Embed Size (px)
Citation preview
04/25/07 1
DMAS Division of Health Care Services
New Billing Instructions for Emergency Air Ambulance, Emergency Ground Ambulance, and
Neonatal Ambulance Services. Instructions include Medicare Cross Over Claims.
Two Code Methodology to Begin with Dates of Service November 1, 2009 and After.
2
Presentation Outline
Health Insurance Claim Form - 1500 Emergency Ground & Neonatal Ambulance Transportation Emergency Air Ambulance Transportation
Title XVIII (Medicare) Deductible and Coinsurance Invoice DMAS 30-R DMAS 31-R
Resources TrailBlazer Revs Line DMAS Website
Contact Information Questions
3
Health Insurance Claim Form CMS 1500
What’s Changed? Beginning with Date of Service (DOS) November 1, 2009 and forward, Emergency
Air, Emergency Ground Ambulance, and Neonatal Ambulance claims will be will be processed using the two CPT/HCPCS code payment methodology. This includes Medicare cross-over claims as well.
Two CPT/HCPCS codes meaning “service” with corresponding “mileage” code. When Medicare “total payment” for both service and mileage added together exceed
DMAS maximum rate, crossover claims will be paid at $0.00 with the claims edit 364 “Exceeds Medicaid Allowed Amount”.
All Emergency Ground and Air Ambulance claims will no longer require attachments.
No longer use Modifier “22” in block 24D. Except for claims that are over 200 miles and more than one transport on same day service. (see billing instructions)
All Emergency Air and Emergency Ground Ambulance claims will be subject to post review.
Emergency Air Ambulance Claims will change to a Post Review for Medical Necessity.
CMS 1500 requires Font size 10 or larger Adjustments must be submitted for only one line of the pair. Mail all Ground Ambulance claims to First Health, address at end of presentation
4
Health Insurance Claim Form CMS 1500
Most Common Mistakes Claims with DOS October 30, 2009 and before still require one
code billing. Block 10b, make sure and check yes for auto accidents Block 10c, make sure to mark for other accidents Third party liability claims – if primary insurance pays at
$00.00 make sure block 11d is marked “yes” and block 24a shaded area has TPL00.00. This needs to be entered for each CPT code line. If primary insurance pays, make sure 11d is marked “yes” and block 24a shaded area has dollar amount paid for each CPT code line example: TPL53.69
Make sure providers NPI number match for blocks 24j and 33a. DO NOT use a physicians NPI in block 24j.
Do not bill DMAS for regular non-emergency service codes A0426, A0428, A0434 and corresponding A0425. However, DMAS is responsible for all emergency and non-emergency Medicare cross-over claims (see billing instructions for cross over claims).
5
Eligibility and Claims status information DMAS offers a web-based Internet option (ARS) to
access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and pharmacy prescriber identification. The website address the use to enroll for access to this system is http://virginia.fhsc.com. The Medical voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.
6
Transportation for Managed Care Organizations (MCO)
The Virginia Medicaid Program includes enrolling eligible Medicaid recipients in Managed Care Organizations (MCO).
Eligible enrollees receive emergency air ambulance, emergency ground ambulance and non-emergency transportation services through the MCO.
Please contact the appropriate MCO for billing
instructions.
7
Billing on the CMS-1500
6
8
Printing
Must be RED OCR dropout ink or the exact match
Should be 10-pitch Pica type, 6 lines per inch vertical and 10 characters per inch horizontal
Claim has to match /line up with the original claim form
9
Printing
Print 100% of actual size Set page scaling to ‘none’ Margins must be exact DMAS will not reprocess claims
denied for scanning issues as a result of failure to follow the above instructions
10
TIMELY FILING
ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE
EXCEPTIONSRetroactive/Delayed EligibilityDenied Claims
NO EXCEPTIONSAccident CasesOther Primary Insurance
11
TIMELY FILING
Submit claims with documentation attached explaining the reason for delayed submission
12
Block 1
Enter an ‘X’ in the MEDICAID box for the Medicaid Program
MEDICAID
(Medicaid #)
Block 1
CHAMPUS
(Sponsor's SSN)
1. MEDICARE
(Medicare #)
MEDICAID CLAIM
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
12
TRICARE
1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
Block 1a: Recipient ID Number
Be sure to include all
12 digits of the VA Medicaid ID.
