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Intellectual Disabilities Mental Retardation Waiver Eligibility Verification Options

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Mental Retardation Waiver. Eligibility Verification Options. CMS-1500 ... 318 (other specified mental retardation) requires an additional 4th digit to be ... – PowerPoint PPT presentation

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Title: Intellectual Disabilities Mental Retardation Waiver Eligibility Verification Options


1
Intellectual Disabilities/ Mental Retardation
Waiver Eligibility Verification Options
CMS-1500 Billing Guidelines July August
2008 www.dmas.virginia.gov
  • Department of Medical Assistance Services

2
  • This presentation is to facilitate training of
    the subject matter in Chapter V of the Virginia
    Medicaid Mental Retardation Community Services
    Manual
  • This training contains only highlights of this
    manual and is not meant to substitute for or take
    the place of the Mental Retardation Community
    Services Manual.

3
Objectives
  • Upon completion of this training you should be
    able to
  • Correctly utilize Medicaid options to verify
    eligibility
  • Understand timely filing guidelines
  • Properly submit Medicaid claims, adjustments and
    voids
  • Identify and transfer ICD-9 diagnosis codes from
    the patient file to claims

4
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
9 9 9 9 9 9 9 9 9 9 9 9
V I RG I N I A J. R E C I P I E N T
DOB 05/09/1994 F
CARD 00001
5
Important Contacts
  • MediCall
  • ARS- Web-Based Medicaid Eligibility
  • Provider Call Center
  • Provider Enrollment

6
MediCall
  • 800-884-9730
  • 800-772-9996
  • 804-965-9732
  • 804-965-9733

7
MediCall
  • Available 24 hours a day, 7 days a week
  • Medicaid Eligibility Verification
  • Claims Status
  • Prior Authorization Information
  • Primary Payer Information
  • Medallion Participation
  • Managed Care Organization Assignment

8
Automated Response System ARS
  • Web-based eligibility verification option
  • Free of Charge.
  • Information received in real time.
  • Secure
  • Fully HIPAA compliant

9
UAC Registration Process
  • Go to https//virginia.fhsc.com
  • Select the ARS tab on FHSC ARS Home Page
  • Choose User Administration
  • Follow the on-screen instructions for help with
    registration, this is a 3-step process to
    request, register and activate a new account
  • Answer the initial Who are you? question by
    selecting I do not have a User ID and need to be
    a Delegated Administrator

10
ARS Users
  • Web Support Helpline-
  • 800-241-8726

11
Provider Call Center
  • Claims, covered services, billing inquiries
  • 800-552-8627
  • 804-786-6273
  • 830am 430pm (Monday-Friday)
  • 1100am 430pm (Wednesday)


12
Provider Enrollment
  • New provider enrollment, Electronic Fund
    Transfer (EFT) or change of address
  • First Health PEU
  • P. O. Box 26803
  • Richmond, VA 23261
  • 888-829-5373
  • 804-270-5105
  • 804-270-7027 - Fax

13
Electronic Billing
  • Electronic Claims Coordinator
  • Mailing Address
  • First Health Services Corporation Virginia
    Operations Electronic Claims Coordinator 4300 Cox
    Road Glen Allen, VA 23060
  • E-mail edivmap_at_fhsc.com
  • Phone (800) 924-6741
  • Fax (804) 273-6797

14
Billing on the CMS-1500
15
MAIL CMS-1500 FORMS TO
  • DEPARTMENT OF MEDICAL ASSISTANCE
  • SERVICES
  • PRACTITIONER
  • P. O. Box 27444
  • Richmond, Virginia 23261

16
TIMELY FILING
  • ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN
    ONE YEAR FROM THE DATE OF SERVICE
  • EXCEPTIONS
  • Retroactive/Delayed Eligibility
  • Denied Claims

17
TIMELY FILING
  • Submit claims with documentation attached (to the
    back of claim) explaining the reason for delayed
    submission

18
CMS-1500 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE Invoice Photo
copies are not Acceptable Computer generated
claims must match NUBC uniform standards
19
Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
19
20
Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
20
21
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
21
22
Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
22
23
Block 11d - Is There Another Health Benefit Plan?
  • d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

If yes, return to and complete item 9 a-d.
NO
YES
Please indicate NO for recipients who have
no other insurance coverage. DMAS does not
require providers to complete Blocks 9 a-d.
23
24
Block 21 Diagnosis Codes (Current ICD-9 Code)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3180
1.
3.
319
2.
4.
May enter up to 4 codes
Omit decimals
24
25
ICD-9 Diagnosis Codes
  • All claims submitted to DMAS will require a
    current ICD-9 diagnosis code for payment
    processing.
  • Some 3-digit diagnosis codes are valid
  • 317 (mild mental retardation) is a valid 3-digit
    DX code
  • 319 (mental retardation) is a valid 3-digit DX
    code

26
ICD-9 Diagnosis Codes
  • If the current year ICD-9 book indicates the
    diagnosis code requires 4-5 digits, the code
    listed on the claim submission must include 4-5
    digits
  • 318 (other specified mental retardation) requires
    an additional 4th digit to be a valid diagnosis
    code 3180, 3181 or 3182
  • Claims submitted without a valid diagnosis code
    will be denied

27
Block 23 Prior Authorization Number
(Conditional)
23. PRIOR AUTHORIZATION NUMBER
27
28
Blocks 24A thru 24J
  • These blocks have been divided into open areas
    and a shaded red line area
  • The shaded area is ONLY for supplemental
    information
  • Instructions will be given on when the use of the
    shaded area is required for claims processing

