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Medicaid Biller Training

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Checks and Remittance Advice (EOB) mailed separately. Replacement ... Hotline advice is followed, but claim is still processed improperly ... – PowerPoint PPT presentation

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Title: Medicaid Biller Training


1
Medicaid Biller Training
  • For Out-of-state Providers

2
Resources
  • New Providers
  • Refer to Michigan Medicaid website, Provider
    Enrollment
  • MI Eligibility Verification System 1-888-696-3510
  • Prior Authorization (All Non Emergency Services
    require PA)
  • MA eligibility 517-335-5198
  • CSHCS eligibility 517-335-9440
  • Michigan Uniform Billing Manual
  • Phone 517-703-8622 Fax  517-327-4564
  • www.michigansubc.org
  • Health Claim Form Association 1500
  • Refer to Michigan Medicaid website, Medicaid
    Provider Manual, BILLING REIMBURSEMENT FOR
    PROFESSIONALS, section 3.
  • Website www.michigan.gov/mdch gtgt PROVIDERS gtgt
    INFORMATION FOR MEDICAID PROVIDERS
  • Medicaid Provider
  • Explanation codes, Reason Remark codes
  • Provider Specific Information (Fee-Screens)
  • Provider Support
  • Phone 800-292-2550
  • Email ProviderSupport_at_michigan.gov

3
PROVIDERS
4
Information for Medicaid Providers
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11
Provider Enrollment
  • When to contact Provider Enrollment
  • New Providers
  • Refer to Michigan Medicaid website, Provider
    Enrollment for the enrollment form
  • When any information associated with your Trading
    Partners Agreement changes
  • Tax ID/Affiliation
  • Addresses
  • License (renewed, restored, additional)
  • Specialties
  • Billing Agents
  • NPI
  • PROVIDER ENROLLMENT UNIT
  • MEDICAID PAYMENTS DIVISION ProviderEnrollment_at_m
    ichigan.gov
  • MEDICAL SERVICES ADMINISTRATION
  • MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
  • PO BOX 30238
    ?Phone 517-335-5492
  • LANSING, MI 48909 Fax 517-241-8233
  •  

12
National Provider Identifier (NPI)
  • Providers may now apply for their NPI through CMS
  • Must have NPI by May 23, 2007
  • MI Medicaid does not currently require NPI but
    greatly encourages applying now
  • More NPI Information
  • https//nppes.cms.hhs.gov
  • 1-800-465-3203 (NPI Toll-Free)
  • customerservice_at_npienumerator.com

13
MMIS
  • Coming Soon
  • Online Provider Enrollment
  • Online Eligibility
  • Online Claims Submission
  • Online Claim Status
  • And More, All Direct from MDCH

14
Eligibility Verification
  • Automated Voice Response System (AVRS) Free
    (1-888-696-3510) Need Provider Type/ID and
    beneficiary information
  • WebDenis - Free (www.bcbsm.com/providers)
  • Medifax - for a fee (www.medifax.com)
  • Healthcare Data Exchange (HDX) - for a fee
    (www.hdx.com )

15
Eligibility Verification
  • Scope/Coverage
  • Level of Care (LOC)
  • Third Party Liability (TPL)
  • Scp/Cvrg 2-digit alpha/numeric code indicating
    which Medical Assistance Program the beneficiary
    is enrolled (i.e. Medicaid, CSHCS, ABW, MOMS,
    etc.)
  • LOC A modifier to the patients Scope/Coverage
    indicating other circumstances (i.e. nursing
    facility or hospice patient, enrolled in HMO,
    beneficiary is incarcerated, etc.)
  • TPL Any other payers preceding Medicaid
    Medicaid is always the payer of last resort.

16
Eligibility Verification
  • Common Scope Code
  • 1 - Medicaid
  • 2 - Medicaid
  • 3 - Adult Benefit Waiver
  • 4 - Refugees and Repatriates
  • Scope/Coverage
  • 0 (zero) - No Medicaid eligibility/coverage
    (Deductible / Spend-down)
  • E - Emergency or urgent Medicaid coverage only
  • F - Full Medicaid coverage
  • G - Adult Benefit Waiver
  • Common Level of Care Code
  • Blank (No LOC code) - fee-for-service (FFS).
  • 02 - nursing facility services
  • 11 - Adult Benefit Waiver (CHP)
  • 07 - Medicaid Health Plan (MHP)
  • 10 Patient Pay amount
  • 16 - hospice

