Online Claim Entry CMS-1500

Online Claim EntryCMS-1500

Presented by: Xerox State Healthcare, LLCProvider Relations

When online use: Ask Service Representative

HIPAA.Desk.NM@xerox.com

NMPRSupport@xerox.com

Call Center 505-246-0710 or 800-299-7304

New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

Resources

Online Claim EntryCMS-1500 Provide information on submitting online CMS-1500 claims: Claim Form Instructions Timely Filing NCCI – National Corrective Coding Initiative Add/Manage Templates Medicaid Primary Claims Medicaid (TPL) Third Party Liability Claims PPO/HMO Claims Medicare Replacement Plan Claims Medicare Primary Claims

Important State Websites

STATE WEBSITES:

PROGRAM POLICY MANUAL• http://www.hsd.state.nm.us/mad/policymanual.html

BILLING INSTRUCTIONS• http://www.hsd.state.nm.us/mad/billinginstructions.html

REGISTERS AND SUPPLEMENTS:• http://www.hsd.state.nm.us/mad/registers/2013.html

Important Update

On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets.

The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

April 22, 20235

Claim Form Instructions

Where to get a copy of claim form instructions

Click Forms , Publications, and Instructions under Provider Information

Where to get a copy of claim form instructions

Open file

Scroll down

Timely Filing

The first digit indicates what the claim “media” is:

2 = electronic crossover

3 = other electronic claim

4 = system generated claim or adjustment

8 = paper claim

9 = Web portal claim entry

The last two digits of the year the claim was received

The numeric day of the year.

This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87th day of 2013, or March 28, 2013

Batch number

The claim number within the batch.

91308700085000001

What is a Transaction Control Number (TCN)?

10

The twelfth digit in an adjustment/ void TCN will either be:

1= Debit2= Credit

Timely Filing DenialsRe-filing Claims and Submitting Adjustments

Indicate the TCN in the “Timely Filing Justification – Prior TCN Number” field.

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NCCI National Corrective Coding

Initiative

NCCI (National Corrective Coding Initiative) Is a CMS program that consists of coding policies and edits.  Medicaid NCCI Edits consist of two types: 

(1) NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and

(2) Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas).

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NCCI (National Corrective Coding Initiative) RA EOB Codes:6501 or 6502 - Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service. 6503 through 6505 - Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit.  Please visit the link below for any additional information:http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html

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Add/Manage Templates

CMS-1500 - Add Claim Template

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Please note template are limited to 25 per user. HINT: think about use procedure code, or dates (billing range dates)

The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice.

CMS-1500 - Add Claim Template

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Fill out any information you would like included in your template

CMS-1500 - Add Claim Template

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Fill out any information you would like included in your template

CMS-1500 Manage Templates

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Medicaid Primary Claim Forms

Online Claims Entry

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Online Claims Entry Primary Claim (Cont.)Click on the RED text for the

CMS-1500 Claim form instructions

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Additional Recipient Information Option

Sections can be expanded by selecting all sections with Red Text

Select “Additional Recipient information” if Patient Condition information is needed to process claim.

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Other Insurance InformationIdentify if another heath benefits plan paid or denied

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Claims Information

Sections can be expanded by selecting all sections with Red Text

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Claims Information – Relevant DatesExpanded ‘Relevant Dates” Section

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Claims Information – Attachments

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Claims Information – Attachment Upload

Review the Uploading Attachments Restrictions.

You can attach files up to 10 MB

Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files.

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Line Item Information

Click to add Line Items

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Adding Additional Line Item Information

The fields with Red Asterisks (*) are REQIRED

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Medicaid Primary Claim FormsIdentify if there is another health benefit plan service that either paid or denied

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Claims Summary

Indicate the Total Charge

Xx

Medicaid Third Party Liability (TPL) Claim Forms

Third Party Liability (TPL) Tips

• TPL is commercial insurance• TPL must be billed primary to Medicaid• Medicaid does not consider Medicare TPL

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Medicaid Third Party Liability (TPL) Claim Forms

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When filling out a Medicaid claim where TPL is primary payer, be sure to fill in all required primary and secondary payer information.

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Claims Information – Attachments Attach a copy of the EOBalong with the explanationof denials page

TPL Summary

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TPL PAYMENT

Co-pay/Co-insurance/Deductible

X

Medicaid PPO/HMO Co-payment Claim Forms

PPO/HMO Co-Pay Tips

• In the “Prior Payment Amount” field, enter the difference between the billed amount and the co-payment.

• Enter the co-payment amount in the “Amount Due” field.

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PPO/HMO Co-Pay

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Claims Information – Attachments Attach a copy of the EOBalong with the explanationof denials page

PPO/HMO Co-Pay

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Difference between total charge and the co-payment amount

Co-payment amount

X

Medicare Replacement Plan Claim Forms

Medicare Replacement Plan

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Indicate “Medicare Advantage” on Medicare Replacement Plan submissions

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Medicare Replacement Plan - Attachments Attach a copy of the EOBalong with the explanationof denials page

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Difference between total charge and the co-payment amount

X

Medicare Replacement Plan

Co-Payment Amount

Total Charge

Medicare Primary Claim Forms

Medicare Primary Claims

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Indicate “Medicare” on Medicare Crossover submissions

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Medicare Primary– Attachments Attach a copy of the EOBalong with the explanationof denials page

Medicare Primary Claims

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X

Only Indicate Total charge on Medicare CrossoversLeave the Prior Payment Amount and Amount Due Blank

When online use: Ask Service Representative

HIPAA.Desk.NM@xerox.com

NMPRSupport@xerox.com

Call Center 505-246-0710 or 800-299-7304

New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

Resources