Department of Medical Assistance Services - PowerPoint PPT Presentation

Loading...

PPT – Department of Medical Assistance Services PowerPoint presentation | free to download - id: 4719ef-ZmUyM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Department of Medical Assistance Services

Description:

Medicaid 101 www.dmas.virginia.gov Agenda DMAS Website www.dmas.virginia.gov Current, most up-to-date information on Virginia Medicaid programs Provider memos ... – PowerPoint PPT presentation

Number of Views:342
Avg rating:3.0/5.0
Slides: 170
Provided by: clj
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Department of Medical Assistance Services


1
Department of Medical Assistance Services
  • Medicaid 101

www.dmas.virginia.gov
2
  • This presentation is to facilitate training of
    the subject matter in Virginia Medicaid Hospital
    Manual.
  • This training contains only highlights of the
    manual and is not meant to substitute for or take
    the place of the manual.
  • Providers are responsible for reviewing and
    adhering to all Medicaid manual requirements.

2
3
Agenda
1. DMAS Website
2. Excluded Individuals/Entities

3. Medicaid Eligibility Verification Options

4. Medicaid Programs and Benefit
Packages
5. UB-04 Billing Guidelines
4
DMAS Website www.dmas.virginia.gov
  • Current, most up-to-date information on Virginia
    Medicaid programs
  • Provider memos available for review
  • Access to Medicaid manuals
  • 50 Common Error Reason Codes with Resolutions
  • Numeric Insurance Code List
  • Primary Carrier Coverage Code List

5
DMAS Website www.dmas.virginia.gov
  • Financial Reason Code Description List
  • Hospital DRG Rates
  • Medicaid Forms
  • 2010 Medicaid/FAMIS-PLUS Handbook

6
(No Transcript)
7
Excluded Individual/Entities
  • No payment can be made for any items or services
    ordered or prescribed by an excluded physician
    when the furnishing party either knew or should
    have known of the exclusion
  • Medicaid providers may be subject overpayment
    liability and civil monetary penalties when they
    do not abide by this Federal Regulation

8
Excluded Individual/Entities
  • This ban includes payment for administrative and
    management services not directly related to
    patient care
  • Providers are required to identify excluded
    individuals and entities
  • This ensures that DMAS is not paying any excluded
    individuals or entities for services rendered

9
How to Ensure Program Integrity
  • Screen all employees and contractors to determine
    whether they have been excluded
  • Search HS-OIG List of Excluded Individuals/Entitie
    s (LEIE) website monthly
  • Immediately report to DMAS any exclusion
    information discovered

10
Reporting
  • Discoveries are to be sent in writing to the
    address below and should include the
  • individual or business name
  • provider identification number
  • State action, if any, has been taken
  • DMAS
  • Attn Program Integrity/Exclusions
  • 600 E. Broad St. Ste 1300
  • Richmond, VA 23219

11
Accessing the LEIE
  • HHS-OIG maintains the LEIE
  • Provides information about parties excluded from
    participation in Medicare, Medicaid and all other
    Federal healthcare programs
  • The online database is located at
  • http//www.oig.hhs.gov/fraud/exclusions.asp

12
As A Participating ProviderYou 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.

13
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 05/09/1964 F
CARD 00001
14
Medicaid Verification Options
  • MediCall
  • Medicaid Web Portal

15
MediCall/Medicaid Web Portal Information
Available
  • Medicaid member eligibility/benefit verification
  • Service limit information
  • Claim status
  • Service authorization
  • Provider check log
  • Primary Payer Information
  • Medallion Participation
  • Managed Care Organization Assignment

16
Copay Indicators
  • Code A
  • Under 21- No copay exists
  • Code B
  • Long Term Care, Home or Community Based Waiver
    Services, Hospice-No copay
  • Code C
  • All other members collect any/all applicable
    copays

17
Copay Exemptions
  • Members in managed care may not have copays
  • Pregnancy related/family planning services
  • Emergency services

18
Copay Amounts
  • Inpatient hospital 100.00 per admission
  • Outpatient hospital clinic 3.00 per
    visit
  • Clinic visit 1.00 per visit
  • Physician office visit 1.00 per visit
  • Other physician visit 3.00 per visit

18
19
General Exclusion
  • Payment cannot be made under the Medicaid
    Program for certain items and services, and
    Virginia Medicaid will not reimburse providers
    for these non-covered services.
  • Medicaid members have been advised that they may
    be responsible for payment to providers for
    non-covered services.

20
General Exclusion - Directive
  • Prior to the provision of service, the provider
    must advise the Medicaid member that he or she
    may be billed for a non-covered service.
  • A directive signed by the patient, meets Virginia
    Medicaids requirement of patient notification
    of financial responsibility for non-covered
    services.

21
MediCall
  • 800-884-9730
  • 800-772-9996
  • 804-965-9732
  • 804-965-9733

22
Medicaid Web Portal
  • Web-based eligibility verification option
  • Free of Charge.
  • Information received in real time.
  • Secure
  • Fully HIPAA compliant

23
Changes-
  • A new enhanced web portal will allow providers to
    transact all Medicaid business via one central
    location.
  • The web portal will provide access to
  • Member Eligibility Status
  • Payment History
  • Remittance Advices
  • Service Authorization

24
Registration Process
  • First Time Users
  • Go to www.virginiamedicaid.dmas.virginia.gov
  • Establish an user ID and password
  • By registering you are acknowledging yourself as
    a staff member with administrative rights for the
    organization
  • Established Users- Delegated Administrators
  • will receive a letter containing their NPI and
    instructions on accessing the Web Portal
  • must access the Web Portal and change their
    temporary password no later than June 27, 2010
  • will be able to add new users beginning June 28,
    2010.

