KANSAS MEDICAL ASSISTANCE PROGRAM … MEDICAL ASSISTANCE PROGRAM GENERAL BILLING PROVIDER MANUAL 5-1 5000. ELECTRONIC MEDIA CLAIMS (EMC) Updated 10/07 Electronic Billing: Remittance

KANSAS

MEDICAL

ASSISTANCE

PROGRAM PROVIDER MANUAL

General Billing

PART I GENERAL BILLING KANSAS MEDICAL ASSISTANCE PROGRAM

TABLE OF CONTENTS

Section General Billing Page 5000 Electronic Media Claims ...... ......... ......... ......... ......... ........ 5-1 5100 Timely Filing . ........ ......... ......... ......... ......... ......... ........ 5-3 5300 Appeals Process ....... ......... ......... ......... ......... ......... ........ 5-7 5400 Remittance Advice/Claim Disposition ......... ......... ......... ........ 5-8 5500 Electronic Deposit of Funds ... ......... ......... ......... ......... ........ 5-9 5600 Adjustments/Refunds . ......... ......... ......... ......... ......... ........ 5-10 Completing the Individual Adjustment Form ... ......... ........ 5-13 5700 Billing/Collection Agencies .... ......... ......... ......... ......... ........ 5-15 5800 The CMS-1500 Claim Form. ........ ......... .... ........ ......... ........ 5-16 5900 Compliance with Section 6032 of Federal Deficit Reduction Act ....... 5-23 FORMS Individual Adjustment Form CMS-1500 Attestation of Compliance with Section 6032 of the Federal Deficit Reduction Act 6000 Reserved for future use

FORM REORDERING Updated 10/07 Providers must use EDS Form #60-7 to order Dental and the Pharmacy claim form and Prior Authorization form. Other items such as the Adjustment form and KAN Be Healthy form should be duplicated from the provider manual or from the KMAP Web site. EDS does not provide the CMS-1500, UB-04, or ADA Dental Claim forms. They must be obtained from a claim form supplier. Listed below are names and addresses of vendors who supply the CMS-1500, UB-04, and ADA Dental Claim forms. This list is not an inclusive list.

CMS-1500

Administrative Services of Kansas, Inc. (A subsidiary of Blue Cross and Blue Shield of Kansas, Inc.) P.O. Box 3500 Topeka, KS 66601-0110

CMS-1500 and UB-04

Advantage Business Forms 211 SW 6th Topeka, KS 66603 (785) 235-6868 Contact: Nicole Schings ADA Dental Claim Forms American Dental Association Attention: Catalog Sales 211 East Chicago Avenue Chicago, IL 60611 (800) 947-4746 www.adacatalog.org

KANSAS MEDICAL ASSISTANCE PROGRAM GENERAL BILLING PROVIDER MANUAL

5-1

5000. ELECTRONIC MEDIA CLAIMS (EMC) Updated 10/07 Electronic Billing:

Remittance Advices (RA) and warrants (checks) are produced weekly for all claims. EMC claims allow providers to experience improved cash flows. Electronic claim submission is the easiest and most efficient way to submit claims. Electronic Data Systems (EDS) has various methods for electronic claims submission. Some of these include:

• batch claim submission through information system vendor or through software supplied by EDS

• on-line claim entry through the Kansas Medical Assistance Program (KMAP) Web site

All claim types may be submitted electronically. Pharmacy claims may be submitted via point-of-service (POS) or batch methods. Contact the KMAP Customer Service Center for assistance with on-line services. Contact the EDI Department for assistance with electronic file transfers and Provider Electronic Solutions Software. Both departments can be reached at 1-800-933-6593. Dental providers can use option 4#. Refer to the KMAP General Benefits Provider Manual or the benefits/limitations section of each program provider manual for all benefit/limitation criteria. Questions regarding checks or claim adjudication information contained on the RA should be directed to the Customer Service Center at 1-800-933-6593, option 0.

Electronic Documentation Signature:

Electronic signatures that meet the following criteria are acceptable for Medicaid documentation:

• Identify the individual signing the document by name and title • Include the date and time the signature is affixed • Assure the documentation cannot be altered after the signature has been affixed by limiting

access to the code or key sequence • Provide for nonrepudiation, that is, strong and substantial evidence that will make it difficult

for the signer to claim the electronic representation is not valid

The use of an electronic signature is deemed to constitute a signature and has the same effect as a written signature on a document.

