CMS-1500 08 -05 Billing Guidelines 04 25 07 Department of

CMS-1500 (08 -05) Billing Guidelines 04/25/07 Department of Medical Assistance Services February 2010 www. dmas. virginia. gov 1

This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Physicians Manual. This training contains only highlights of this manual and is not meant to substitute for or take the place of the Physicians. Manual. Providers are responsible for reviewing and adhering to the Physicians Manual requirements. 2

Objectives To familiarize the providers with the billing guidelines of the CMS-1500 claim form. ¢ To give the providers clear instructions on the requirements of DMAS for the completion of the CMS-1500 claim form. ¢ 3

Participating Providers Must ¢ Determine the patient’s identity. ¢ Verify the patient’s age. ¢ Verify the patient’s eligibility. ¢ Accept, as payment in full, the amount paid by Virginia Medicaid. ¢ Bill any and all other third party carriers. 4

COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 002286 999999 V I RG I N I A J. R E C I P I E N T DOB: 05/09/1994 F CARD# 00001 5

Medi. Call/Automated Response System (ARS) ¢ Available 24 hours a day, 7 days a week ¢ Medicaid Eligibility Verification ¢ Claims Status ¢ Patient Pay Information ¢ Prior Authorization Information ¢ Primary Payer Information ¢ Medallion Participation ¢ Managed Care Organization Assignment 6

Medi. Call 800 -884 -9730 800 -772 -9996 804 -965 -9732 804 -965 -9733 7

Automated Response System (ARS) ¢ Web-based eligibility verification option l Free of Charge. l Information received in “real time”. l Secure l Fully HIPAA compliant 8

ARS Registration Process https: //uac. fhsc. com/uac/pages/unsecured/common/ho me. jsf l Select the ARS tab on FHSC ARS Home Page l Choose “User Administration” l Follow the on-screen instructions for help with registration, this is a 3 -step process to request, register and activate a new account l Answer the initial ‘Who are you? ’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’ 9

ARS – Users ¢ARS User’s Guide http: //www. dmas. virginia. gov/prclaims_billing. htm ¢Web Support Helpline 800 -241 -8726 10

Important Contacts ¢ Provider Call Center ¢ Provider Enrollment ¢ Electronic Claims Coordinator 11

Provider Helpline Claims, covered services, billing inquiries: 800 -552 -8627 804 -786 -6273 8: 30 am – 4: 30 pm (Monday-Friday) 11: 00 am – 4: 30 pm (Wednesday) 12

Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888 -829 -5373 804 -270 -5105 804 -270 -7027 - Fax 13

Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services Corporation Virginia Operations Electronic Claims Coordinator 4300 Cox Road Glen Allen, VA 23060 E-mail: edivmap@fhsc. com Phone: (800) 924 -6741 Fax: (804) 273 -6797 14

Claim Attachment Form DMAS-3 ¢ ¢ ¢ The DMAS-3 form is to be used by Electronic Data Interchange (EDI) billers only to submit a non-electronic attachment to an electronic claim. See Chap. V Exhibits pg. 5 Attachment Control Number (ACN) should be indicated on the electronic claim submitted. The ACN number is the combined information from: l Patient Account Number l Date of Service l Sequence Number 15

Claim Attachment Form DMAS 3 – Sample ACN# ¢ Patient Account Number l ¢ Date of Service l ¢ 09/11/2009 Sequence Number l ¢ 123456789 12345 ACN number listed on form will bel 1234567890911200912345 16

Billing on the CMS-1500 17 7

MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261 18

TIMELY FILING ¢ ¢ ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive/Delayed Eligibility l Denied Claims l ¢ NO EXCEPTIONS Accident Cases l Other Primary Insurance l 19

TIMELY FILING ¢ Submit claims with documentation attached to the back of the claim form, explaining the reason for delayed submission 20

Block 1 The locator will now be used to indicate if the claim is Medicaid, TDO, or ECO. ¢ Enter an ‘X’ in the MEDICAID box for the Medicaid Program ¢ Enter an ‘X’ in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO) ¢ 21

Block 1 1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor's SSN) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) MEDICAID CLAIM 22 13

Block 1 CHAMPVA GROUP HEALTH PLAN FECA BKL LUNG (Member ID#) (SSN or ID) (SSN) OTHER (ID) TDO or ECO CLAIM 23 14

Block 1 a: Recipient ID Number 1 a. INSURED'S I. D. NUMBER (FOR PROGRAM IN ITEM 1) 123456789014 (Be sure to include all 12 digits) 24 15

Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 5. PATIENT'S ADDRESS (No. , Street) 25 16