24
25
ACS Web Registration Support Call Center
  • Questions regarding new user registration,
    existing user access letter, or temporary
    password
  • 1-866-352-0496
  • Available after June 8, 2010
  • 8 am 5 pm Monday thru Friday
  • No holidays

26
Key Dates and Times
  • May 26th
  • New registration to FHS/UAC discontinued
  • Through June 27th
  • Current FHS/UAC users can continue to request
    password resets, routine maintenance, or access
    information as normal
  • June 27th
  • Access to ARS via FHS/UAC will be discontinued

27
Key Dates and Times
  • June 28th
  • new registration and users can be added via the
    new Virginia Medicaid Web Portal
  • access to eligibility and claims information will
    be available in the new Virginia Medicaid Web
    Portal at 701 am
  • www.virgniniamedicaid.dmas.virginia.gov

28
Provider Call Center
  • Claims, covered services, billing inquiries
  • 800-552-8627
  • 804-786-6273
  • 830am 430pm (Monday-Friday)
  • 1100am 430pm (Wednesday)


29
Provider Enrollment
  • NPI enrollment, EFT sign-up, update facility
    contact and email, change of address or phone
    number
  • Provider Enrollment Unit
  • P. O. Box 26803
  • Richmond, VA 23261
  • 888-829-5373
  • 804-270-5105
  • 804-270-7027 - Fax

30
Medicaid Programs/Benefit Packages
31
Medicaid Programs
  • Medicaid Fee-for-Service
  • No Primary Care Physician (PCP)
  • No mandatory referral from the PCP.
  • Medallion
  • Primary Care Physician who directs all care.
  • PCP referral required for all non-emergency
    services.

32
Medicaid Programs
  • FAMIS
  • Medicaid program for children under age 19
  • First 30 days coverage provided under the FAMIS
    fee-for-service program
  • Mandatory Managed Care Organization assignment
    (where available) after the initial 30 days of
    coverage

33
Medicaid Programs
  • FAMIS MOMS
  • For pregnant women with incomes above the
    Medicaid income guidelines
  • Managed Care Organization assignment rules same
    as FAMIS
  • Apply thru local Department of Social Services or
    Central Processing Unit
  • Baby is not covered until application submitted
    and approved

34
Medallion II MCO ID Cards
  • Issued by the Managed Care Organizations
  • Medicaid member will have both MCO and Medicaid
    cards
  • Eligibility verification is a REQUIREMENT
  • Each verification option will give the MCO
    enrollment information if applicable

35
Medallion II MCO ID Cards
  • The Anthem card for Medicaid members indicates
    Anthem Health Keepers Plus (PLUS identifies the
    Medicaid plan).
  • The Optima Card for Medicaid members indicates
    Optima Family Care (FAMILY CARE identifies the
    Medicaid plan).
  • Virginia Premier - anyone presenting a VA Premier
    Card is a Medicaid client.

36
Medallion II MCO ID Cards
  • CareNet identifies the Southern Health Services
    card for Medicaid members.
  • AMERIGROUP of Virginia is for Medicaid members.

37
Virginia Medicaid MCO Contacts
Medicaid HMO Plan Telephone Number
Anthem HealthKeepers Plus 800-901-0020
Optima Family Care 800-881-2166
Virginia Premier 800-727-7536
CareNet 800-279-1878
AMERIGROUP of Virginia 800-600-4441
37
38
Member Choice - MCO Selection(Areas Where MCO is
Available)
  • Member will be enrolled in Medicaid
    fee-for-service plan for the first 30 days.
  • Member will then have 90 days to select an MCO
    plan.
  • During the 90 day period, a member can select a
    new MCO for the upcoming month as long as the
    request is received by the 15th of the current
    month.
  • At the end of the 90 day period, the member will
    be enrolled in the chosen MCO until the next open
    enrollment period.

39
Managed Care Helpline
1-800-643-2273 TDD 1-800-817-6608 Monday
Friday 830 a.m. 600 p.m. (Translation
Services Available)
40
Client Medical Management- CMM
  • Mandatory Primary Care Physician (PCP) and
    Pharmacist who directs all care
  • Responsibilities
  • coordinating routine medical care
  • making referrals to specialists as necessary
  • arrange 24 hour coverage when not available
  • explain to members all procedures to follow when
    office is closed or there is an urgent or
    emergency situation

41
Client Medical Management - CMM
  • Services received by a CMM member not provided by
    the PCP will be reimbursed only
  • in a medical emergency/delay in treatment may
    cause death, lasting injury or harm
  • on written referral from PCP using the
    Practitioner Referral Form (DMAS-70), includes
    covering physicians
  • covered services excluded from CMM program
    requirements
  • If not a medical emergency or no referral form is
    attached, hospital emergency room CMM claims will
    be denied, not paid at a reduced rate
  • CMM patient can be billed for these non-emergency
    services

41
42
Aliens
  • Section 1903v of the Social Security Act requires
    Medicaid to cover emergency services for
    specified aliens when the services are provided
    in an emergency room or inpatient hospital
    setting.
  • Hospital outpatient follow-up visits or physician
    office visits are not included in the covered
    services.

43
Aliens
  • Emergency medical treatment only
  • Eligibility requests should be sent to the local
    DSS
  • Emergency Medical Certification form required for
    claim submission

44
Aliens
  • Covered services must meet emergency treatment
    criteria and are limited to
  • Emergency room care
  • Physician services
  • Inpatient hospitalization not to exceed limits
    established for other Medicaid recipients
  • Ambulance service to the emergency room
  • Inpatient and outpatient pharmacy services
    related to the emergency treatment

45
Early Periodic Screening Diagnosis and Treatment
- EPSDT
  • The EPSDT Program is Medicaids comprehensive and
    preventative child health program for individuals
    under the age of 21.
  • Federal law requires a broad range of outreach,
    coordination, and health services under EPSDT
    distinct from general state Medicaid
    requirements.
  • The goal of EPSDT is to identify and treat health
    problems as early as possible.
  • EPSDT provides examination and treatment at no
    cost to the individual.