The provider must have written policies and procedures in effect regarding the use of electronic signatures. In addition to complying with security policies and procedures, the provider who


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5000. Updated 10/07

uses computer keys of electronic signatures must sign a statement assuring exclusive access and use of the key or computer password. The policies and procedures and statement of exclusive use must be maintained at the provider’s location and available upon request by the State or fiscal intermediary.

Additionally, the use of electronic signatures must be consistent with the applicable accrediting and licensing authorities and the provider’s own internal policies.

Failure to properly authenticate medical records (sign and date the entry) and maintain written policies and procedures regarding electronic documentation and security compliance may result in the recoupment of Medicaid payments or other actions deemed appropriate by the State.

Original signatures are still required on provider enrollment forms.

Electronic Documentation:

Electronic documentation that meets the following criteria is acceptable for Medicaid:

• Meet all documentation and signature requirements contained in the General BenefitsProvider Manual

• Meet all documentation and signature requirements specific to the KMAP program and services provided

• Assure the documentation cannot be altered once entered • Maintain a system to document when records are created, modified or deleted to provide an

audit trail

Providers must have written policies and procedures in effect regarding the use of electronic documentation that must be maintained at their location and available upon request by the State or fiscal intermediary. These requirements for clinical documentation apply only to Medicaid claims and do not preclude other state or federal requirements.

Failure to properly authenticate medical records (sign and date the entry) and maintain written policies and procedures regarding electronic documentation and security compliance may result in the recoupment of Medicaid payments or other actions deemed appropriate by the State. Note: Documentation can be requested at any time to verify that services have been provided within program guidelines.


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5100. TIMELY FILING Updated 06/08 Initial Filing of Medicaid/MediKan Claims

KMAP must receive claims within 12 months of the date the service was provided (KSA 39-708a). Inpatient hospital services must be received within 12 months of the date of discharge or the last date of service on an interim bill. Nursing facility claims must be received within 12 months from the last day of the month in which the service was billed. Claims not received within 12 months as defined here will be denied.

Filing a Claim Prior to Beneficiary Becoming Kansas Medicaid/MediKan Eligible

For timely filing purposes, you may file a claim for services provided to beneficiaries whose application for benefits is delayed due to determination of eligibility. Enter the word "PENDING" in place of the beneficiary ID number. EDS will process the claim and deny it with explanation of benefits (EOB) code 615 on the RA. When a beneficiary’s eligibility is approved, enter the Medicaid ID number and resubmit the claim with the original ICN number date stamped claim for processing. It is the beneficiary’s responsibility to inform the provider of eligibility. If you believe eligibility has been determined but have not received this information from the beneficiary, you can inquire regarding eligibility through the Automated Voice Response System (refer to Section 1200 of the General Introduction Provider Manual), the KMAP Web site, or KMAP Customer Service Center.

Initial Filing of Medicare or Third Party Related Claims

Claims must be filed to Medicare or the third party payer within 12 months of the service date. Once benefits have been determined by Medicare or the third party payer, EDS must receive the claim within 12 months of the date of service or with proof of timely filing attached. (Reference 'Filing Claims With Service Dates Over 12 Months Old' criteria given below.) We recommend that a claim filed with Medicare or a third party payer also be filed with Medicaid within 12 months of the date of service to ensure timely filing criteria is met. However, the Medicare or third party liability EOB can be used for proof of timely filing if the date on that EOB falls within the 12-month timely filing period.

Filing Claims With Service Dates Over 12 Months Old

Claims which are originally filed within 12 months of the service date but are not resolved before the 12-month filing limitation expires may be resubmitted to Medicaid for up to 24 months from the date of service. When resubmitting a claim, include the original ICN number in the appropriate field as specified in the billing instructions. Resubmissions do not require attachments proving timely filing if the claim was originally submitted to EDS within 12 months from the date of service and the following data elements are unchanged from the original submission: CMS-1500 Claims UB-04 Claims (Inpatient/Outpatient/LTC) Same Beneficiary ID Number Same Beneficiary ID Number Same Performing Provider Number Same Provider Number Same Dates of Service Same Dates of Service Same Procedure Code Same Revenue Codes (Inpatient/LTC only)

Same Billed Amount Providers may check claim status on the KMAP Web site or by contacting the KMAP Customer Service Center at 1-800-933-6593, option 0.


