Community Mental Health Rehab Services Eligibility Verification Options and CMS1500 Billing Guidelin

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Community Mental Health Rehab ServicesEligibility
Verification Options and CMS-1500 Billing
Guidelines
Department of Medical Assistance Services

• April June 2009
• www.dmas.virginia.gov

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• This presentation is to facilitate training of
  the subject matter in Chapter V of the Virginia
  Medicaid Community Mental Health Rehabilitative
  Services Manual.
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Community Mental Health
  Rehabilitative Services Manual.
• Providers are responsible for reviewing and
  adhering to the Community Mental Health
  Rehabilitative Services Manual requirements.

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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

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As a Participating Provider You Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Virginia Medicaid.
• Bill any and all other third party carriers.

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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
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Important Contacts

• MediCall
• ARS- Web-Based Medicaid Eligibility
• Provider Call Center
• Provider Enrollment
• Electronic Claims Coordinator

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MediCall/Automated Response System (ARS)

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

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MediCall

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

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Automated Response System (ARS)

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

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UAC Registration Process

• https//uac.fhsc.com/uac/pages/unsecured/common/
  home.jsf
• 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

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ARS Users

• ARS Users Guide
• http//www.dmas.virginia.gov/pr-claims_billing.ht
  m
• Web Support Helpline-
• 800-241-8726

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Provider Call Center

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

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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

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Electronic Billing

• Electronic Claims Coordinator
• Mailing Address
• First Health Services CorporationVirginia
  OperationsElectronic Claims Coordinator4300 Cox
  RoadGlen Allen, VA 23060
• E-mail edivmap_at_fhsc.com
• Phone [phone]
• Fax [phone]

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Billing on the CMS-1500
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MAIL CMS-1500 FORMS TO

• DEPARTMENT OF MEDICAL ASSISTANCE
• SERVICES
• PRACTITIONER
• P. O. Box 27444
• Richmond, Virginia 23261

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TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN
  ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS
• Retroactive/Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Other Primary Insurance

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TIMELY FILING

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

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CMS-1500 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE Invoice Photo
copies are not Acceptable Computer generated
claims must match NUBC uniform standards
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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
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21
Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
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Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
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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
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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.
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Block 21 Diagnosis Codes (Current ICD.9 Code)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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Block 23 Prior Authorization Number
(Conditional)
23. PRIOR AUTHORIZATION NUMBER
For services which require prior authorization,
the prior authorization number must be listed on
all claims submitted for billing.
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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

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Block 24A Shaded Red AreaTPL Information
Block Billing Scenarios

• No other insurance
• Check NO in Locator 11d or leave blank
• Primary Carrier pays covered service
• Provider receives Explanation of Benefits (EOB)
• Check YES in Locator 11d
• Document primary payment information in the
  shaded red area of 24A on claim form
• DMAS does not require an attached copy of the EOB
  when provider receives payment from primary
  carrier

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Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
09
09
03
01
03
01
1
03
01
09
03
16
09
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
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TPL Billing Scenarios

• Primary carrier does not pay
• Payment applied to deductible/claim denied
• Provider receives EOB
• Check YES in Locator 11d
• Attach copy of EOB showing non-payment to the
  back of the DMAS claim form
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Service not covered
• Check YES in Locator 11d
• Attach EOB documenting that services are not
  covered or, attach letter verifying the service
  is not covered
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Carrier will not enroll provider
• Check YES in Locator 11d
• Attach letter documenting the primary carrier
  will not enroll the provider
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Policy is no longer active/coverage terminated
• Check YES in Locator 11d
• Attach EOB verifying that the policy is not
  active or, attach letter verifying the policy is
  not active
• Advise patient/guardian to contact Local DSS with
  policy termination documentation/information

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Block 24B Place of Service
Note Type of Service is no longer required
B.
Place
11-Office location 12- Patients Home 53
Community Mental Health Center
of
Service
11
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
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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

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Block 24C EMG
C. EMG
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
H0023

H0035
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
2.
4.
E.
DIAGNOSIS
POINTER
1
Enter the identifier of the ICD-9-CM diagnosis
code listed in Locator 21. To identify more than
one diagnosis code, separate the indicators with
a comma.
1,2
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Block 24 F Charges
F.
CHARGES
Enter the usual
and customary charges
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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
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Block 24H EPSDT/Family Plan
H.
EPSDT Family Plan
1
1-EPSDT
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ID.QUAL Block-24I

• Qualifier 1D is to be used in the red shaded
  area for claims being submitted using the
  Atypical Provider Identifier (API).
• Qualifier ZZ is to be used to indicate the
  taxonomy code - only when the National Provider
  Identifier is used and only if necessary to
  adjudicate the claim.

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Rendering Provider ID Block-24J

• The shaded red area will contain the API
• OR
• The open area will contain the NPI of the
  provider rendering the service

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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
0001234567
NPI
Atypical Provider Identifier
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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
ZZ
Taxonomy (if needed)
1234567890
NPI
National Provider Identifier
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Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 14 alphanumeric digits
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Block 28 Total Charges
28. TOTAL CHARGE

Please list the total all charges in Block 28.
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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.
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Block 32Service 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

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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 API in 32b

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Block 32 Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
NPI
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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

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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 API in 33b

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Block 33 Billing Provider Info PH
33. BILLING PROVIDER INFO PH
( )
a.
b.
NPI
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Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From Original
Adjustment or
Remittance
Void
Resubmission Code
Chap. V, Community Mental Health
Rehabilitative Services Manual has resubmission
code list.
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THANK YOU

• Department of Medical Assistance Services
• www.dmas.virginia.gov