46
Early Periodic Screening Diagnosis and Treatment
- EPSDT
  • For individuals under age 21, EPSDT must include
    the services listed below-
  • Screening services, which encompass all of the
    following services
  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate immunizations according to age and
    health history
  • Laboratory tests (including blood lead screening)
  • Health education

47
Qualified Medicare Beneficiaries- QMB
  • Eligible only for Medicaid payment of Medicare
    premiums, deductibles, coinsurance and Medicare
    Advantage Plan copays.
  • Medicaid will consider the Medicare deductibles,
    coinsurance and copays for benefits.
  • If Medicare does not cover the service, the
    service cannot be billed to Medicaid.

48
Qualified Medicare Beneficiaries- QMB Extended
  • This group is eligible for Medicaid coverage of
    premiums, deductibles, coinsurance and Medicare
    Advantage Plans copays, plus all other
    Medicaid-covered services.
  • Medicaid will consider the Medicare deductibles,
    coinsurance and copays for benefits.
  • Members are also eligible for all Medicaid
    covered services.

49
Medicare Advantage Plans
  • VA Medicaid handles and processes Medicare
    Advantage Plans the same way as traditional
    Medicare.
  • DMAS does not process the Medicare Advantage
    Plans as Third Party Liability (TPL)
  • Advantage Plan deductible, copay or coinsurance
    amounts submitted, will be considered by VA
    Medicaid for payment

50
Special Low-Income Beneficiaries- SLMB
  • This group is only eligible for Medicaid coverage
    of the Medicare Part B premium only.
  • The member will have a Medicaid number, but will
    not received a Medicaid card.
  • Medicaid will not cover any medical services for
    this member.

51
Plan First
  • Medicaid fee-for-service family planning waiver
    program
  • Men and women ages 19 years and older may be
    eligible
  • Participant income must be less than or equal to
    133 of federal poverty level
  • Must meet citizenship and identity requirements

52
Plan First
  • Plan First includes coverage of those services
    necessary to prevent or delay a pregnancy
  • Family planning does not include counseling
    about, recommendations for or performance of
    abortions, hysterectomies or procedures performed
    for medical reasons such as the removal of
    intrauterine devices due to infections.

53
Plan First
  • Not eligible for the waiver
  • Individuals who have major medical insurance
  • Individuals who are eligible for full Medicaid
    benefits coverage
  • Individuals who have had a sterilization
    procedure

54
Plan First- Covered Services
  • Plan First covers routine and periodic family
    planning office visits and related services.
  • Medicaid will only reimburse approved procedure
    codes and the code must be accompanied with a V25
    category (family planning) as a primary diagnosis
    on the claim.
  • Please review the Plan First manual, Chapter IV
    for codes.

55
Spend Down
  • Medicaid applicants whose income is over the
    Medicaid limit, the applicant may become eligible
    for a limited period of Medicaid coverage if all
    other eligibility factors are met.
  • This process is called a spend-down.
  • The applicants medical expenses must equal or
    exceed the difference between his or her income
    and the Medicaid income limit.

56
Spend Down
  • If the allowable expenses of the applicant equal
    this spend-down amount before the end of a
    budget period (six months for non-institutionalize
    d individuals or a one month period for
    institutionalized individuals), the applicant
    may receive a limited period of Medicaid coverage
    which will stop at the end of the budget period.
  • Eligibility must be re-determined in order to
    establish eligibility in subsequent budget
    periods.

57
Medicaid Waiver
  • There are key requirements with which a states
    Medicaid program must comply.
  • These basic requirements govern Medicaid
    programs nationwide.
  • State must make services available to individuals
    on a comparable basis.
  • State must guarantee members freedom of choice in
    selecting service providers when obtaining
    Medicaid services.
  • State must make Medicaid services available
    statewide and provide that individuals have ready
    access to them.

58
Medicaid Waiver
  • In some cases the states may request waivers of
    some of these requirements.
  • Medicaid home and community-based service waiver
    programs operate under these rules.
  • The waiver allows Medicaid to pay for additional
    services not covered by traditional Medicaid.
  • The state has the ability to decide who gets
    funded for what service (criteria for eligibility
    and coverage).

59
VA Medicaid Waivers
  • Alzheimers Assisted Living Waiver
  • Assisted Technology and Environmental
    Modifications
  • Elderly or Disabled With Consumer Direction
  • HIV/AIDS
  • Individual and Family Developmental Supports
    (IFDDS)
  • Intellectual Disabilities/Mental Retardation
    (ID/MR)
  • Technology Assisted (Tech)

60
Temporary Detention Order
  • The General Assembly directed DMAS to process all
    requests for payment of services rendered as a
    request of Civil/Criminal Mental Temporary
    Detention Orders (TDO) effective July 1, 1995.
  • Any magistrate may, within the specified
    guidelines, issue a temporary detention.
  • A law enforcement officer executes Temporary
    Detention Orders.
  • Employee of the community services board or its
    designee shall determine the facility of
    temporary detention for all individuals.

61
Temporary Detention Order
  • The duration of the temporary detention shall not
    exceed 48 hours prior to a hearing.
  • If the forty-eight hour period herein specified
    terminated on a Saturday or Sunday, or a legal
    holiday, such person shall be detained until the
    next day which is not a Saturday, Sunday or legal
    holiday, but in no event may be detained longer
    than 96 hours.

