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Medicaid Eligibility Verification Options

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Title: Medicaid Eligibility Verification Options


1
Medicaid Eligibility Verification Options
Residential Treatment Facility CMS-1450
(UB-04) Billing Requirements September
October 2010
Department of Medical Assistance Services
  • http//dmasva.dmas.virginia.gov/

2
This presentation is to facilitate training of
the subject matter in the Virginia Medicaid
Psychiatric Services manual. This training
contains only highlights of the manuals 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.
3
Agenda
1. Medicaid Eligibility Verification Options
2. Service Authorizations
3. Timely Filing
4. CMS-1450 (UB-04) Billing Requirements
4
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.

5
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. MEMBER
DOB 05/09/1994 F
CARD 00001
6
Important Contacts
  • MediCall
  • ARS- Web-Based Medicaid Eligibility
  • Provider Call Center
  • Provider Enrollment
  • Electronic Claims Coordinator

7
MediCall/ Automated Response System (ARS)
  • Available 24 hours a day, 7 days a week
  • Medicaid Eligibility Verification
  • Claims Status
  • Service Limits
  • Service Authorization Information
  • Primary Payer Information
  • Medallion Participation
  • Managed Care Organization Assignment

8
MediCall
  • 800-884-9730
  • 800-772-9996
  • 804-965-9732
  • 804-965-9733

9
Automated Response System (ARS)
  • Web-based eligibility verification option
  • Free of Charge.
  • Information received in real time.
  • Secure
  • Fully HIPAA compliant

10
Registration Process
  • First Time Users
  • To establish an user ID and password go to
  • www.virginiamedicaid.dmas.virginia.gov
  • By registering you are acknowledging yourself as
    a staff member with administrative rights for the
    organization

11
Registration Process
  • Established Users- Delegated Administrators
  • Received a letter containing their NPI and
    instructions on accessing the Web Portal
  • Must have accessed the Web Portal and changed
    their temporary password
  • Capable of adding or deleting ARS users

12
ACS Web Registration Support Call Center
  • Questions regarding new user registration,
    existing user access letter, or temporary
    passwords
  • 1-866-352-0496
  • 8 am 5 pm Monday thru Friday
  • No holidays
  • Virginia.Websupport_at_acs-inc.com

13
Provider Call Center
  • Claims, covered services, billing inquiries
  • 800-552-8627
  • 804-786-6273
  • 830am 430pm (Monday-Friday)
  • 1100am 430pm (Wednesday)


14
Provider Enrollment
  • NPI enrollment, EFT sign-up, update provider
    email phone contact or change of address
  • Provider Enrollment Unit
  • P. O. Box 26803
  • Richmond, VA 23261
  • 888-829-5373
  • 804-270-5105
  • 804-270-7027 - Fax

15
ARS Prior Authorization Status Codes/Descriptions
Status Code Description
A Accepted
AJ Approved and rejected
AM Approved and modified
AR Approved/Received (New Data Received)
C Cancelled
D Denied
DR Denied/Received (Supporting Document Received)
15
16
ARS Prior Authorization Status Codes/Descriptions
Status Code Description
J Rejected
P Pend
PR Pend/Received (Supporting Document Received)
R Received
RJ Received/Rejected
16
17
Service Authorization Log
Service Authorization ID

Header Status 1234567890

Rejected

Service Line Item Information
Procedure Code
Begin Date
End Date
Authorized Units
Authorized Amount
Units Used
Remaining Units
Used Amount
90806 09/12/2010 12/12/2010 15

15
Please review the status of your service
authorization. Just because an authorization
number was assigned to your request, that does
not mean it was approved. All requests are
assigned a Service Authorization ID.
17
18
Electronic Billing
  • Electronic Claims Coordinator
  • Phone (866) 352-0766
  • Fax (888) 335-8460
  • E-mail virginia.edisupport_at_acs-inc.com

19
MAIL CMS-1450 (UB-04) FORMS TO
  • Virginia Medical Assistance Program
  • P. O. Box 27443
  • Richmond, Virginia 23261

20
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

21
TIMELY FILING
  • Submit claims with documentation attached (to the
    back of claim) explaining the reason for delayed
    submission

22
Printing
  • Must be RED OCR dropout ink or the exact match
  • Computer generated form must match/line up with
    National Uniform Claim Committee standard
  • Print 100 of actual size, set page scaling to
    none
  • Set page scaling to none
  • Margins must be exact
  • DMAS will not reprocess claims denied for
    scanning issues as a result of failure to follow
    the above instructions

23
CMS-1450 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE UB-04
Invoice Photocopies are not Acceptable Computer
generated claims must match NUBC uniform standards
24
Locator 1 Providers 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.