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5100. TIMELY FILING cont. Updated 03/08

Dental Claims Pharmacy Claims Same Beneficiary ID Number Same Beneficiary ID Number Same Performing Provider Number Same Billing Provider ID/Service Location Same Procedure Code Same Dispense Date (Date of Service) Same Dates of Service Same National Drug Code (NDC) Same Tooth Number Same Provider Number Same Tooth Surface Same RX Number

Note: For compound drugs, all ingredients must match.

When any of these data elements change, proof of timely filing must be attached to the claim.

When the claim is filed in a timely manner with Medicare or a third party, attach a copy of the claim submitted to Medicare or the third party with documentation of the claim's original submission date or a dated copy of proof of payment or denial from Medicare or the third party which proves they received the claim within 12 months of the service date. (If the claim is Medicare related and was originally timely filed but exceeds the 24-month limitation, it may be filed to Medicaid within 30 days of Medicare's response. This is the only situation in which a claim over 24 months old will be considered for payment.) If you are unable to prove a claim was initially timely filed with any other carrier and dates of service are over 12 months old, Medicaid cannot consider the claim for payment.

Claims not submitted within 12 months of the date of service cannot be billed to the beneficiary when a provider has knowledge of Medicaid coverage. Claims which are timely filed and subsequently denied because of provider errors cannot be billed to the beneficiary if the provider fails to correct the errors and resubmit the claim for final adjudication within 24 months from the date of service. Regardless of original timely filing or resubmissions, state regulations prohibit KMAP from processing any claim received beyond 24 months from the date of service. Noncovered Medicaid services may be billed to the beneficiary when the beneficiary is notified prior to the provision of services.


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5100. TIMELY FILING cont. Updated 10/07 Helpful tips to aid in processing of timely filing:

• Request assistance from the KMAP Customer Service Center for specific claims processing problems.

• Do not wait until 24 months to seek assistance. • Use a cover letter and do not write on the face of the claim or use sticky notes. • Be specific and clearly explain why timely filing should be bypassed. • Include a contact name and phone number with your request. If EDS has questions or needs

clarification, the contact person will be notified. • If additional documentation is required, the provider has 10 business days after being contacted to

get that documentation to EDS. If it is not received within 10 business days, the request is closed and the claim will be denied.

• If the request is due to retroactive eligibility and the provider does not have the retroactive eligibility letter, EDS can access the letter, but the provider must indicate retroactive eligibility in the cover letter.

• Kansas Foundation for Medical Care (KFMC) adjustments must have the KFMC letter attached. • The provider is responsible for all information on the face of the claim being correct and current.

If the claim is more than 24 months old, for instance, the provider number must be updated to reflect the current KMAP provider ID.

• Proof of why timely filing should be bypassed should be attached along with the cover letter and claim. This proof should be something similar to a RA or explanation of benefits rather than something from the provider’s own computer program.

• Send information for timely filing bypass requests to: Kansas Medical Assistance Program Office of the Fiscal Agent Timely Filing Coordinator PO Box 3571 Topeka, KS 66601-3571

All timely filing requests are tracked. Any customer service agent can assist providers with questions once the request is received. If the request is denied, providers are contacted and the claim is not processed; however, if the request is approved, it is processed immediately.


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5200. TRACER CLAIM FILING Updated 02/08

If 30 days have lapsed since you submitted a claim to EDS and the status of that claim has not appeared on the KMAP RA, a tracer claim needs to be filed. A tracer claim is a copy of the claim initially filed. Submit the tracer claim to EDS and mark "TRACER" in blue or black ink on the face of the claim. Also, include copies of all the attachments that accompanied the first claim.


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5300. APPEALS PROCESS Updated 10/07

If you, as a provider, disagree with the action KHPA has taken on your claim you have the right to request an administrative fair hearing under the Kansas Administrative Procedures Act, K.S.A. 77-501, et seq. and K.A.R. 30-7-64 et seq.