123456789014
13
Block 2: Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle Initial)
Smith, Sam5. PATIENT'S ADDRESS (No., Street)
14
16
Is Patient’s Condition Related To Block- 10a,10b & 10c
10a - Mark box with appropriate ‘Yes’ or ‘No’
10b - If the condition is related to an auto accident, mark ‘Yes’ and place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.
10c - Mark box with appropriate ‘Yes’ or ‘No’
Block 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 & c16
WV
Block 10d
If Applicable
*Emergency Ground Ambulance trips 200 miles and over, and more than one transport with same service day MUST use the word
"ATTACHMENT"
Trips over 200 miles must have Pre-Hospital Patient Care Report (PPCR) attached
More than one transport per day, attach statement “This is second/third/forth transport”.
10d. RESERVED FOR LOCAL USE
*ATTACHMENT
17
Block 11c - Insurance Plan Name or Program Name
c. INSURANCE PLAN NAME OR PROGRAM NAME
Other Insurance Name
18
20
Is There Another Health Benefit Plan?Block-11d
Providers should only check yes if there is another third party carrier
If Medicare pays $00.00 mark this block “yes” and follow instructions for shaded area block 24A.
Block 11d - 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.
20
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
31100
Block 21: Diagnosis Codes
May enter up to 4 codes
Omit decimals (List of frequently used diagnosis codes are in the
Transportation Manual)
30130
21
23
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
24
TPL Information Block 24A
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 (TPL00.00 or TPL payment amount: TPL123.45)
Decimal between dollars and cents is required to read paid amount correctly
Must be left justified Enter dollar amount paid for each CPT Code
line
25
TPL Information Block 24A
DMAS will set COB code based on the information given in locator 11d.No, or nothing indicated-no other carrier-
old COB code 2No, or nothing indicated/system has other
insurance-claim will deny bill other insurance
No, or nothing indicated/‘TPL’ qualifier with payment in 24a red area-old COB code 3
26
TPL Information Block 24A
DMAS will set COB code based on the information given in locator 11d.Yes, but nothing in 24a red area-other
carrier billed and made no payment-old COB code 5
Yes, and ‘TPL’ qualifier with payment in 24a red area-other carrier billed and paid-old COB code 3
24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
(TPL example added if applicable)
11 01 09 11 01 091
2
Both FROM and TO datesmust be completed
Dates must be within same calendar month26
TPL8.60
TPL27.08
11 01 09 11 01 09
B.
Placeof
Service
Block 24B: Place of Service
41
41- Ambulance – Land
Or
42- Ambulance – Air or Water
“Not both”
Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare.
27
41
29
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
Make sure and mark ‘Y’ on both service and mileage lines
C.
EMG
Block 24C: EMG
Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency
29
Y
Y
Block 24D: Procedure Codes
Neonatal Transport with “U1” Modifier
“U1” Modifier is for Neonatal Mileage Only
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
A0225
30
DMAS Recognizes the
Following codes:
A0225 w/A0425 “U1”A0427 w/A0425A0429 w/A0425A0433 w/A0425A0430 w/A0435A0431 w/A0436 A0425 U1
32
Block 24D: Procedure CodesService and Mileage CPT Codes
One CPT Code on Each Line
No Modifier is required
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
A0427
30
DMAS Recognizes the
Following codes:
A0225 w/A0425 “U1”A0427 w/A0425A0429 w/A0425A0433 w/A0425A0430 w/A0435A0431 w/A0436 A0425
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
34431
Block 24E: Diagnosis Code
E.
DIAGNOSISPOINTER
1,2
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.
31
F.
$ CHARGES
Block 24 F: Charges
Enter the usual and customary
charges for each CPT code32
500
001500
00
G.DAYS
ORUNITS
Block 24G: Days or Units
1 Enter “1” for one unit of service.
Enter the number of “loaded miles” of transport.
33
31
36
ID.QUALBlock-24I – Shaded Area
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.
Make sure to follow these instructions for each line.
Taxonomy code must be used for each CPT code line.
37
If Taxonomy codes are usedBlock-24J
If needed the shaded red area will contain the Taxonomy codes
If Taxonomy codes are used in shaded area, NPI number must be provided in the open area.
Make sure and follow these instructions for both lines.
Fill in only if Taxonomy codes are needed
Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
36
ZZ3416A0800X
Or3416L0300X
3416A0800X is Taxonomy code for Air Transport 3416L0300X is Taxonomy code for Land Transport
If taxonomy codes are used, make sure and use same codes for each line.
Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
Make sure and use ZZ and same taxonomy code for each line.
37
I.ID.