25
Locator 1 Provider Name, Address and Phone
Number
1
Our Place Facility
121 Friendly Street
Any Town
VA
12345-6456 8049781234
25
26
Locators 3a and 3b
  • 3a Patient Control Number - Enter the patients
    unique financial account number which does not
    exceed 20 alphanumeric characters.
  • 3b Medical/Health Record - Enter the number
    assigned to the patients medical/health record
    by the provider. This number cannot exceed 24
    alphanumeric characters.

26
27
Locators 3a- Patient Control Number 3b-
Medical/Health Record Number
3a PAT. CNTL
123456789ABCDEFGH012
b. MED REC.
987654321HGFEDCBA1234567
Patient Control Number and Medical/Health Record
Number are required for all UB-04 claim
submissions.
27
28
Locator 4 Type of Bill
  • Enter the code as appropriate.
  • The Type of Bill field is four digits with a
    leading zero.
  • Claims submitted without the required four digit
    bill type will be denied.

29
Locator 4 Type of Bill
  • 0161 Original Residential Treatment Invoice
  • 0162 First Interim Residential Treatment
    Invoice
  • 0163 Subsequent Residential Treatment
    Invoice (s)
  • 0164 Final Residential Treatment Invoice
  • 0167 Adjustment Residential Treatment
    Invoice
  • 0168 Void Residential Treatment Invoice
  • Only approved claims can be adjusted or voided.

29
30
Locator 4 Type of Bill
  • 0161-
  • Use this bill type for patients who are admitted
    and discharged within the same month.
  • For established patients who leave your facility
    for admission to an acute care hospital, and
    return within the same month, two separate claims
    must be submitted.

31
Example Same Month Admit/Discharge/Re-Admit
  • First claim will be a Bill Type 0164, as the
    patient was discharged to be admitted to the
    acute care facility.
  • The second claim, billed for the patient being
    readmitted to your facility, will be a Bill Type
    0162.

32
Admit/Discharge/Re-Admit
  • Patient admitted to residential facility
    08/13/10. Patient developed pneumonia and was
    admitted to a hospital on 09/12/10. Patient
    returned to the residential facility on 09/20/10.
  • Bill Type 0164 for dates 09/01/10 09/12/10,
    with a status of 02.
  • Bill Type 0162 for dates 09/20/10 09/30/10,
    with a status code of 30.

33
Locator 4 Type of Bill
Interim Bill

33
34
Locator 6 Statement Covers Period
  • STATEMENT COVERS PERIOD
  • FROM THROUGH

083110
080110
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. Invoice billing periods cannot
overlap months.
34
35
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.
35
36
Locator 10 Patient Birthdate
10 BIRTHDATE
10011995
Enter the date of birth of the patient using
the following format - MMDDYYYY.
36
37
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
37
38
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
  • Residential Treatment Facility Original
    admission date or new date the patient is
    re-admitted to the facility.

39
Locator 12 Admission/Start of Care
ADMISSION 12 DATE
080110
39
40
Locator 13 Admission Hour
ADMISSION 13 HR
14
Enter the hour during which the patient was
admitted to the facility. Medicaid will allow a
default time for Residential Facility
patients. NOTE Military time is used as defined
by NUBC.
40
41
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
41
42
Locator 14 Priority (Type) of Visit
ADMISSION 14 TYPE
3
Enter the code indicating the priority of this
admission /visit.
42
43
Locator 15 Source of Referral/Admission
Code Description
1 Physician Referral
2 Clinic Referral
4 Transfer From Another Acute Care Facility
6 Transfer From Another Healthcare Facility
7 Emergency Room
8 Court Law Enforcement
9
Information Not Available
44
Locator 15 Source of Referral for Admission
Visit
15 SRC
6
Enter the code indicating the source of
the Referral for this admission or visit.
44
45
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
45
46
Locator 17 Patient 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
46
47
Locator 17 Patient Discharge Status
17 STAT
30
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).
47
48
Locators 18-28 Condition Codes
  • These codes are used by DMAS in the adjudication
    of claims

Code Description
39 Private Room Necessary
A1 EPSDT
NOTE Condition Code A1 is a required for all
Residential Facility Claims submitted to DMAS.
48
49
Locators 18-28 Condition Codes (Required if
Applicable)
Condition Codes 18 19 20 21 22 23 24 25
26 27 28
A1
Enter the code (s) in alphanumeric sequence Used
to identify conditions or events related to this
bill that may affect adjudication.
49
50
Locators 39-41Value Codes and Amount
  • Note DMAS will be capturing the number of
    covered or non-covered day (s) or units for
    outpatient services with these required value
    codes
  • Enter the number of covered days for inpatient
    facility.
  • Enter the number of non-covered days for
    facility.