To request an appeal on a timely basis, you must send a written request for such an appeal to:

Office of Administrative Hearings 1020 South Kansas Avenue Topeka, KS 66612-1327

The request must be received by that office within 30 days of the date of our notification letter. Because we mail such notices to you, we will add three days to your 30 day appeal period.

You do not need to use any special form to request a Fair Hearing. You may simply put the request in writing and send it to the Office of Administrative Hearings. Your request must specifically request a Fair Hearing. The request should describe the decision appealed and the specific reasons for the appeal.


5-8

5400. REMITTANCE ADVICE/CLAIM DISPOSITION Updated 10/07

RAs have been designed to provide detailed information in an easy to understand format with content tailored to the various claim types including hospital, pharmacy, professional and nursing facility. RAs itemize all payments to providers, including line-item explanations of the adjudication of each claim. In addition, all suspended claims, denials, financial transactions and notices are included on the RAs. The RA groups the services by agency. The agency is identified directly under the provider number as SRS-629 or KDOA-039. Electronic RAs (835) are also available. Call the EDI department at 1-800-933-6593, option 3, for additional information on receiving your RA electronically.

The RA is organized in six sections: remittance notices, denied claims, paid claims, financial transactions, activity summary, and suspended claims. Claims within each section are presented in sequential order by beneficiary last name, three digits of the first name, and the ICN region code.

Each section of the RA is subtotaled, including claim counts, submitted charges, allowable reimbursement, and paid reimbursement. The RA summary provides cumulative totals for the current payment period, month-to-date, and year-to-date totals. The totals included for all providers are:

• Number of claims paid, denied, suspended, adjusted, and processed • Dollar amount processed • Financial transactions including payouts and recoupments • Warrant amount

The following fields are common to all RA formats: Provider Number: Identifying the provider for whom the RA was printed RA #: A unique 9-digit number identifying the RA Agency: Agency identified (SRS-629 or KDOA-039) RA As Of: The last day of the period for which the RA was produced Page: Page number of the RA Beneficiary Name: The name of the beneficiary for whom the claim was made. Medicaid ID Number: The Medicaid ID number of the beneficiary. Internal Control Number: The internal control number for the claim. Service Dates From To: The beginning and ending date of service. Billed Amount: The dollar amount the provider billed for the service rendered. Allowed Amount: The dollar amount allowed by Medicaid for the service. Spenddown: The spenddown amount Payment Amount: The dollar amount paid by Medicaid for the claim. EOB SYS INS: Explanation of benefits, a code indicating the reason for the

payment or denial Category Totals: Category totals Agency Totals: Agency totals Provider Totals: Provider totals

For questions regarding the claim adjudication information contained on the RA or ERN, providers may contact the KMAP Customer Service Center at 1-800-933-6593. See examples of remittance advice forms in the forms section at the end of this manual.


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5500. ELECTRONIC DEPOSIT OF FUNDS Updated 10/07

The State of Kansas offers Electronic Deposit of Funds to vendors who request this service. Electronic deposit will provide you with funds without the delay normally associated with mailing of state warrants. Many providers receive funds from more than one state agency. All payments for the state are made through the same payment system. The system is unable to process payments to more than one bank account for each vendor. If your agency has requested electronic deposit through another state agency, all funds will be deposited using the bank information you provided. You must decide if you want all payments to be made electronically or if you want all payments to be made via paper warrants. To enroll in the electronic deposit program, please complete the Authorization for Electronic Deposit of Vendor Payment form on the KMAP Provider Web site under Ancillary Documents. This form may be photocopied for your use. This form may also be used to discontinue the electronic deposit service. You must also complete Form W-9, "Request for Taxpayer Identification Number and Certification". Please return both forms to:

Department of Social and Rehabilitation Services Docking State Office Building SRS Payables 915 SW Harrison Room 1051 South Topeka, KS 66612


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5600. ADJUSTMENTS/REFUNDS Updated 10/07 Adjustments:

In order to be considered for additional payment, underpayment adjustments must be submitted within two years from the date of service on the claim. Underpayment adjustments received for dates of service more than two years old cannot be processed by EDS and will be returned to the provider.

Overpayment adjustments can be submitted and will be processed regardless of how old the date(s) of service.

Overpayment Recoupments:

When a claim has paid incorrectly resulting in an overpayment, the overpayment amount is subject to recoupment regardless of when the claim paid, or how old the dates of service.