62
Temporary Detention Order
  • Hospitals and physicians must submit claims to
    DMAS as the result of issuance by a court.
  • DMAS will accept only the original claim forms.
  • All TDO submissions must have the TDO form
    attached to the claim with the pre-printed case
    identification number.
  • Failure to provide the TDO form will result in
    claims being returned to the provider for
    incomplete information.
  • The Execution section on the TDO form must be
    signed by the law enforcement officer and dated
    to be valid.

62
63
Temporary Detention Order
  • Processing of TDO claims includes both
    Medicaid-eligible and non-Medicaid eligible
    patients.
  • TDO is the payer of last resort and attempts must
    always be made to first bill the primary carrier
    , including Medicaid, prior to billing TDO.
  • Each claim will be researched for coverage by
    another resource.
  • If the patient has other resources, the claim
    will be returned to the provider.
  • The returned claim will have a letter attached,
    advising the provider to bill primary payer.

64
Fiscal Agent Transition
  • Updates and Changes

65
Paper Claims
  • Process for submitting claims remains the same
  • Continue to send to the appropriate P.O. Box
  • Claims received
  • By close of business 6/21 will process as usual
  • Inquiry on clean claims should be available on or
    after 6/28
  • Should be on 7/2 remit
  • From 6/22-6/27 will be held and processed on 6/28
  • Inquiry on clean claims will not be available
    until at least 6/28
  • Will not be on remit until 7/9

65
66
Paper Claims Requirements
  • Claims must be submitted on the original red and
    white claim form
  • The National Uniform Billing Committee and
    National Uniform Claims Committee standards and
    specifications must be met for margins, formats,
    and fonts
  • 10 pitch Pica type
  • 6 lines per in vertical
  • 10 characters per inch

67
Electronic Data Interchange (EDI)
  • EDI Claims received by 500 pm June 24
  • Will process as usual
  • Should be available for inquiry 6/28
  • Should be on 7/9 remit
  • EDI Claims received after 500 pm June 24
  • Will be processed starting June 28

68
Electronic Data Interchange (EDI)
  • Requirements
  • You or your designee must have established and
    been given a
  • New user ID
  • New password
  • New File Transfer Protocol (FTP)

69
Trader Partner Testing
  • Communications validation testing is being
    conducted
  • Clearinghouses
  • Service centers
  • Software vendors
  • Letter sent to all trading partners containing
    information regarding testing of EDI batch
    processing

70
Trader Partner Testing
  • If you or your designee has not received this
    letter
  • email Virginia.EDISupport_at_acs-inc.com
  • four position submitter ID
  • contact information

71
Hospital Billing Guidelines
72
MAIL CMS-1450 FORMS TO
  • DEPARTMENT OF MEDICAL
  • ASSISTANCE SERVICES
  • Facility
  • P. O. Box 27443
  • Richmond, Virginia 23261-7443

73
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
  • Accidents
  • Other Primary Insurance

74
TIMELY FILING
  • Submit claims with documentation attached (to the
    back of claim) explaining the reason for delayed
    submission

75
CMS-1450 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE Invoice Photo
copies are not Acceptable Computer generated
claims must match NUBC uniform standards
75
76
Locator 1Providers Name, Address and Phone
Number
  • Enter the providers name, complete mailing
    address and telephone number of the provider that
    is submitting the bill and which payment is to be
    sent.
  • NOTE DMAS will need to have the 9 digit zip code
    on line four, left justified for adjudicating the
    claim.

77
Locator 1 Provider Name, Address and Phone
Number
1
Our Neighborhood Hospital
121 Friendly Street
Any Town
VA
12345-6456 8049781234
77
78

Locators 3aPatient Control Number 3b Medical
Record Number
3a PAT. CNTL
123456789ABCDEFGH012
b. MED REC.
987654321HGFEDCBA1234567
Patient Control Number (not to exceed 20
characters) and Medical/Health Record Number (not
to exceed 24 characters) are required for all
UB-04 claim submissions.
78
79
Locator 4 Type of Bill
OriginalBill

79
80
Locator 4 Enter the code as appropriate. Valid
codes for VA Medicaid Inpatient Bill Types
  • 0111- Original Inpatient Hospital Invoice
  • 0112- Interim Inpatient Hospital Invoice
  • 0113- Continuing Inpatient Hospital Invoice
  • 0114- Last Inpatient Hospital Invoice
  • 0117- Adjustment Inpatient Hospital
  • 0118- Void Inpatient Hospital Invoice
  • Only APROVED claims can be adjusted or voided

80
12
81
The proper use of these codes will enable DMAS
to reassemble cycle-billed claims to form DRG
cases for purposes of DRG payment calculations
and cost settlement.
82
Locator 4 Type of Bill
OriginalBill
  • 0131- Original Outpatient Invoice
  • 0137- Adjustment Outpatient Invoice
  • 0138- Void Outpatient Invoice


82
83
Locator 6 Statement Covered Period
  • For hospital admissions, the billing cycle for
    general medical surgical services has been
    expanded to a minimum of 120 days for both
    children and adults, except for psychiatric
    services.
  • Interim claims (bill types 0112 or 0113)
    submitted with less than 120 days will be denied.
  • Bill types 0111 or 0114 submitted with greater
    than 120 days will be denied.

