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

Resources • New Providers Refer to Michigan Medicaid website, Provider Enrollment MI Eligibility Verification Resources • New Providers Refer to Michigan Medicaid website, Provider Enrollment MI Eligibility Verification System 1 -888 -696 -3510 MI Eligibility Verification System 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 & Refer to Michigan Medicaid website, Medicaid Provider Manual, REIMBURSEMENT FOR PROFESSIONALS, section 3. Website – www. michigan. gov/mdch >> PROVIDERS >> INFORMATION FOR MEDICAID PROVIDERS • Medicaid Provider • Explanation codes, Reason & Remark codes • Provider Specific Information (Fee-Screens) Provider Support Phone: 800 -292 -2550 Email: Provider. [email protected] gov

PROVIDERS PROVIDERS

Information for Medicaid Providers Information for Medicaid Providers

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Provider Enrollment: When to contact Enrollment • New Providers • Refer to Michigan Medicaid Provider Enrollment: When to contact 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 Provider. [email protected] gov MEDICAL SERVICES ADMINISTRATION MICHIGAN DEPARTMENT OF COMMUNITY HEALTH PO BOX 30238 LANSING, MI 48909 Phone: 517 -335 -5492 Fax: 517 -241 -8233

National Provider Identifier (NPI) Providers may now apply for their NPI through CMS Must 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: n n n https: //nppes. cms. hhs. gov 1 -800 -465 -3203 (NPI Toll-Free) [email protected] com

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

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

Eligibility Verification • Scope/Coverage • Level of Care (LOC) Third Party Liability (TPL) Scp/Cvrg 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.

Eligibility Verification Common Scope Code n n 1 - Medicaid 2 - Medicaid 3 Eligibility Verification Common Scope Code n n 1 - Medicaid 2 - Medicaid 3 - Adult Benefit Waiver 4 - Refugees and Repatriates • Scope/Coverage n n 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 n n n 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

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

Third Party Liability (TPL) To remove or update other insurance information from Third Party Third Party Liability (TPL) To remove or update other insurance information from Third Party Liability (TPL) file: Phone 800 -292 -2550 (option 4) n Fax 517 -346 -9817 n Email [email protected] gov n

Medicare. Lewis Cass Building Phone: 517 -335 -5488 “Buy-In” Unit 517 -335 -0478 (MDCH) Medicare. Lewis Cass Building Phone: 517 -335 -5488 “Buy-In” Unit 517 -335 -0478 (MDCH) 320 South. MIWalnut Fax: Buy. In. [email protected] gov Lansing, 48913 Email 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.

Medicaid Billing Limitations 1 2 month limitation from Date of Service (DOS) –Inpatient admission- Medicaid Billing Limitations 1 2 month limitation from Date of Service (DOS) –Inpatient admission- 12 month from discharge date C ontinuous Activity Within 120 days from last rejection D ocumentation is needed for: –Claim replacements when Previously billed with incorrect: P rovider ID Number B eneficiary ID Number

Claim Submission PAPER n n No confirmation until CRN appears on RA 30 -60 Claim Submission PAPER n n 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 n n 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

Electronic Billing Shopping for an Electronic Billing Agent Authorization Form 835/277 U Request Form Electronic Billing Shopping for an Electronic Billing Agent Authorization Form 835/277 U Request Form Billing Agent’s responsibilities Billing And Reimbursement Chapters, Medicaid Provider Manual Automated. [email protected] gov

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

Crossover Claims (Special Services) Medicaid is accepting crossover claims from WPS and Admina. Star Crossover Claims (Special Services) Medicaid is accepting crossover claims from WPS and Admina. Star w Bulletin All Provider 04 -05, issued June 1, 2004 w Bulletin MSA 05 -02, issued January 1, 2005 Provider ID must be included in Loop 2010 AA n Example = REF*1 D*108888888~ Medicaid will soon allow the Provider ID in Loop 2310 B, Rendering Billing Provider ID FAQ’s posted at Provider Updates webpage

Crossover Claims (Special Services) Troubleshooting Crossover n Medicare EOB says that the “Claim was Crossover Claims (Special Services) Troubleshooting Crossover n Medicare EOB says that the “Claim was forwarded to MDCH for Reimbursement” but claim never appears on Medicaid Remittance Advice: w This means that your Medicaid Provider Type and ID were not in the proper provider identifying field within your electronic claim n n n 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

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

Remittance Advice Checks and Remittance Advice (EOB) mailed separately MSA Remittance Advice Payment Information 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 “ 39 S 391”= MDCH/Medicaid One RA issued to each Tax ID

Replacement Examples of when a claim may need to be replaced: Ø Ø To Replacement Examples of when a claim may need to be replaced: Ø Ø 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).

Replacement To replace a previously paid claim, Ø UB-92 - indicate 7 (xx 7) Replacement To replace a previously paid claim, Ø UB-92 - indicate 7 (xx 7) as the third digit in the Type of Bill Form locator frequency. Ø enter the 10 -digit Claim Reference Number (CRN) of the last approved claim being replaced Ø 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 Ø

Replacement To replace a previously paid claim, Ø HCFA 1500 - Report code 7 Replacement To replace a previously paid claim, Ø HCFA 1500 - Report code 7 in the left side of Item 22 Ø Report the ten-digit Claim Reference Number (CRN) of the previously paid claim in the right side of Item 22 Ø 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 Ø

Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number, Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number, providers must void/cancel the claim. UB-92 Ø indicate an 8 in the Type of Bill (xx 8) as the third digit frequency. Ø enter the 10 -digit CRN of the last approved claim or adjustment being cancelled and Ø enter in Remarks Section the reason for the void/cancel. Ø A new claim may be submitted immediately using the correct provider or beneficiary ID number. Ø A void/cancel claim must be completed exactly as the original claim. Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR INSTITUTIONAL, section 3. 2

Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number, Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number, providers must void/cancel the claim. HCFA 1500 Ø Report code 8 in the left side of Item 22 Ø Report the ten-digit Claim Reference Number (CRN) of the previously paid claim in the right side of Item 22 Ø complete one service line and enter zero dollars Ø (000) in all money fields. Ø State reason in the Remarks section Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR PROFESSIONALS, section 4. 2

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

Appeals 1. Claim is submitted to MDCH (PO Box 30043) 2. Claim is denied Appeals 1. Claim is submitted to MDCH (PO Box 30043) 2. Claim is denied 3. If necessary, correct claim information indicated as insufficient/incorrect on RA and resubmit 4. If corrected claim is rejected contact Provider Support Hotline for counsel (1 -800 -292 -2550)

Appeals 5. Hotline advice is followed, but claim is still processed improperly 6. Send Appeals 5. Hotline advice is followed, but claim is still processed improperly 6. Send paper claim with letter explaining situation/history and request for action to Special Payments’ Research and Analysis (PO Box 30731) 7. Research and Analysis either denies request or processes but system still rejects

Appeals 8. If all requirements have been satisfied and all instruction followed but claim Appeals 8. 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