Department of Medical Assistance Services

1. 1 Department of Medical Assistance Services Eligibility Verification Options and CMS-1500 Billing Guidelines For Intellectual Disabilities (Mental Retardation) Waiver

2. 2

3. 3 Agenda

4. 4 As a Participating Provider You 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.

5. 5 Important Contacts MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Provider Enrollment Electronic Claims Coordinator

6. 6 The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

7. 7 MediCall/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

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

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

10. 10 ARS Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Select the ARS tab on FHSC ARS Home Page Choose “User Administration” Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’ Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process. Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process.

11. 11 ARS –Users ARS User’s Guide http://www.dmas.virginia.gov/prclaims_billing.htm Web Support Helpline- 800-241-8726 You are required to enroll and begin using the new Web Site by May 23, 2007. You are required to enroll and begin using the new Web Site by May 23, 2007.

12. 12 Patient Pay Information Effective March 1, 2009, the local department of social services (LDSS) will enter data regarding the individual’s patient pay obligation into the Medicaid Management Information System (MMIS) at the time action is taken on a case: Result of application for long term care services Time of the annual redetermination of eligibility Change in the enrollee’s situation is reported

13. 13 Patient Pay Information It is anticipated that patient pay information for all long term care enrollees will be in the MMIS by December 2009. MMIS patient pay information is available via MediCall and ARS. Providers responsible for collecting the patient pay amount should review the information prior to billing each month.

15. 15 Provider Helpline Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

16. 16 Duplicate Remittance Advice Effective July 1, 2009, DMAS will process and send requests for duplicate provider remittance advices via secure email. A processing fee will be applied to all paper requests for duplicate remittance advices, effective July 1, 2009. The requests should be directed to the Provider Helpline.

17. 17 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

18. 18 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

19. 19 Excluded Individuals/Entities The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and all Federal healthcare programs HHS-OIG excluded individuals or entities are prohibited from being reimbursed by DMAS for any items or services that they have furnished, ordered or prescribed

20. 20 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 Excluded Individuals/Entities

21. 21 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 Excluded Individuals/Entities

22. 22 How to Ensure Program Integrity Screen all employees and contractors to determine whether they have been excluded Search HS-OIG List of Excluded Individuals/Entities (LEIE) website monthly Immediately report to DMAS any exclusion information discovered There are steps that can be taken to ensure compliance with these Federal regulations and Virginia Medicaid policy First, screen all new and existing employees and contractors to ascertain whether they have been excluded Next-Once this information has been determined it is advised that you search this database monthly to validate continued eligibility. And lastly If any exclusion information is discovered this should immediately be reported to DMAS.There are steps that can be taken to ensure compliance with these Federal regulations and Virginia Medicaid policy First, screen all new and existing employees and contractors to ascertain whether they have been excluded Next-Once this information has been determined it is advised that you search this database monthly to validate continued eligibility. And lastly If any exclusion information is discovered this should immediately be reported to DMAS.

23. 23 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 The information pertaining to these discoveries should be sent in writing and should include the indiv. or bus. Name, and the provider’s identification number (if applicable) also with what action , if any has been taken to date. The information should be sent to the address provided. The information pertaining to these discoveries should be sent in writing and should include the indiv. or bus. Name, and the provider’s identification number (if applicable) also with what action , if any has been taken to date. The information should be sent to the address provided.

24. 24 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 The Dept of Health and Human Services’ Office of the Inspector General maintais the LEIE which is the database which provides the information on excluded parties. We have provided the link directly into this site. The Dept of Health and Human Services’ Office of the Inspector General maintais the LEIE which is the database which provides the information on excluded parties. We have provided the link directly into this site.

25. 25 Billing on the CMS-1500

26. 26 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

27. 27 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

28. 28 TIMELY FILING Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

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34. d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

36. 36 ICD-9 Diagnosis Codes All claims submitted to DMAS will require a current ICD-9 diagnosis code for payment processing. Some 3-digit diagnosis codes are valid 317 (mild mental retardation) is a valid 3-digit DX code 319 (mental retardation) is a valid 3-digit DX code

37. 37 ICD-9 Diagnosis Codes If the current year ICD-9 book indicates the diagnosis code requires 4-5 digits, the code listed on the claim submission must include 4-5 digits 318 (other specified mental retardation) requires an additional 4th digit to be a valid diagnosis code: 3180, 3181 or 3182 Claims submitted without a valid diagnosis code will be denied

39. 39 Blocks 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 Instructions will be given on when the use of the shaded area is required for claims processing

40. 40 Block 24A – Shaded Red Area:TPL Information Billing Scenarios No other insurance Check ‘NO’ in Locator 11d or leave blank Primary Carrier pays covered service Provider receives Explanation of Benefits (EOB) Check ‘YES’ in Locator 11d Document primary payment information in the shaded red area of 24A on claim form DMAS does not require an attached copy of the EOB when provider receives payment from primary carrier

42. 42 TPL Billing Scenarios Primary carrier does not pay Payment applied to deductible/claim denied Provider receives EOB Check ‘YES’ in Locator 11d 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 24A

43. 43 TPL Billing Scenarios Primary carrier does not pay Service not covered Check ‘YES’ in Locator 11d 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 24A

44. 44 TPL Billing Scenarios Primary carrier does not pay Carrier will not enroll provider Check ‘YES’ in Locator 11d Attach letter documenting the primary carrier will not enroll the provider Do not document any information in the shaded red area of 24A

45. 45 TPL Billing Scenarios Primary carrier does not pay Policy is no longer active/coverage terminated Check ‘YES’ in Locator 11d Attach EOB verifying that the policy is not active or, attach letter verifying the policy is not active Advise patient/guardian to contact Local DSS with policy termination documentation/information

47. 47 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

53. 53  ID.QUAL Block-24I Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (API). OR- Qualifier ‘ZZ’ is to be used to indicate the taxonomy code - only when the National Provider Identifier is used and only if necessary to adjudicate the claim.

54. 54 DMAS Service Types May Require A Taxonomy Code on Claims

55. 55 Rendering Provider ID # Block-24J The shaded red area will contain the API OR The open area will contain the NPI of the provider rendering the service

60. 60 Block 29: Amount Paid Patient pay amount is taken from services billed in Block 24A – line 1 If multiple services are provided on the same date of service, another form must be completed. Only one line per claim form can be submitted if patient pay is to be considered in the processing of this service.

63. 63 Block 32Service Facility Location Information Enter information for the location where services were rendered 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 code

64. 64 Block 32, cont’d.Service Facility Location Information Providers with multiple offices/locations - the zip code must reflect the office/ location where services were rendered Enter the 10 digit NPI number of the service location in 32a. OR Enter ‘1D’ qualifier with the API in 32b

66. 66 Block 33 Billing Provider Info & PH #- 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

67. 67 Billing Provider Info & PH #-Block-33a-b Enter the 10 digit NPI number of the service location in 33a. OR Enter ‘1D’ qualifier with the API in 33b

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