84
Locator 6 Statement Covers Period
  • STATEMENT COVERS PERIOD
  • FROM THROUGH

030710
030710
Enter the beginning and ending service dates
reflected by this invoice (include both covered
non-covered days). Use both from and to for
a single day.
84
85
Locator 8 Patient Name/Identifier
8 PATIENT NAME
a
b
Last First M
Enter the last name, first name and middle
initial of the patient.
85
86
Locator 10 Patient Birthdate
10 BIRTHDATE
10011980
Enter the date of birth of the patient using
the following format - MMDDYYYY.
86
87
Locator 11 Sex
11 SEX
F
Enter the sex of the patient as recorded at
admission, outpatient or start of care. M
Male F Female U Unknown
87
88
Locator 12 Admission/Start of Care
  • The start date for this episode of care. For
    inpatient services this is the date of admission.
    For all other services, the date the episode of
    care began
  • IP- Day admitted
    OP- Day episode of care began

89

Locator 12 Admission/Start of Care
ADMISSION 12 DATE
030510

89
90
Locator 13 Admission Hour
ADMISSION 13 HR
22
Enter the hour during which the patient was
admitted for inpatient or outpatient care.
NOTE Military time is used as defined by NUBC.
90
91
Locator 14 Priority Type of Visit
  • Appropriate PRIORITY TYPE codes accepted
    by DMAS are

CODE DESCRIPTION
1 Emergency
2 Urgent
3 Elective
5 Trauma
9 Information not available
91
92
Locator 14 Priority Type of Visit
ADMISSION 14 TYPE
9
Enter the code indicating the priority of this
admission /visit.
92
93
Source of Referral for Admission or Visit
  • Appropriate codes accepted by DMAS are

Code Description
1 Physician Referral
2 Clinic Referral
4 Transfer from Another Acute Care Facility
5 Transfer from a Skilled Nursing Facility
6 Transfer from Another Health Care Facility
7 Emergency Room
8 Court/Law Enforcement
9 Information not available
D Transfer from Hospital Inpatient in the Same Facility
94
Locator 15 Source of Referral for
Admission/Visit
15 SRC
8
Enter the code indicating the source of
the Referral for this admission or visit.
94
95
Locator 16 Discharge Hour
16 DHR
15
Enter the code indicating the discharge hour of
the patient from inpatient care.
NOTE Military time is used as defined by the
NUBC.
95
96
Locator 17Patient Discharge Status
  • Appropriate codes accepted by DMAS in claims
    processing

Code Description
01 Discharge to Home
02 Discharged/transferred to Short Term General Hospital for Inpatient Care
03 Discharged/transferred to SNF
04 Discharged/transferred to ICF
05 Discharged/transferred to Another Facility not Defined Elsewhere
97
Locator 17Patient Discharge Status
  • Appropriate codes accepted by DMAS in claims
    processing

Code Description
07 Left Against Medical Advice/Discontinued Care
20 Expired
30 Still a Patient
50 Hospice Home
51 Hospice Medical Care Facility
98
Locator 17Patient Discharge Status
Code Description
61 Discharge/transfer to Hospital Based Medicare Approved Swing Bed
62 Discharged/transferred to an Inpatient Rehabilitation Facility
63 Discharged/transferred to a Medicare Certified Long Term Care Hospital
64 Discharged/transferred to Nursing Facility Certified Under Medicaid but not Medicare
65 Discharged/transferred to Psychiatric Hospital or Psychiatric Distinct Part Unit of Hospital
99
Locator 17 Patient Status
Correct reporting of patient status code will
facilitate quick and accurate determination of
DRG reimbursement. In particular, accurate
reporting of the values 01,02,05, and 30 will be
very important in DRG methodology.
100
Locator 17 Patient Discharge Status
NOTE If the patient was a one-day treatment,
enter code 01.
17 STAT
01
Enter the code indicating the disposition or
Discharge status of the patient at the end for
the Service period covered on this bill
(Statement Covered Period, Locator 6).
100
101
Locators 18-28 Condition Codes
  • These codes are used by DMAS in the adjudication
    of claims

Code Description
39 Private Room Necessary
40 Same Day Transfer
A1 EPSDT
A4 Family Planning
A5 Disability
A7 Induced Abortion Danger to Life
102
Locators 18-28Condition Codes
  • These codes are used by DMAS in the adjudication
    of claims

Code Description
AA Abortion Performed Due to Rape
AB Abortion Performed Due to Incest
AD Abortion Performed Due to Life Endangering Physical Condition
AH Elective Abortion
AI Sterilization
103
Locators 18-28 Condition Codes (Required if
Applicable)
Condition Codes 18 19 20 21 22 23 24 25
26 27 28
30
40
Enter the code (s) in alphanumeric sequence Used
to identify conditions or events related to this
bill that may affect adjudication. NOTE DMAS
limits the number of codes to a maximum of 8 on
one claim.
103
104
Locator 29 Accident State (Conditional)
  1. ACDT STATE

VA
Enter if known, the state ( two digit Postal
State Code abbreviation) where the motor vehicle
accident occurred.
104
105
Locator 30 Crossover Part A Indicator (Required
If Applicable)

30
CROSSOVER
NOTE DMAS is requiring for Medicare Part
A crossover claims that the word CROSSOVER be
in this locator.
105
106
Locators 31-34 Occurrence Codes and
Dates (Required If Applicable)
  • OCCURRENCE
  • CODE DATE

030110
a
A3
b
Enter the code and associated date defining a
significant event relating to this bill. Enter
codes in alphanumeric sequence.
106
107
Locators 35-36 Occurrence Codes and Span
Dates (Required If Applicable)
  • OCCURRENCE SPAN
  • CODE FROM THROUGH

a
b
Enter the code and related dates that identify an
event that relates to the payment of the claim.
Enter codes in alphanumeric sequence.
107
108
Locators 39-41Value Codes and Amounts
  • DMAS will capture the number of covered or
    non-covered day (s) or units for outpatient
    services with these required value codes
  • 80 Enter the number of covered days for
    inpatient hospitalization or the number of
    days for re-occurring outpatient claims.
  • 81 Enter the number of non-covered days for
    inpatient hospitalization

109
Locators 39-41 Value Codes and Amount
  • Enter the appropriate code (s) to relate amounts
    or values to identify data elements necessary to
    process this claim.
  • One of the following codes must be used to
    indicate coordination of third party insurance
    carrier benefits
  • No Other Coverage
  • Billed and Paid
  • (Enter Amount Paid by Primary Carrier)
  • 85 Billed Not Covered/No Payment
    (Documentation Required)

109
110
Locators 39-41 Value Codes and Amount
  • For Part A Medicare Crossover Claims, the
    following codes must be used with one of the
    third party insurance carrier codes
  • A1 Deductible from Part A
  • A2 Coinsurance from Part A
  • Other codes may be used if applicable.