Once an overpayment is identified, a recoupment letter is sent to the provider. If the provider disagrees with the recoupment, a response must be made within the time specified in the recoupment letter. When a response is not received within the specified time, the overpayment adjustment is deducted from a future RA. Adjusted amounts may vary from the original identified amount due to system changes that have occurred since payment of the original claim.

Finalized adjustments have an ICN beginning with '50'-claim specific or '56'-non-claim specific. To identify the specific beneficiary involved, it is necessary to refer to the adjustment notification letter sent to your facility.

Refunds:

If an overpayment is discovered on the RA, please complete the Individual Adjustment Form reporting the overpayment. All identified overpayments are processed by recoupment from subsequent RA payments. Personal or company checks will be accepted only when EDS or KHPA specifically requests the repayment to be made by check. Checks received but not requested will be returned to the provider. In general, checks will only be requested when the provider is a low-volume provider, and no claims have been paid within 60 days of the adjustment date. When a refund check is requested, forward it to:

Medicaid TPL/Financial Unit P.O. Box 3571 Topeka, KS 66601-3571

Remember to submit necessary information (e.g., recoupment letter, remittance advice, etc.) in order for the Collections Unit to determine how to apply the refund check. Providing this information will assist in eliminating errors in posting to accounts.

Requests for Additional Payments: If it appears an underpayment has been made for a claim appearing on the RA, you may adjust the claim on the KMAP Web site, call the KMAP Customer Service Center, or complete the Individual Adjustment Form reporting the underpayment.


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5600. Requests for Additional Payments cont Updated 10/07

After processing the overpayment or underpayment, results are reported on a subsequent RA. The original claim will appear on the RA with negative dollar amounts. The adjusted claim will be located directly above the original claim. The adjusted claim will have an internal control number (ICN) that begins with a '5.' When there is a need to adjust a claim that has been adjusted before, indicate the adjusted claim's ICN on the Individual Adjustment Form. The original claim's ICN has been voided from the KMAP system.

Adjustment Request Minimums:

Adjustment requests, both overpayments and underpayments, must exceed a minimum amount on a claim for hospital, pharmacy or nursing facility and minimum amount per service on all professional claims (unless it is to correct the history). Below are the minimum amounts for each type:

Hospital per claim - Inpatient $12.00 Inpatient Hospital per claim - Outpatient $ 5.00 Outpatient Nursing facility per claim $12.00 Pharmacy per prescription $ 5.00** Professional* per service $ 5.00

*Professional includes: Advanced Registered Nurse Practitioners (ARNPs), Ambulances, Ambulatory Surgical Centers, Attendant Care for Independent Living (ACIL), Audiologists, Behavior Management, Chiropractors, Community Mental Health Centers, Day Treatment, Dentists, Durable Medical Equipment Suppliers, Federally Qualified Health Centers (FQHCs), Head Start Facilities, Home Health Agencies, Hospice, ICF/MR Dental, Local Education Agencies (LEAs), Local Health Departments, Optometrists, Physical Therapists, Physicians, Podiatrists, Prosthetics and Orthotics, Psychologists, Qualified Medicare Beneficiaries (QMBs) and Rural Health Clinics.

**The $5 minimum does not apply to adjusted incentive fees generated by the pharmacy reimbursement for nursing facility returned medications.

There are two exceptions to the minimum amount policy. One exception is when "other insurance" makes a payment after a KMAP payment. Payments made by KMAP must be refunded by the provider upon receipt of payment from any other insurance source. The other exception is overpayments identified as the result of a postpayment utilization management review.

Adjustments cannot be processed for zero paid claims unless other insurance, Medicare, or patient liability is involved and you want to adjust any of these items. When all of the details but one on a claim have been paid, submit a new claim for the unpaid detail only.


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5600. Individual Adjustment Form Fields Required Updated 10/07

To speed processing and ensure your adjustment is processed correctly, verify that the following fields are completed before submitting an Individual Adjustment Form to EDS:

• Internal Control Number - can be found in Column 4 of the Remittance Advice (RA)

• Beneficiary ID Number - can be found in Column 2 of the RA

• Billing Provider’s KMAP Provider ID or National Provider Identifier (NPI)

• Beneficiary Name

• Qty/Units on RA and corrected Qty/Units - if applicable

• NDC/Procedure Code on RA and Corrected NDC/Procedure Code - if applicable

• Drug Name - if applicable

• Billed Amount on RA and Corrected Billed Amount - if applicable

• Other/Remarks - enter the specific reason for the adjustment request

• Signature and Date - signature of provider or the authorized party and date

In addition to the above information, please attach a copy of your claim and the Remittance Advice to facilitate processing.