Is Patient’s Condition Related To? Block-10 ¢ If the condition is related to an auto accident, and you have this information, place the postal code (i. e. VA, TN, WV) of the state in which the accident occurred. 26

Block 10: Accident-Related 10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) YES b. AUTO ACCIDENT? YES NO PLACE (State) NO WV c. OTHER ACCIDENT? YES NO You MUST check YES or NO for a, b & c 27 18

Insurance Plan Name or Program Name Block-11 c ¢ ¢ Providers that are billing for non-Medicaid Managed Care Organizations (MCO) co-pays please insert ‘HMO COPAY’ The amount billed to Medicaid in 24 F (Charges) must represent only the enrollees co-payment amount for the HMO, and the Explanation of Benefits (EOB) must be attached. Use the CPT or HCPCS procedure code that was billed as the primary procedure to the HMO. This does not apply to enrollees in a Medicaid HMO, e. g. , Medallion II. 28

Block 11 c - Insurance Plan Name or Program Name c. INSURANCE PLAN NAME OR PROGRAM NAME HMO COPAY 29 21

CHANGE – Is There Another Health Benefit Plan? Block-11 d Providers should always check ‘YES’ if there is verification of Third Party Liability ¢ If there is no other coverage check no or leave blank ¢ 30

Block 11 d - Is There Another Health Benefit Plan? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, return to and complete item 9 a-d. DMAS does not require items 9 a-d to be completed. 31 23

Blocks 17 and 17 b- Conditional 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17 - Name of the Recipient’s PCP 17 b- PCP’s NPI 17 a. 17 b. NPI 1234567890 32 58

Block 19 - Conditional Use 19. RESERVED FOR LOCAL USE Clinical Laboratory Improvement Amendment (CLIA) Number of the physician office laboratory (POL) performing the service. 33 28

Block 21: Diagnosis Codes 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 3441 2. 2963 3. 4. May enter up to 4 codes Omit decimals 34 29

Prior Authorization Number Block-23 If service requires prior authorization, enter the eleven digit PA number assigned by Ke. PRO ¢ Enter the number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO. ¢ 35

Block 23: Prior Authorization Number - Conditional 23. PRIOR AUTHORIZATION NUMBER 36 31

Blocks 24 A thru 24 J 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 ¢ 37

TPL Information Block 24 A-shaded red area ¢ ¢ Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier No spaces between the qualifier and dollars and no $ symbol used Decimal between dollars and cents is required to read paid amount correctly Must be left justified 38

Block 24 A: Dates of Service 24. amount paid by primary carrier $27. 08 A. DATE(S) OF SERVICE From MM DD YY To MM DD YY TPL 27. 08 1 12 01 09 2 12 01 09 12 31 09 TPL Information 39 68

TPL Billing Scenarios ¢ No other insurance l l ¢ Check ‘NO’ in Locator 11 d or leave blank Do not document any information in the shaded red area of 24 A Primary Carrier pays covered service l l l Provider receives Explanation of Benefits (EOB) Check ‘YES’ in Locator 11 d Document primary payment information in the shaded red area of 24 A on claim form 40

TPL Billing Scenarios ¢ Primary carrier does not pay l l l Payment applied to deductible/claim denied Provider receives EOB Check ‘YES’ in Locator 11 d 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 24 A 41

TPL Billing Scenarios ¢ Primary carrier does not pay l l Service not covered Check ‘YES’ in Locator 11 d 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 24 A 42

TPL Billing Scenarios ¢ Primary carrier does not pay l l Provider not enrolled with carrier Check ‘YES’ in Locator 11 d Attach letter documenting the provider is not enrolled with the primary carrier Do not document any information in the shaded red area of 24 A 43

TPL Billing Scenarios ¢ Primary carrier does not pay l l Policy is no longer active/coverage terminated Check ‘YES’ in Locator 11 d Attach EOB verifying that the policy is not active or, attach letter verifying the policy is not active Do not document any information in the shaded red area of 24 A 44

NDC Information Block-24 A Qualifier ‘N 4’ is used followed by the National Drug Code (NDC) whenever a HCPCS J-code is submitted in 24 D. ¢ No spaces between the qualifier and the NDC number ¢ Must be left justified ¢ 45

Block 24 A: Dates of Service 24. A. DATE(S) OF SERVICE From MM DD YY To MM DD YY N 400026064871 1 12 01 09 2 12 01 09 12 16 09 NDC Information 46 37

Block 24 A: Dates of Service 24. If both NDC and TPL apply to a single procedure both must be placed on the same line, it does not matter which 1 comes first 2 A. DATE(S) OF SERVICE From MM DD YY To MM DD YY TPL 27. 08 N 400026064871 12 01 09 12 31 09 TPL and NDC information 47 31

Block 24 A: Dates of Service 24. A. DATE(S) OF SERVICE From MM DD YY To MM DD YY 1 12 01 09 2 12 01 09 12 16 09 Both FROM and TO dates must be completed 48 36 Dates must be within same calendar month

Block 24 B: Place of Service B. Place of Service Note: Type of Service is no longer required 11 -Office location 21 - Inpatient 11 Medicaid accepts the same 2 digit CMS Place of Service codes as 49 37 Medicare.

