Department of Medical Assistance Services Department of Education Medicaid Eligibility Verification Options and Billing October 6, 2009 www.dmas.virginia.gov
Department of Medical Assistance Services
Department of EducationMedicaid Eligibility Verification Options and Billing
October 6, 2009www.dmas.virginia.gov
As a Participating ProviderYou must
• Accept as payment in full, the amount paid by Medicaid
• Determine the patient's identity
• Verify the patient's age
• Verify the patient's eligibility
• Maintain records for minimum 5 years
DOB: 05/09/1994 F CARD# 00001
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
COMMONWEALTH OF VIRGINIA
V I RG I N I A J. R E C I P I E N T
9 9 9 9 9 9 9 9 9 9 9 9
002286
Medicaid Verification Options
• MediCall • ARS- Web-Based Medicaid Eligibility
MediCall/ARS- Information Available
• Medicaid client eligibility/benefit verification• Service limit information• Claim status• Prior authorization• Provider check log• Primary Payer Information• Medallion Participation• Managed Care Organization Assignment
MediCall
800-884-9730800-772-9996804-965-9732804-965-9733
Automated Response System (ARS)
• Web-based eligibility verification option– Free of Charge– Information received in “real
time”– Secure– Fully HIPAA compliant
Automated Response System- Registration
• Registration
virginia.fhsc.com• Questions concerning registration
process
Web Support Helpline 800-241-8726
ARS User Guide
• Located on the DMAS web-site under Provider Services section
• General information on ARS eligibility verification
• Instructions on the using the system• “FAQ”(frequently asked questions) section
Provider Call Center
Claims, covered services, billing inquiries:
800-552-8627
804-786-62738:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)
Provider Enrollment
New provider numbers or change of address:
First Health – PEUP. O. Box 26803Richmond, VA 23261888-829-5373804-270-5105804-270-7027 - Fax
Electronic Billing
Electronic Claims Coordinator
Mailing Address
First Health Services CorporationVirginia Operations
Electronic Claims Coordinator4300 Cox Road
Glen Allen, VA 23060
E-mail: [email protected]
Phone: (800) 924-6741
Fax: (804) 273-6797
Billing on the CMS-1500
MAIL CMS-1500 FORMS TO:
Department of Medical Assistance Services
PractitionerP. O. Box 27444
Richmond, VA 23261
TIMELY FILING• ALL CLAIMS MUST BE SUBMITTED AND
PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS– Retroactive/Delayed Eligibility– Denied Claims
• Submit claims with documentation attached explaining the reason for delayed submission.
CMS-1500 CLAIM FORM
Use ONLY the ORIGINAL RED & WHITEWHITE
Invoice
Photocopies are not Acceptable
Computer generated claims must match NUBC uniform standards
MEDICAID
(Medicaid #)
Locator 1: Medicaid
CHAMPUS
(Sponsor's SSN)
1. MEDICARE
(Medicare #)
MEDICAID CLAIM
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
TRICARE
1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
Locator 1a: Recipient ID Number
(Be sure to include all 12 digits)
123456789014
Locator 2: Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle Initial)
Smith, Sam5. PATIENT'S ADDRESS (No., Street)
Locator 10: Accident-Related
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
YES NO
PLACE (State)
YES
YES
NO
NO
You MUST check YES or NO for a, b & c
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
3441
Locator 21: Diagnosis Codes
May enter up to 4 codes
Omit decimals
2963
Locators 24A thru 24J
• These blocks have been divided into open areas and a shaded red line area
• The shaded area is ONLY for supplemental information
24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Locator 24A: Dates of Service
06 30 08 06 30 08
07 01 08 07 07 08
1
2
Both FROM and TO datesmust be completed
Dates must be within same calendar month
B.Place
ofService
Locator 24B: Place of Service
11
11-Office location
12 – Patients Home
Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare
Note: Type of Serviceis no longer required
Emergency Indicator-24C
• 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
C.
EMG
Locator 24C: EMG
Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency
Y
D.
Locator 24D: Procedure Codes
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
S9129
90806
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
34431
Locator 24E: Diagnosis Code
E.
DIAGNOSISPOINTER
1
2963
1,2
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.
F.
$ CHARGES
Locator 24 F: Charges
Enter the usualand customary charges
G.DAYS
ORUNITS
Locator 24G: Days or Units
3
Enter the number of times or hours the procedure, service, or item was provided during the service period
H.
Locator 24H: EPSDT/Family Plan
1
EPSDTFamilyPlan
1-EPSDT2-Family Planning Service
Rendering Provider ID #Locator-24I-J
• The open area of 24J will contain the NPI of the provider rendering the service
Locator 24I: ID. Qual.
& 24J: Rendering Provider ID #I.
ID.QUAL
J.RENDERING
PROVIDER ID. #
NPI 12345647890
26. PATIENT ACCOUNT NUMBER
Locator 26: Patient’s Account Number
(Optional)
12345678918765
Can not exceed 17 alphanumeric digits
Total ChargeLocator 28
• DMAS now requires this locator to be completed
• Enter the total charges for the services in 24F lines 1-6
28. TOTAL CHARGE
Locator 28: Total Charges
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverseapply to this bill and are made a part thereof.)
SIGNED DATE
Locator 31: Signature & Date
If there is a signature waiveron file, you may stamp, print,
or computer-generate the signature
Service Facility Location InformationLocator 32
• Enter information for the location where services were rendered
– First line-Name– Second line-Address– Third line-City, State, 9 digit zip code
• 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
Service Facility Location InformationLocator 32a-b
• Enter the 10 digit NPI number of the service location in 32a
Locator 32: Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a. b.NPI1234567890
Billing Provider Info & PH #-Locator 33
• Enter the information to identify the provider that is requesting to be paid– First line-Name– Second line-Address– 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
Service Facility Location InformationLocator 33a-b
• Enter the 10 digit NPI number of the service location in 33a
Locator 33: Billing Provider Info & PH #
33. BILLING PROVIDER INFO & PH #
a. b.NPI1234567890
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
Locator 22: Adjustments and Voids
1032 xxxxxxxxxxxxxxxx
Adjustment or
Resubmission Code
From originalremittanceVoid
Chap. V, Medicaid Physician’s Manual has code list.
THANK YOUDepartment of Medical
Assistance Serviceswww.dmas.virginia.gov