Nursing Facility Providers: Submitting Individual Adjustment Form If you need to correct information on an ICN that has been paid or has an allowed amount present, submit the corrected information on an Individual Adjustment Form.

Hospital Claims:

If a hospital stay is denied as inappropriate resulting from KFMC review, recoupment of collateral claims will be pursued from the admitting physician only. Other ancillary claims will not be recouped.


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5600. Updated 10/07 Completing the Individual Adjustment Form

To facilitate processing, please attach the following:

• Corrected Claim Copy – Please attach a corrected claim to this form.

• Remittance Advice Copy – Please attach a copy of the most current remittance advice of claim being adjusted.

Adjustment Type Checkboxes

Total Claim Recoupment – Check this box if the request is for a full claim recoupment.

Claim Adjustment – Check this box if the request is for a previously paid claim that requires changes.

Underpayment – Check this box if the claim was underpaid.

Overpayment – Check this box if the claim was overpaid. Section I Billing Provider and Beneficiary Information (Required)

Field 1 Name – Billing Provider – Enter the billing provider name.

Field 2 Billing Provider’s KMAP Provider ID – Enter the billing provider’s nine-digit number and alpha location character.

Field 3 Name – Beneficiary – Enter the beneficiary’s name as it appears on medical card.

Field 4 Beneficiary’s ID Number – Enter the beneficiary’s 11-digit identification number.

Field 5 NPI – Enter the billing provider’s National Provider Identifier (NPI). Section II – Claim Information (Required)

Field 6 Internal Control Number – Enter the 13-digit claim number to be adjusted or recouped.

Field 7 Remittance Advice Date – Enter the remittance advice date for the claim number indicated in field 6. Section III – Adjusted Detail Information (indicate only adjusted information).

Field 8 Claim Detail(s) Delete/Add –

Delete – Check the Delete box if the original detail is to be deleted on the adjusted claim.

Add – Check the Add box if this detail is to be added to the adjusted claim. Enter new detail information in fields 9-17.

Note: If the detail exists on the original claim and detail information needs to be changed, do not check these boxes. Indicate changed information accordingly in fields 9-17.

Field 9 Claim Detail To Be Adjusted – Indicate the original line detail to be changed.

Field 10 Date(s) of Service From/To – Enter the From and To date if they need to be changed for the detail line.


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5600. Updated 10/07

Field 11 POS – Enter appropriate two-digit place of service code if detail requires change.

Field 12 Procedure/NDC/Revenue Code – Enter the single most appropriate code to be changed.

Field 13 Modifiers 1-4 – Enter modifiers to be changed.

Field 14 Billed Amount – Enter the changed billed amount for the detail line.

Field 15 Unit Quantity – Enter the appropriate number of units for each detail line to be changed. Always use a decimal (for example, 2.0 units).

Field 16 Performing Provider – Enter the performing provider’s KMAP nine-digit number and alpha location character to be changed.

Field 17 NPI – Enter the performing provider’s NPI to be changed.

Field 18 Third Party Liability (TPL) – Please attach explanation of benefits. Indicate primary insurance and/or Medicare in this field and attach appropriate Explanation of Benefits (EOB) or Explanation of Medicare Benefits (EOMB) to adjustment form.

Field 19 Remarks Section – Enter any additional remarks in this field. Note: Dental Providers – Enter the tooth # and surface code in the Remarks Section.

Attachments with adjustment – Check this box if attachments were submitted with adjustment form.

Contact Name – Indicate an office contact name for questions regarding this adjustment.

Contact Phone Number – Indicate the office contact phone number for questions regarding this adjustment.

Field 20 Provider Signature – Authorized signature of the provider. Required.

Field 21 Date – Enter the signature date. Required.