QUAL
J.RENDERING
PROVIDER ID. #
NPI
ZZ Taxonomy # (if needed)
12345647890
26. PATIENT ACCOUNT NUMBER
Block 26: Patient’s Account Number
(Optional)
12345678918765
38
Can not exceed 17 alphanumeric digits
41
Total ChargeBlock 28
DMAS now requires this locator to be completed
Enter the total charges together for the services in 24F lines 1-6.
28. TOTAL CHARGE
Block 28: Total Charges
40
$
29. AMOUNT PAID
Block 29: Amount Paid
(By Other Insurance)
41
$
44
30. Balance Due
Block 30: Balance Due
(Block 28 minus Block 29)
42
$
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
Block 31: Signature & Date
If there is a signature waiveron file, you may stamp, print,
or computer-generate the signature.43
46
Service Facility Location InformationBlock-32
Enter information for the location where recipient was dropped off - services were rendered First line-Name Second line-Address Third line-City, State, 9 digit zip code
The zip code must reflect the hospital/facility location where services were rendered
No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code
47
Service Facility Location InformationBlock-32a-b
Leave Blank
Block 32: Service Facility Location Information
Drop off location - Local Hospital or Facility NameXXXX Anywhere St.
Your Town, ST 12345-1456
32. SERVICE FACILITY LOCATION INFORMATION
Leave Blank Leave Blanka. b.
46
49
Billing Provider Info & PH #-Block-33
Enter the information to identify the provider that is requesting to be paidFirst line-NameSecond line-AddressThird 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
50
Billing Provider Info Block-33a-b
33a - Enter the 10 digit NPI number of the service location in 33a. (This is required on all claims).
33b – If applicable, Enter ‘ZZ’ qualifier with the taxonomy code in 33b (example – ZZ3416L0300Z).
NOTE: 33a and 33b - NPI number and taxonomy codes must match information in blocks 24I and 24J
Block 33: Billing Provider Info & PH #
Your Local HospitalXXXX Anywhere St.
Your Town, ST 12345-1456
33. BILLING PROVIDER INFO & PH #
ZZ3416L0300X (If needed)a. b.1234567890
(123) 456-7890
49
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
Block 22: Adjustments and Voids
Send in Adjustment for MILEAGE CODE ONLY with mileage ICN number.
1032 xxxxxxxxxxxxxxxxAdjustment
or
Resubmission Code
From OriginalRemittance
Void
Chap. V, Medicaid Transportation Manual has code list.
50
Block 22: Medicaid Resubmission Codes
Original Reference Number/ICN - Enter the claim reference number/ICN of the mileage code paid on the claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted. Only one claim can be adjusted on each CMS-1500 (08-05) submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim.)
Medicaid Resubmission of Adjustment Codes
1023 Primary Carrier has made additional payment1024 Primary Carrier has denied payment1025 Accommodation charge corrected1026 Patient payment amount charged1027 Correcting service periods1028 Correcting procedure/service code1029 Correcting diagnosis code1030 Correcting charges1031 Correcting units/visits/studies/procedures1032 IC reconsideration of allowance, documented1033 Correcting admitting, referring, prescribing,
provider ID 1041 Incorrect Amount paid1053 Adjustment reason is in the Misc. Category
Medicaid Resubmission of Void Invoice Codes
1042 Original claim has multiple incorrect items1044 Wrong provider identification number1045 Wrong enrollee eligibility number1046 Primary carrier has paid DMAS maximum allowance1047 Duplicate carrier has paid full charge1048 Primary carrier has paid full charge1051 Enrollee is not my patient1052 Miscellaneous1060 Other insurance is available
51
54
More than One Emergency Air or Ground Claim with Same Day Service
Please complete second/third claim using the same billing instructions as the first plus in block 10d add the word “ATTACHMENT” and add modifier “22” in block 24d. Please provide a cover letter explaining this claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of second claim with PPCR/run/call sheets and mail to:
DMAS
Transportation Unit, Suite 1300
600 East Broad Street
Richmond, Virginia 23219
55
Air Ambulance Claim Procedure and Claim Reconsideration
All air ambulance claims with a date of service November 1, 2009 and after are subject to a post claim review. Claims submitted that do not establish air ambulance medical necessity will be adjusted to DMAS emergency ground ambulance rates.
In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be reconsidered if the original claim was missing attachments or other medical information. For reconsideration please write a brief description or explanation on why the claim needs to be reconsidered.