Emergency Indicator Block 24 C 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 ¢ 50

Block 24 C: EMG C. EMG Y Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an 51 39 emergency

Block 24 D: Procedure Codes D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS 99254 MODIFIER 22 52 40

J Code Mandate: Block 24 D ¢ ¢ When billing a J Code the red shaded area must have the unit of measurement (UOM) qualifier. Valid qualifiers: F 2: international unit l ML: milliliter l GR: gram l UN: unit l 53

J-Code Mandate: Block 24 D Enter the actual metric decimal quantity (units) administered to the patient ¢ If reporting a fraction of a unit, use the decimal point ¢ The maximum number of bytes allowed for the quantity is 13, including the decimal point. ¢ 54

Block 24 D: Procedure Codes D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER GR 0. 0004 J 0881 constitutes 1 mcg of a drug, the quantity given 55 was 400 mcg which converts to 0. 0004 grams

Block 24 E: Diagnosis Code 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 34431 3. 2963 4. E. DIAGNOSIS POINTER Enter the entry 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 1, 2 56 41

Block 24 F: Charges F. $ CHARGES Enter the usual and customary charges 57 42

Block 24 G: Days or Units G. DAYS OR UNITS 1 31 Enter the number of times or hours the procedure, service, or item was provided during the service period. 58 43

Block 24 H: EPSDT/Family Plan H. EPSDT Family Plan 1 1 -EPSDT 2 -Family Planning Service 59 44

CHANGE – ID. QUAL Block-24 I Qualifier ‘ 1 D’ 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 NPI is used and only if necessary to adjudicate the claim. ¢ 60

CHANGE – Rendering Provider ID # Block-24 J The shaded red area will contain the current Atypical Provider Identifier (API) or; ¢ The open area will contain the NPI of the provider rendering the service ¢ 61

Block 24 I: ID. Qual. & 24 J: Rendering Provider ID # I. ID. QUAL ID J. RENDERING PROVIDER ID. # 9876543210 NPI 62 48

Block 24 I: ID. Qual. & 24 J: Rendering Provider ID # I. ID. QUAL ZZ NPI J. RENDERING PROVIDER ID. # Taxonomy (if needed) 12345647890 63 49

Block 26: Patient’s Account Number (Optional) 26. PATIENT ACCOUNT NUMBER 12345678918765 Can not exceed 17 alphanumeric digits 64 50

Total Charge Block 28 DMAS now requires this locator to be completed ¢ Enter the total charges for the services in 24 F lines 1 -6. ¢ 65

Block 28: Total Charges 28. TOTAL CHARGE $ 66 52

Amount Paid (Personal/Waiver Services ONLY) Block 29 Patient pay amount is taken from services billed on 24 A – line 1 ¢ If multiple services are provided on the same date of service another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service ¢ 67

Block 29: Amount Paid (Personal and Waiver Services ONLY) 28. AMOUNT PAID $ Enter the Patient Pay amount as indicated on the DMAS-122 68 54

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. 69 55

Service Facility Location Information Block-32 ¢ ¢ ¢ Enter information for the location where services were rendered l First line-Name l Second line-Address l Third line-City, State, 9 digit zip code Physicians with multiple offices-the zip code must reflect the office location where services were rendered No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code 70

Service Facility Location Information Block-32 a-b Enter the 10 digit NPI number of the service provider in 32 a OR; ¢ Enter ‘ 1 D’ qualifier with the API in 32 b ¢ 71

Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a. NPI b. 72 58

Billing Provider Info & PH #Block-33 ¢ ¢ ¢ Enter the information to identify the provider that is requesting to be paid l First line-Name l Second line-Address l 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 73

Billing Provider Info & PH #Block-33 a-b Enter the 10 digit NPI number of the service location in 33 a OR; ¢ Enter ‘ 1 D’ qualifier with the API in 33 b ¢ 74

Block 33: Billing Provider Info & PH # 33. BILLING PROVIDER INFO & PH # a. NPI ( ) b. 75 61

Block 22: Adjustments and Voids 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1032 Adjustment or Void Resubmission Code xxxxxxxx From original remittance Chap. V, Medicaid Physician’s Manual has code list. 76 64

THANK YOU Department of Medical Assistance Services www. dmas. virginia. gov 77