Notes: If additional space is needed, please attach an additional page. Please retain a copy of the adjustment for your files. This form may be obtained from the KMAP Web site at https://www.kmap-state-ks.us. This form may be faxed or postage mailed to the KMAP Adjustment Unit. Adjustments resulting in an overpayment are deducted from future RAs.

Submission of the Individual Adjustment Form:

Mail or fax the completed Individual Adjustment Form to: Kansas Medical Assistance Program Attn: Adjustment Unit P.O. Box 3571 Topeka, Kansas 66601-3571 Fax: (785) 274-4296


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5700. BILLING/COLLECTION AGENCIES Updated 10/07

If a KMAP provider uses a billing agent to file Medicaid claims or contracts with a collection agency to recover outstanding payments, the billing agent or collection agent may contact the fiscal agent on behalf of the provider when they are administratively (the act of processing medical claims) trying to submit or resubmit a claim. The billing agency or collection agency must have either one of the following:

1) The internal control number (ICN)

2) The date of service (DOS) and either one of the following:

a) The beneficiary’s identification number b) The Medicaid provider number

Here are the only examples where a billing agent or collection agent may contact the fiscal agent:

1) The collection agency/billing agent has an ICN number, or DOS, the beneficiary’s ID number and/or the provider's Medicaid number. The fiscal agent's staff may talk to the collection agency/billing agent about that claim.

2) A collection agency/billing agent calls in to follow-up on the resubmission of a claim. An update of payment or denial can be given.

3) Determination of eligibility for a beneficiary.

The fiscal agent cannot disclose to a collection agency/billing agent:

1) Any diagnoses on a claim 2) What other services were given to this beneficiary 3) Answer any questions that are not administrative in nature about the processing or

reprocessing of a claim


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5800. THE CMS-1500 CLAIM FORM Updated 02/08

Providers must use the CMS-1500 red claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. Any CMS-1500 claim not submitted on the red claim from will be returned to the provider. An example of the CMS-1500 claim form is in the Forms section at the end of this manual. Instructions for completing this form are included on the following pages. Any of the following billing errors may cause a CMS-1500 claim to deny or be sent back to the provider:

• The Kansas interChange MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed.

• Information which is not legible such as blurred, light print, typed over claim lines.

• A CMS-1500 claim form carbon copy.

The fiscal agent, EDS, does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual.

Complete the following CMS-1500 claim form fields when applicable:

Fields not identified below should be left blank.

Field 1 Program Identification: Check appropriate box(es).

Field 1A Insured's ID Number:

Enter the 11-digit beneficiary identification (ID) number from patient's KMAP ID card. If newborn services, use mother's beneficiary ID number if newborn's number is unknown.

Field 2 Patient's Name:

Enter patient's last name, first name and middle initial exactly as it appears on the medical ID card. If patient is a newborn, enter "newborn", "baby boy", or "baby girl", in the first name field and enter the last name.


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5800. Updated 10/07

Field 3 Patient's Date of Birth: Enter patient's date of birth as month, day and year - MM/DD/YYYY (i.e., October 1, 1957 would be listed as 10/01/1957). If newborn services, enter baby's date of birth (not mother's).

Patient's Sex:

Check the appropriate box.

Field 5 Patient's Address: Enter patient's street address including city, state and zip code.

Field 9 Other Insured's Name:

If patient has secondary or supplemental insurance complete fields 9 and 9A-D. (Enter the primary insurance information in field 11.)

Field 10 Is Patient's Condition Related To:

Check appropriate box when billing for accident related services only. If box is checked:

• Enter all available information in field 11. • Check "other" box if related to "child abuse" or a "self inflicted"

injury and note "child abuse" or "self inflicted" in field 10D.

Field 11 Insured's Policy Group or FECA Number: This field should be completed if the patient has insurance primary to Medicaid. If yes, complete fields 11 and 11A-D.

Field 14 Date of :

Complete field when billing for accident related services only. Enter date of accident in MM/DD/YY format. Otherwise, leave blank.

Field 17 Name of Referring Physician or Other Source:

Enter the name of the referring/ordering physician for the following types of claims:

• Those filed by a consultant for consultation services. • Those filed by laboratory and radiology services. • Those filed by a provider who has rendered services to a Lock-In

beneficiary.