111
LOCATORS 39-41
Value Codes and Amount
  • VALUE CODES
  • CODE AMOUNT
  • VALUE CODES
  • CODE AMOUNT

41 VALUE CODES CODE AMOUNT
80 25
a
83
A1 1100 00
7841
08
b
c
d
111
112
Locator 42 Revenue Code
  • Enter the appropriate revenue code (s) for the
    service provided. Note
  • Multiple services for the same item, providers
    should aggregate the service under the assigned
    revenue code and then total the number of units
    that represent those services
  • DMAS has a limit of five pages for one claim
  • The Total Charge revenue code (0001) should be
    the last line of the last page of the claim

113
Locator 42 Revenue Code
42 REV. CD.
1
0123
0251
2
0300
3
0330
4
Revenue codes are four digits, leading zero,
left justified and should be reported in
ascending numeric order.
113
114
Outpatient Hospital Setting Billing Requirements
for NDC
  • CMS requirements related to the Deficit Reduction
    Act (DRA) of 2005, mandate DMAS to require
    hospital providers who bill drug products
    administered in an outpatient hospital setting to
    include the National Drug Code (NDC) information
    of the drug dispensed on all claim submissions.

115
Outpatient Hospital Setting NDC Billing
Requirements
  • The NDC information will be required on all
    electronic (ASC X12N837I) and paper (Universal
    Billing UB) claim submissions.
  • This requirement also applies to Medicare
    Crossover claim submissions.
  • Outpatient hospital claims submitted without a
    valid NDC will have the revenue code line reduced
    to a non-covered service line.

116
Outpatient Hospital Setting NDC Billing
Requirements
  • Providers billing for compound medication with
    more than one NDC included in the medication
    dispensed, each applicable NDC must be submitted
    on a separate claim line to include both
    prescription and over-the-counter ingredients.
  • Each claim line submitted with pharmacy revenue
    codes 0250-0259 and 0630-0639 will require the
    NDC information.

117
Outpatient Hospital Setting NDC Billing
Requirements
  • Effective 07/01/08, a valid NDC will be required
    for all drug products administered in an
    outpatient hospital setting.
  • By definition, a valid NDC is a formatted number
    using the 5-4-2 format, i.e., 5-digits, followed
    by 4-digits, followed by 2-digits
  • 99999888877
  • Each NDC must be an 11-digit code unique to the
    manufacturer of the specific product administered
    to the patient.

117
118
Outpatient Hospital Setting NDC Locator 43
Billing Requirements
  • Form Locator 43 must have N4 modifier as the
    first indicator in this field, the corresponding
    11-digit NDC number, followed by the Unit of
    Measure Qualifier and the NDC unit quantity.
  • Billing for the same medication dispensed in
    different packages, each package size MUST be
    listed separately using N4 modifier, the revenue
    code, and all the required information on
    separate lines.
  • The DMAS system will not consider these drugs as
    duplicates.

119
Outpatient Hospital Setting NDC Billing
Requirements
  • If available, providers should enter the HCPCS
    code in Locator 44 (HCPCS/Rate/HIPPS Code) and
    the HCPCS units in Locator 46 (Serv Unit).
  • DMAS will validate all HCPCS codes.
  • Submission of an invalid HCPCS code will cause
    denial of the entire claim.
  • The NDC number submitted to Medicaid must be the
    actual NDC number on the package or container
    from which the medication was administered.

119
120
Locator 43 Revenue Description
43 DESCRIPTION
N412345678901UN1234.567
Radiology
Radiology
Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
120
121
Locator Revenue Description
43 DESCRIPTION
RB-2 Bed-Pediatric
Drugs-Generic
Laboratory (Lab) General
Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
121
122
Locator 44 HCPCS/Rates/HIPPS Rate Codes
44 HCPCS / RATE / HIPPS CODE
Inpatient Enter the accommodation rate.
Outpatient Enter the applicable code. When
billing for outpatient surgery, enter the
CPT code on the same line as revenue code 0490.
112
122
123
Locator 45 Service Date
45 SERV. DATE
030510
Enter the date the outpatient service was
provided.
123
124
Locator 46 Service Units
Inpatient Enter the total number of
covered accommodation days or ancillary units of
service where appropriate.
46 SERV. UNITS
6
12
Outpatient Enter the unit (s) of service for
physical therapy, occupational therapy or
speech-language pathology visit or session (1
visit 1 unit, even if more than 1 modality is
done).
124
125
Locator 47 Total Charges
47 TOTAL CHARGES
1755
75
29
305
Enter the total charge (s) for the primary payer
pertaining to the related revenue code for
the current billing period as entered in the
statement covers period. Total charges include
both covered and non-covered charges. Note
Use code 0001 for TOTAL.
125
126
Locator 48 Non-Covered Charges
48 NON-COVERED CHARGES
75
00
To reflect the non-covered charges for the
primary payer as it pertains to the
related revenue code.
126
127
Locator 50 Payer Name A-C
  • Enter the payer from which the provider may
    expect some payment for the bill.
  • When Medicaid is the only payer, enter Medicaid
    on line A.
  • If Medicaid is the secondary or tertiary payer,
    enter on lines B or C.