29
Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
08
08
05
01
05
01
1
05
01
08
08
31
08
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
30
Block 24B Place of Service
Note Type of Service is no longer required
B.
Place
of
Service
11-Office location 12- Patients Home
11
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
30
31
Emergency Indicator-24C
  • This locator will be used to indicate whether the
    procedure was an emergency
  • DMAS will only accept a Y for yes in this
    locator
  • If there was no emergency leave blank

32
Block 24C EMG
C. EMG
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
32
33
Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
97535

97537 U1
33
34
Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3180
1.
3.
319
2.
4.
E.
DIAGNOSIS
POINTER
1
Enter the identifier of the ICD-9 diagnosis code
listed in Locator 21. To identify more than one
diagnosis code, separate the indicators with a
comma.
1,2
34
35
Block 24 F Charges
F.
CHARGES
Enter the usual
and customary charges
35
36
Medicaid Memo- 06/18/08- Rates
  • Providers with a Dept. of Rehab Services (DRS)
    approved rate, will be reimbursed the DRS rate
    for DMAS payment of agency-directed individual
    supported employment services.
  • Medicaid RA reason code 0670 (Pricing by Provider
    Procedure Rate) will identify procedures paid
    based on the DRS rate.
  • Providers without the DRS approved rate will
    continue to receive the DMAS fee-for-service rate.

36
37
Block 24G Days or Units
G.
DAYS
OR
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
UNITS
1
31
37
38
ID.QUAL Block-24I
  • Qualifier 1D is to be used in the red shaded
    area for claims being submitted using the 10
    digit Atypical Provider Identifier (API).
  • Qualifier ZZ is to be used to indicate the
    taxonomy code-only when the NPI is used and only
    if necessary to adjudicate the claim.

39
DMAS Service Types May Require A Taxonomy Code
on Claims
40
Rendering Provider ID Block-24J
  • The red shaded area will contain the 10 digit
    Atypical Provider Identifier (API)
  • OR
  • The white open area will contain the NPI of the
    provider rendering the service.

41
Block 24I ID. Qualifier 24J Rendering Provider
ID Atypical Provider Identifier (API)
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
0012345670
NPI
41
42
Block 24I ID. Qualifier 24J Rendering Provider
ID National Provider Identifier (NPI)
I. ID. QUAL
J. RENDERING PROVIDER ID.
ZZ
Taxonomy (if needed)
1234567890
NPI
42
43
Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 14 alphanumeric digits
43
44
Block 28 Total Charges
28. TOTAL CHARGE

Please list the total all charges in Block 28.
44
45
Block 29 Amount Paid
  • Patient pay amount is taken from services billed
    in Block 24A line 1
  • If multiple services are provided on the same
    date of service, another form must be completed.
    Only one line per claim form can be submitted if
    patient pay is to be considered in the processing
    of this service.

46
Block 29 Amount Paid (Personal and Waiver
Services ONLY)
29. AMOUNT PAID

Enter the Patient Pay amount as indicated on the
DMAS-122
46
47
Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.
47
48
Block 32 Service Facility Location Information
  • Enter information for the location where services
    were rendered
  • First line-Name
  • Second line-Address
  • Third line-City, State, 9 digit zip code
  • No punctuation in the address
  • Space between city and state
  • Include hyphen for the 9 digit zip code

49
Block 32, contd. Service Facility Location
Information
  • Providers with multiple offices/locations - the
    zip code must reflect the office/ location where
    services were rendered
  • Enter the 10 digit NPI number of the service
    location in 32a.
  • OR
  • Enter 1D qualifier with the 10 digit API in the
    red shaded area of 32b

50
Block 32 Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
NPI
50
51
Block 33 Billing Provider Info PH -
  • Enter the information to identify the provider
    that is requesting to be paid
  • First line-Name
  • Second line-Address
  • Third line-City, State, 9 digit zip code
  • No punctuation in the address
  • Space between city and state
  • Include hyphen for the 9 digit zip
  • Phone number is to be entered in the area to the
    right of the field title, no hyphen or space used

51
52
Billing Provider Info PH -Block-33a-b
  • Enter the 10 digit NPI number of the service
    location in 33a.
  • OR
  • Enter 1D qualifier with the 10 digit API in the
    red shaded area of 33b

53
Block 33 Billing Provider Info PH
33. BILLING PROVIDER INFO PH
( )
a.
b.
NPI
53
54
Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From original
Adjustment or
remittance
Void
Resubmission Code
Chap. V, Mental Retardation Community Services
Manual has resubmission code list.
54
55
REMITTANCE VOUCHER Sections of the Voucher
  • APPROVED For payment.
  • PENDING For review of claims.
  • DENIED No payment allowed.
  • DEBIT () Adjusted claims creating a
    positive balance.
  • CREDIT (-) Adjusted/Voided claims
    creating a negative balance.

55
56
REMITTANCE VOUCHER Sections of the Voucher
  • FINANCIAL TRANSACTION
  • EOB DESCRIPTION
  • ADJUSTMENT DESCRIPTION/REMARKS- STATUS
    DESCRIPTION
  • REMITTANCE SUMMARY- PROGRAM TOTALS

56
57
THANK YOU
  • Department of Medical Assistance Services
  • www.dmas.virginia.gov
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