filing.) Timely Filing Limits

117. FEBRUARY/MARCH 2006 Adjustments – 6 months from the date of the incorrect payment (include a copy of the page of the RA(s) where the claim paid). TPL - 365 days from the initial date of service (remember to include a copy of the EOB from the insurance carrier, plus a copy of the explanation page). Timely Filing Limits

118. FEBRUARY/MARCH 2006 Medicare - 6 months from the date that Medicare either paid or denied the claim (remember to include a copy of the EOMB along with the explanation page) Final Limit - all payments must be finalized within 2 years of the date of service. Timely Filing Limits

119. FEBRUARY/MARCH 2006 Completing the Claim Form

120. FEBRUARY/MARCH 2006 Paper Claim Tips You May Use: Dry line correction tape Colored Pens Highlighters

121. FEBRUARY/MARCH 2006 Claim Submission HCFA - 1500 The following claim is how a paper HCFA 1500 claim form is generally filled out using the procedure codes, etc., that are specific to your claims. If there is TPL, the proper attachments need to be attached, plus box 29 needs to be filled in if there was a payment.

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124. FEBRUARY/MARCH 2006 Claim Submission UB-92 The following claim is how a paper UB92 claim form is generally filled out using the procedure codes, etc. that are specific to your claims. If there is TPL, the proper attachments need to be attached, plus box 54 needs to be filled in, if there was a payment.

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127. FEBRUARY/MARCH 2006 Claim Submission The following are “tips” when Medicaid is the secondary insurance to commercial (private) insurance (TPL)

128. FEBRUARY/MARCH 2006 When the client has private insurance, aka Third Party Liability (TPL), Medicaid becomes secondary. Always enter the amount the insurance has paid in the appropriate box on the claim form (Box 29 on the HCFA or Form Locator 54 on the UB-92) Claim Submission – TPL is Primary

129. FEBRUARY/MARCH 2006 Attach the TPL EOB showing the payment with the claim. Always include the explanation page of the EOB along with the page of the EOB that shows payment. Claim Submission – TPL is Primary

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132. FEBRUARY/MARCH 2006 COMING ATTRACTIONS!

133. FEBRUARY/MARCH 2006 COMING IN SPRING 2006 On-Line Claims Inquiry will allow providers to check claim status on the Web. This is a FREE service! On-Line Eligibility Inquiry client eligibility, and prior authorization information. This is a FREE service! Check your RA Newsletter for more information.

134. FEBRUARY/MARCH 2006 COMING IN SPRING 2006 On-Line PA allows providers to check their PAs on file with ACS. These will be free services to providers. Check your RA Newsletter for more information.

135. FEBRUARY/MARCH 2006 ALSO IN SPRING 2006 Claim Scanning (rather than microfilming). This will speed up claims processing and eliminate the waiting period for pulling claims.

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