17
Eligibility Policies
  • Beneficiary Eligibility Chapter, Medicaid
    Provider Manual (Eligibility Code Descriptions)
  • Adult Benefits Waiver Chapter, Medicaid Provider
    Manual (Coverages and Limitations)
  • Childrens Special Health Care Services Program
    Chapter, Medicaid Provider Manual
  • Medicaid Health Plans, Medicaid Provider Manual
    (HMO responsibilities)
  • MI CHILD www.michigan.gov/mdch gtgt Health Care
    Coverage gtgt Children and Teens (NOT MEDICAID)
  • Third Party Liability (TPL) at MDCH
  • Medicare Buy-In Unit at MDCH

18
Third Party Liability (TPL)
  • To remove or update other insurance information
    from Third Party Liability (TPL) file
  • Phone 800-292-2550 (option 4)
  • Fax 517-346-9817
  • Email TPL_Health_at_Michigan.gov

19
Medicare Buy-In Unit (MDCH)
  • Lewis Cass Building Phone 517-335-5488
  • 320 South Walnut Fax 517-335-0478
  • Lansing, MI 48913 Email BuyInUnit_at_Michigan.g
    ov
  • The Medicare Buy-In Unit is responsible for
  • Processing Medicare premium payments for eligible
    Medicaid beneficiaries.
  • Other Insurance Coding for Medicare on the
    Medicaid system.
  • Alien information for Medicaid beneficiaries that
    are age 65 or over, must have the date of entry
    forwarded to the Buy-In Unit if the beneficiary
    has not been in the US for over 5 consecutive
    years.
  • The Medicare Buy-In unit will not be able to
    address questions from the beneficiaries.

20
Medicaid Billing Limitations
  • 12 month limitation from Date of Service (DOS)
  • Inpatient admission- 12 month from discharge date
  • Continuous Activity Within 120 days from last
    rejection
  • Documentation is needed for
  • Claim replacements when Previously billed with
    incorrect
  • Provider ID Number
  • Beneficiary ID Number

21
Claim Submission
  • PAPER
  • No confirmation until CRN appears on RA
  • 30-60 days to appear on Medicaid RA
  • Must attach EOB
  • No paper clips, white out or dot matrix printers
  • ELECTRONIC
  • 997 Acknowledgement receipt from Medicaid
  • 7-14 days to appear on Medicaid RA
  • No EOB needed
  • A list of approved billing agents is posted at
    Electronic Billing website

22
Electronic Billing
  • Shopping for an Electronic Billing Agent
  • Billing Agent Authorization Form
  • 835/277U Request Form
  • Billing Agents responsibilities
  • Billing And Reimbursement Chapters, Medicaid
    Provider Manual
  • AutomatedBilling_at_michigan.gov

23
Electronic Claims
  • Medicaid accepts electronic Primary, Secondary
    and Tertiary claims
  • EOBs are not needed when submitting
    secondary/tertiary claims electronically
  • CAS Codes are required
  • Complete Loop 2400 and 2430 for claim Procedure
    Code and Modifier (Professional)
  • Professional claims only need to be sent on paper
    when attachments (besides EOBs) are needed

24
Crossover Claims(Special Services)
  • Medicaid is accepting crossover claims from WPS
    and AdminaStar
  • Bulletin All Provider 04-05, issued June 1, 2004
  • Bulletin MSA 05-02, issued January 1, 2005
  • Provider ID must be included in Loop 2010AA
  • Example REF1D108888888
  • Medicaid will soon allow the Provider ID in Loop
    2310B, Rendering Billing Provider ID
  • FAQs posted at Provider Updates webpage

25
Crossover Claims(Special Services)
  • Troubleshooting Crossover
  • Medicare EOB says that the Claim was forwarded
    to MDCH for Reimbursement but claim never
    appears on Medicaid Remittance Advice
  • This means that your Medicaid Provider Type and
    ID were not in the proper provider identifying
    field within your electronic claim
  • See your vendor for correction
  • Rebill to Medicaid any crossover claims that do
    not appear within 30 days of Medicare EOB
  • Groups of providers who submit batches of claims
    under one Medicare group ID but more than one
    Medicaid Provider ID should not attempt to
    crossover until further notice

26
835 Electronic Remittance Advice
  • The 835 is the only electronic format available
  • Paper is still available
  • 835 reports all paid and rejected claims
  • 277U will report pended claims
  • MDCH edits no longer exist
  • Nationally recognized Reason/Remark codes
  • Posted electronically and on paper RA
  • Crosswalk available at website
  • www.michigan.gov/mdch gtgt Providers gtgt Information
    for Medicaid Providers gtgt Electronic Billing