51
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
  • 82 No Other Coverage
  • Billed and Paid (enter amount
  • paid by primary carrier)
  • 85 Billed Not Covered/No Payment

52
LOCATORS 39-41
Value Codes and Amount
  • VALUE CODES
  • CODE AMOUNT
  • VALUE CODES
  • CODE AMOUNT

41 VALUE CODES CODE AMOUNT
80 30
a
83
1529
08

b
c
d
52
53
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

54
Locator 42 Revenue Code
42 REV. CD.
1
0120
0001
2

3
4
Revenue codes are four digits, leading zero,
left justified and should be reported in
ascending numeric order.
54
55
Locator 43 Revenue Description
43 DESCRIPTION
RB-Semi-Pvt-2 Bed-General
Total Charge

Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
55
56
Locator 44 HCPCS/Rates/HIPPS
Rates Codes
44 HCPCS / RATE / HIPPS CODE
Inpatient Enter the accommodation rate.
56
57
Locator 45 Service Date (Required if
Applicable)
45 SERV. DATE
080110
57
58
Locator 46 Service Units
46 SERV. UNITS
30

Inpatient Enter total number of covered
accommodation days or ancillary units of service
where appropriate.
58
59
Locator 47 Total Charges
47 TOTAL CHARGES
46 SERV. UNITS
1755 75
TOTALS
Enter the total charge(s) for the primary payer
during the statement covers period including
both covered and non-covered charges. Note
Use code 0001 for TOTAL.
59
60
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.

61
Locator 50 Payer Name A-C
50 PAYER NAME
MEDICAID
A Primary Payer B Enter the secondary
payer identification, if
applicable. C Enter the tertiary
payer if applicable.
61
62
Locator 56 National Provider Identification
(NPI)
  • Providers must share their NPI with the DMAS
    Provider Enrollment Unit (PEU).
  • Once your NPI is on file with the PEU, providers
    will bill their NPI in this field.

63
Locator 56 NPI
56 NPI
1234567890
10 digit NPI should be listed in this field.
63
64
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.
64
65
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
66
Locator 59 Patients Relationship to Insured
52 REL. INFO
18
Enter the code indicating the relationship of
the insured to the patient.
66
67
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.
68
Locator 63 Treatment Authorization Codes
63 TREATMENT AUTHORIZATION CODES
A B
12345678910
Enter the 11 digit service authorization number
assigned by KePRO for the appropriate services
to be billed to Virginia Medicaid.
68
69
Locator 64 Document Control Number (DCN)
  • 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.
  • The ICN will be listed on the Remittance Advice
    with the original approved claim.

70
Locator 64Document Control Number (Required if
Applicable)
64 DOCUMENT CONTROL NUMBER
2010363123456701
The internal control number (ICN) assigned to the
original payment by Virginia Medicaid as part of
the claims process.
70
71
Locators 67A-Q Principal Diagnosis Code 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

72
Locator 67 A-Q POA Indicator
  • The POA indicator should be listed in the shaded
    area. Reporting codes are
  • CODE DEFINITION
  • Y YES
  • N NO
  • U No information in the record
  • W Clinically
    undetermined

73
Locator 67 Principal Diagnosis Code
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.
73
74
Locator 69 Admitting Diagnosis
  • ADMIT
  • DX

2963
Enter the diagnosis code describing the
patients diagnosis at the time of admission.
Medicaid requires the diagnosis code billed to
be a current ICD-9 code. NOTE Cross check
DSM-4 codes with ICD-9 codes. Do not use
decimals.
74
75
Locator 76 Attending Provider
76 ATTENDING
NPI 1234567890
Enter NPI for the physician who has overall
responsibility for the patients medical care and
treatment reported on this claim..
75
76
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.
76
77
Locator 81 Code-Code Field
  • DMAS previously assigned different provider
    numbers for each type of service performed.
  • Medicaid payment was then issued based on the
    type of service billed.
  • 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., Residential or Psychiatric units within
    an acute care facility).

78
Locator 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.

79
Locator 81 Code-Code Field
81CC a b c d
B3 323P00000X
Enter the provider taxonomy code for the billing
provider when the adjudication of the claim is
known to be impacted.
79
80
DMAS Services That May Require Taxonomy Codes on
Claims
Service Type/Description Taxonomy Codes
Private Mental Hospital (IP) 283Q00000X
Hospital General 282N00000X
Psychiatric Unit of Hospital 273R00000X
Psychiatric Residential Inpatient Facility 323P00000X Psychiatric Residential Treatment Facility
81
THANK YOU
  • Department of Medical Assistance Services
  • http//dmasva.dmas.virginia.gov/
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