128
Locator 50 Payer Name
50 PAYER NAME
Medicaid
A Primary Payer B Enter the secondary
payer identification, if
applicable. C Enter the tertiary
payer if applicable.
128
129
Locator 56 NPI National Provider Identifier
56 NPI
1234567890
Providers must list their NPI in this field.
129
130
Locator 58 Insureds Name
58 INSUREDS NAME
Virginia J. Member
A B C
Enter the name of the insured person covered
by the payer in locator 50. The name on the
Medicaid line must correspond with the member
name when eligibility is verified.
130
131
Locator 59 Patients Relationship to Insured
  • Note appropriate codes accepted by DMAS are

Code Description
01 Spouse
18 Self
19 Child
21 Unknown
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship
132
Locator 59 Patients Relationship to Insured
52 REL. INFO
18
Enter the code indicating the relationship of
the insured to the patient.
132
133
Locator 60 Insureds Unique Identification
60 INSUREDS UNIQUE ID
012345678910
For lines A-C, enter the unique identification
number of the person insured that is assigned by
the payer organization shown on lines A-C,
Locator 50. NOTE The Medicaid member ID number
is 12 numeric digits.
134
Locator 63 Treatment Authorization Codes
63 TREATMENT AUTHORIZATION CODES
A B
12345678910
Enter the 11 digit Service Authorization (SA)
number assigned by KePRO for the appropriate
inpatient and outpatient services as required by
Virginia Medicaid.
134
135
Locator 64Document Control Number
  • This locator is to be used to list the original
    Internal Control Number (ICN) for APPROVED claims
    that are being submitted to adjust or void the
    original claim.

136
Locator 64 Document Control Number
64 DOCUMENT CONTROL NUMBER
2009363123456701
The control number (ICN) assigned to the original
bill by Virginia Medicaid as part of their
internal claims reference number. Only required
to adjust or void previously approved claims.
91
137
Locator 66 Diagnosis and Procedure Code
Qualifier (ICD Version Indicator)
66 DX
9
The qualifier that denotes the version of
the International Classification of Diseases.
Qualifier 9 for the Ninth Revision. NOTE
Virginia Medicaid currently only accepts a 9 in
this locator.
137
138
Locator 67 Principal Diagnosis CodeLocators
67A-Q Present on Admission (POA) Indicator
  • The eighth digit of the Principal, Other and
    External Cause of Injury Codes are to indicate
    if
  • the diagnosis was know at the time of admission,
    or
  • the diagnosis was clearly present, but not
    diagnosed, until after the admission took place
    or
  • was a condition that developed during an
    outpatient encounter

139
Locators 67 A-Q Present on Admission (POA)
Indicator
  • The POA indicator should be listed in the shaded
    area. This field is required for hospitals,
    (06/30/09 Memo). Reporting codes are
  • CODE DEFINITION
  • Y YES
  • N NO
  • U No information in the record
  • W Clinically undetermined

139
140
Locator 67 Principal Diagnosis Code Locators
A-Q Present on Admission (POA) Indicator
67
A
B
C
I
J
K
L
Enter the diagnosis codes corresponding to
all conditions that coexist at the time of
admission, that develop subsequently, or that
affect the treatment received and/or the length
of stay. NOTE Do not use decimals.
140
141
Locator 69 Admitting Diagnosis
  • ADMIT
  • DX

4019
Enter the diagnosis code describing the
patients diagnosis at the time of
admission. NOTE Must be a current ICD-9 code. Do
not use decimals.
141
142
Locator 70a-c Patients Reason for
Visit (Required If Applicable)
34501
b
c
70 PATIENT REASON DX
Enter the diagnosis code describing the
patients reason for visit at the time of
outpatient registration.
142
143
Locator 72 External Cause of Injury (Required If
Applicable)
E895
c
72 ECI
b
Enter the diagnosis code pertaining to
external causes of injuries, poisoning, or
adverse effect.
143
144
Locator 74 Principal Procedure Code and Date
  • Note for outpatient claims, a procedure code
    must appear in this locator when revenue codes
    0360-0369, 0420-0429, 0430-0439, and 0440-0449
    (if covered by Medicaid) are used in Locator 42
    or the claim will be rejected.
  • For inpatient claims, a procedure code or one of
    the diagnosis codes of V64.1 through V64.3 must
    appear in this locator (or Locator 67) when
    revenue codes 0360-0369 are used in Locator 42 or
    the claim will be rejected.

144
145
Locator 74 Principal Procedure Code and Date
(Required If Applicable)
  • PRINCIPAL PROCEDURE
  • CODE DATE

030510
6501
Enter the ICD-9-CM procedure code that
identifies the inpatient principal
procedure Performed at the claim level during the
period Covered by this bill and the corresponding
date.
145
146
Locator 74a-e Other Procedure Codes and Date
(Required If Applicable)
  • OTHER PROCEDURE
  • CODE DATE

6601
030710
Enter the ICD-9-CM procedure codes
identifying all significant procedures other than
the principal procedure and the dates on which
the procedures were performed. Report those that
are most important for the episode of care and
specifically any therapeutic procedures closely
related to the principal diagnosis.
146
147
Locator 76 Attending Provider
76 ATTENDING
NPI 1234567890
Enter the NPI for the physician who has overall
responsibility for the patients medical care and
treatment reported on this claim.
147
148
Locator 77 Attending Provider
77 OPERATING
NPI 1234567890
Enter the NPI of the individual with the primary
responsibility for performing the surgical
procedure (s).
148
149
Locators 78-79Other Provider Name and
Identifiers
  • This field will be used to list the NPI for the
    Primary Care Physician (PCP) who authorized the
    inpatient stay or outpatient visit.
  • For MEDALLION patients referred to an outpatient
    clinic, enter the NPI for the PCP who authorized
    the outpatient visit.
  • This information is required for all MEDALLION
    patients treated for non-emergency services.