Please mail the letter, a new original CMS 1500 with attachment to:DMASTransportation Unit, Suite 1300600 East Broad StreetRichmond, Virginia 23219
If reconsideration is denied, then please use the formal appeal process.
56
Mailing Address for Emergency Ground Ambulance, Emergency Air Ambulance, and Neonatal Ambulance Service Claims
Emergency Air, Emergency Ground and Neonatal Ambulance Claims with a Date of Service on or after November 1, 2009 mail to:
DMAS-TransportationP. O. Box 27447
Richmond, Virginia 23261-7447
Note: Emergency ground ambulance claims with 200 miles and over and/or multiple emergency transports on the same day must be mailed to:
DMASTransportation Unit, Suite 1300
600 East Broad StreetRichmond, Virginia 23219
57
Billing on the DMAS 30 & 31
56
58
Title XVIII Common Mistakes
Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only) Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only)
59
CHANGES
Locator 01-Billing Provider Number Locator 06-Rendering Provider
Number Locator 08-Type of Coverage
Title XVIII- Block 01
01 Billing Provider Number
Enter the billing provider NPI number
59
Title XVIII- Block 06
06 Rendering Provider Number
Enter the rendering provider NPI number
60
62
Primary Carrier Information Other ThanMedicare
072 No Other Coverage
5 Billed No Coverage3 Billed and Paid
Title XVIII – Block 7
63
Type OfCoverageMedicare
B
Type Coverage Medicare- Mark type of coverage “B”.
6
08
Title XVIII – Block 08
64
Title XVIII- Block 17
Charges To Medicare
Block 17: Charges to Medicare- Enter the total charges submitted to Medicare.
17
65
Title XVIII- Block 18Allowed By Medicare
Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare.
18
66
Title XVIII- Block 19
Paid By Medicare
Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the
EOB).
19
67
Title XVIII- Block 20
Deductible
Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB).
20
68
Title XVIII- Block 21
Co-Insurance
Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare
EOB).
21
69
Title XVIII- Block 22
Paid By Carrier Other Than Medicare
Block 22: Paid by Carrier Other Than Medicare- Enter the payment received from the
primary carrier (other than Medicare). If Code 3 is marked in Block 7, enter an amount in this block.
(Do not include Medicare payments.)
22
70
Title XVIII- Block 23
Patient Pay Amt. LTC Only
Block 23: Patient Pay Amount, LTC Only-
Leave Blank.
23
71
TITLE XVIII- Adjustment InvoiceDMAS-31
Block 1 Adjustment/Void
Check the appropriate block Block 2 Billing Provider Number
Enter the NPI of the billing provider
Block 6 Rendering Provider NumberEnter the NPI of the rendering
provider Block 2A Reference Number
Enter the ICN number taken from the Remittance Voucher for the line of payment needing adjustment.
72
TITLE XVIII- Adjustment Invoice
Blocks 3-20 Refer to instructions for the DMAS-31 for the completion of these blocks.
Remarks This section of the invoice should be used to give a brief explanation of the change needed.
Signature Signature of the provider or agent and the date signed.
73
REMINDERS Xeroxed copies of DMAS forms are still unacceptable Medicaid reimburses providers for the coinsurance and
deductible amounts on Medicare claims for Medicaid recipients who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid
Use the same CPT/HPCS codes that were billed to Medicare (this means using the two code system)
Make sure and attach Medicare EOB to 30-R & 31-R
74
LogistiCare Contact Telephone Number For A0426, A0428, and A0434 Non-Emergency Ambulance Non-Emergency Services
LogistiCare’s Medicaid recipients toll-free reservation line: 1-866-386-8331
- This line is intended for recipients, facilities, and hospitals to schedule trips
All A0426, A0428, and A0434 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.
75
Resources TrailBlazer – Federal Source for Medicaid and
Medicare Information Website: http://www.Trailblazerhealth.com/
Medicall Line (Eligibility) – 1-800-884-9730 or 1-800-772-9996
DMAS Internet - Providers are encouraged to monitor all Medicaid memorandums and the DMAS website for additional directions. Website: http://www.dmas.virginia.gov
76
Help Line
HELPLINE The “HELPLINE” is available to answer questions
Monday through Friday from 8:30 a.m. to 4:30 p.m., except state holidays. The “HELPLINE” numbers are:
1-804-786 -6273 Richmond area and out-of-state long distance
1-800-552-8627 All other areas (in-state, toll-free long distance)
Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Number or your NPI number available when you call.
78
THANK YOU