27
Remittance Advice
Checks and Remittance Advice (EOB) mailed
separately
  • MSA
  • Remittance Advice
  • Payment Information by beneficiary
  • Issued by MDCH
  • Date, Provider Type/ID, Amounts match Warrant
    Date, Provider Type/ID, Amounts
  • One RA issued to each Provider ID
  • State of Michigan Remittance Advice
  • Attached to the Check
  • Check and RA (AKA Warrant)
  • Payment information by Provider Type/ID and Tax
    ID
  • Issued by Department of Treasury
  • 39S 391 MDCH/Medicaid
  • One RA issued to each Tax ID

28
Replacement
  • Examples of when a claim may need to be
    replaced
  • To return an overpayment (report "returning
    money" in Remarks section)
  • To correct information submitted on the original
    claim (other than to correct the Provider ID
    number and/or the beneficiary ID number). Refer
    to the Void/Cancel subsection below
  • To report payment from another source after MDCH
    paid the claim (report "returning money" in
    Remarks section) and/or
  • To correct information that the scanner may have
    misread (state reason in Remarks section).

29
Replacement
  • To replace a previously paid claim,
  • UB-92-
  • indicate 7 (xx7) as the third digit in the Type
    of Bill Form locator frequency.
  • enter the 10-digit Claim Reference Number (CRN)
    of the last approved claim being replaced
  • the reason for the replacement in Remarks. The
    Provider ID number and beneficiary ID number on
    the replacement claim must be the same as on the
    original claim.
  • Refer to Michigan Medicaid manual, BILLING
    REIMBURSEMENT FOR INSTITUTIONAL, section 3.1

30
Replacement
  • To replace a previously paid claim,
  • HCFA 1500-
  • Report code 7 in the left side of Item 22
  • Report the ten-digit Claim Reference Number (CRN)
    of the previously paid claim in the right side of
    Item 22
  • State reason in the Remarks section
  • NOTE If the resubmission code of 7 is missing
    the claim cannot be processed as a replacement
    claim.
  • If all service lines of a claim were rejected,
    the services must be resubmitted as a new claim,
    not a replacement claim.
  • Refer to Michigan Medicaid manual, BILLING
    REIMBURSEMENT FOR PROFESSIONALS, section 4.1

31
Void/Cancel
  • If a claim was paid under the wrong provider or
    beneficiary ID Number,providers must void/cancel
    the claim.
  • UB-92
  • indicate an 8 in the Type of Bill (xx8) as the
    third digit frequency.
  • enter the 10-digit CRN of the last approved claim
    or adjustment being cancelled and
  • enter in Remarks Section the reason for the
    void/cancel.
  • A new claim may be submitted immediately using
    the correct provider or beneficiary ID number.
  • A void/cancel claim must be completed exactly as
    the original claim.
  • Refer to Michigan Medicaid manual, BILLING
    REIMBURSEMENT FOR INSTITUTIONAL, section 3.2

32
Void/Cancel
  • If a claim was paid under the wrong provider or
    beneficiary ID Number,providers must void/cancel
    the claim.
  • HCFA 1500
  • Report code 8 in the left side of Item 22
  • Report the ten-digit Claim Reference Number (CRN)
    of the previously paid claim in the right side of
    Item 22
  • complete one service line and enter zero dollars
  • (000) in all money fields.
  • State reason in the Remarks section
  • Refer to Michigan Medicaid manual, BILLING
    REIMBURSEMENT FOR PROFESSIONALS, section 4.2

33
Prior Authorization
  • All out of state services that have been prior
    authorized must
  • indicate in Remarks (F.L. 19) OUT OF STATE
  • prior authorization number in prior authorization
    field

34
Appeals
  • Claim is submitted to MDCH (PO Box 30043)
  • Claim is denied
  • If necessary, correct claim information indicated
    as insufficient/incorrect on RA and resubmit
  • If corrected claim is rejected contact Provider
    Support Hotline for counsel
  • (1-800-292-2550)

35
Appeals
  1. Hotline advice is followed, but claim is still
    processed improperly
  2. Send paper claim with letter explaining
    situation/history and request for action to
    Special Payments Research and Analysis (PO Box
    30731)
  3. Research and Analysis either denies request or
    processes but system still rejects

36
Appeals
  • If all requirements have been satisfied and all
    instruction followed but claim continues to
    reject, MDCH Administrative Tribunal should be
    contacted
  • MDCH Administrative Tribunal Appeals Division
  • PO Box 30763
  • Lansing, MI 48909
  • Phone 517-334-9500
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