150
Locators 78-79Other Provider Name and
Identifiers
  • For Client Medical Management (CMM) patients
    referred to the emergency room by the PCP or
    admitted for non-emergency inpatient stay, enter
    the providers ID number and attach the
    Practitioner Referral Form (DMAS-70).

151
Locator 78 Other Provider Name and Identifier
NPI 1234567890
78 OTHER
The NPI of the Primary Care Physician is required
for Medallion and Client Medical Management (CMM)
patients admitted for non-emergency treatment.
151
152
Locator 80 Remarks Field
80 REMARKS
Enter additional information necessary to
adjudicate the claim. Enter a brief description
of the reason for the submission of the
adjustment or void. If there is a delay in
filing, indicate the reason for the delay here
and include an attachment.
152
153
TAXONOMYLocator 81 Code-Code Field
  • DMAS will be using this field to capture a
    taxonomy code for claims that are submitted for
    one NPI with multiple business types or locations
    (e.g., Rehabilitative or Psychiatric units
    within an acute care facility, Home Health Agency
    with multiple locations).

154
TAXONOMYLocator 81 Code-Code Field
  • The taxonomy code will be required for providers
    who do not have a separate NPI for each different
    service billed to VA Medicaid.
  • The taxonomy code will also be required for
    providers who have one NPI for multiple business
    locations.
  • Code B3 is to be entered in the first small space
    and the provider taxonomy code is to be entered
    in the second large space. The third space should
    be blank.

155
Locator 83 Code-Code Field
81CC a b c d
B3 282N00000X
Enter the provider taxonomy code for the billing
provider when the adjudication of the claim is
known to be impacted.
155
156
DMAS Service Types That May Require a Taxonomy
Codes
Service Type Description Taxonomy Code (s)
Hospital, General 282N00000X
Laboratory 291U00000X
Rehabilitation Unit of Hosp. 273Y00000X
Psychiatric Unit of Hospital 273R00000X
Private Mental Hospital (IP) 283Q00000X
Rehabilitation Hospital 283X00000X
156
157
Outpatient Surgery
  • For elective outpatient surgical procedures which
    require Service Authorization (SA) by Medicaid
    Medical Support (Physicians Manual, Appendix B),
    submit paper claim.
  • Contact the surgeon and request a copy of his SA
    letter ( the facility services do not required
    service authorization).
  • Attach a copy of the SA letter to the back of
    your claim form.
  • Do not put the Physicians SA on your claim.
  • Charges- including facility- for elective
    surgery not approved with a service
    authorization, will be denied.

157
158
Medicare Primary
  • Crossover Claims

159
Medicare Primary Billing Instructions for
CMS-1450
  • The word CROSSOVER must be entered in Block 30
    of the UB-04 to identify Medicare crossover
    claims.
  • Coordination of Benefits (COB) codes 83 and 85
    must be accurately printed in Blocks 39-41 of the
    UB-04.

160
Medicare Primary Billing Instructions for
CMS-1450
  • The first occurrence code 83 indicates that
    Medicare paid and there should always be a dollar
    value associated with this code. The A1 indicates
    Medicare deductible and code A2 indicates
    Medicare coinsurance

161
Medicare Primary Blocks 39-41
  • Line a 83 Billed and Paid (enter amount paid by
    Medicare or other insurance).
  • Line a A1 Deductible Payer A. (enter Medicare
    Deductible Amount listed on the EOMB).
  • Line a A2 Co-Insurance Payer A. (enter Medicare
    Co-Insurance amount listed on the EOMB).

162
Medicare Primary Billing Instructions for
CMS-1450
  • Note Complete all information in Locators 39a
    through 41a first (payments by Medicare or
    payments by other insurance) before entering
    information in 39b through 41b locators etc.
  • COB code 85 is to be used when another insurance
    carrier is billed and there is no payment from
    that carrier.
  • For the deductibles and co-insurance due from any
    other carrier (s) (not Medicare) the code for
    reporting the amount paid is B1 for the
    deductibles and B2 for the coinsurance.

162
163
Medicare Exhaust Days
  • MEDICARE PRIMARY/Days Exhausted
  • Service authorization from KePRO is required.
  • Proof of exhausted Medicare days must be
    submitted with service authorization request.

164
Medicare Exhaust Days
  • All days must be billed.
  • Initial stay less than 120 days, bill type 0111.
  • First 120 days bill type 0112 next 120 days
    bill type 0113 continue bill type 0113 for any
    additional 120 day periods.
  • Final bill type 0114.

165
Medicare Exhaust Days
  • Providers should list the amount Medicare paid on
    the 0112 bill type (less than 120 days list
    payment on 0111 bill type).
  • Medicare payment should be listed in Block 39a
    and use COB code 83 (billed and paid).

166
Medicare Exhaust Days
  • DO NOT WRITE the word CROSSOVER in Block 30
    (Medicare is exhausted and the days billed to
    Medicaid were not paid by Medicare)
  • Block 80- providers MUST put write a statement
    MEDICARE DAYS EXHAUSTED and attach something
    showing Medicare are exhausted (Medicare EOB).

167
Medicare Exhaust Days
  • If Medicaid has considered a crossover claim for
    deductible and coinsurance on days Medicare paid
    or any Part B charges-
  • If the provider keeps all charges on the claim
    submitted for Medicare Exhaust days, all payments
    must be listed.
  • If the provider deletes Part B charges, do not
    list any Part B payment amounts.

168
Special Note
  • If the Medicaid member does not have Part A
    coverage, the COB code should be 82 (No Other
    Coverage).

169
THANK YOU
  • Department of Medical
  • Assistance Services

www.dmas.virginia.gov
About PowerShow.com