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5800. Updated 10/07

Field 17A I.D. Number of Referring Physician: Enter qualifier ‘ZZ’ and a taxonomy code or qualifier ‘1D’ and the 10-digit KMAP provider ID of the referring or ordering physician. Enter all nines if the referring physician is not a KMAP provider.

Field 17B Provider’s NPI: Enter the NPI of the referring physician.

Field 18 Hospitalization Dates Related to Current Services:

Enter dates of admission and discharge.

Field 20 Outside Lab: Check appropriate box:

• If "no," bill for procedures performed. • If "yes," provider who actually performed service must bill.

Field 21 Diagnosis or Nature of Illness or Injury:

Enter the appropriate ICD-9-CM code. If more than one diagnosis applies, list the primary on line 1, secondary on line 2, etc.

Field 22 Original Ref. No.

If this is a resubmission of a claim, enter the previous ICN.

Field 23 Prior Authorization Number: Enter the assigned PA number from the approval letter, when applicable.

Field 24A Date(s) of Service:

Enter date of service in MM/DD/YY format. If multiple services were performed on consecutive dates, give beginning date in "from" and give the last date of service in the "to" field and complete the units field (24G) accordingly. Note: Commercial Non-Emergency Transportation providers (NEMT) are not to use date ranges. Each date of service must be billed as a separated line item.


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5800. Updated 10/07

Field 24B Place of Service: Enter appropriate "place of service code" for each service. Not all of the place of service codes may be appropriate for the service provided. Indicate the place of service code that most accurately reflects where the service was provided 11 – Office 12 – Home 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room – Hospital 24 – Ambulatory Surgical Center 31 – Skilled Nursing Facility 32 – Nursing Facility 33 – Custodial Care Facility 34 – Hospice 41 – Ambulance – Land 42 – Ambulance-Air or Water 50 – Federally Qualified Health Center (FQHC) 53 – CMHC 54 – ICF/MR 65 – End Stage Renal Disease Treatment Facility 71 – Local Health Department 72 – Rural Health Clinic (RHC) 81 – Independent Laboratory 99 – Other Locations

Field 24D Procedures, Services, or Supplies:

Enter HCPCS 5-digit base procedure code (add modifier(s) if appropriate). Explain unusual circumstances.

Field 24E Diagnosis Code:

Enter the appropriate line number from field 21.

Field 24F Charges: Enter your usual and customary charge for each service.

Field 24G Days or Units:

Enter number of visits, days or units of service rendered, as applicable to each detail line. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC) should bill only one encounter per claim detail.


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5800. Updated 10/07

Field 24H EPSDT Family Plan:

COB:(EPSDT/KBH referral value) Enter the 2-digit value when an EPSDT (KAN Be Healthy) screen results in a

referral. The value choices include: AV – the beneficiary refused the referral S2 – the beneficiary is currently under treatment ST – new services requested

EPSDT / Family Planning:

Enter “E” when completing an EPSDT (KAN Be Healthy) screen. Enter “F” when completing a Family Planning visit. Enter “B” when both, an EPSDT (KBH) and Family Planning visit, are completed.

Field 24I ID Qualifier:

Enter qualifier ‘ZZ’ if billing with a taxonomy code in the top half of field 24J. Enter qualifier ‘1D’ if billing with a KMAP provider ID in the top half of field 24J.

Field 24J Rendering Provider ID. #:

Enter in the top half a 10-digit KMAP provider ID or a taxonomy code. Enter in the bottom half the provider’s NPI.

Field 26 Your Patient's Account Number:

OPTIONAL: Any alpha/numeric character entered in this field will be referenced on the Remittance Advice. No unique characters should be indicated, e.g., *, @, -, #, etc.

Field 27 Accept Assignment:

Leave blank. All providers of Kansas Medical Assistance Program services must accept assignment in order to receive payment on a Medicare related claim.


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5800. Updated 10/07

Field 28 Total Charge: Enter total of all itemized charges on this page of the claim. (Do not include co-payment amount. Refer to Section 8100 of each individual provider manual.)

When more than one claim page is utilized for the same beneficiary, for the same date of service, follow the instructions below:

1) Ensure that multiple pages of the claims are sent to Medicaid together 2) Do not total the charges in Field 28 on each claim form. Only total all itemized charges (on all claim forms) on the last claim page. 3) Enter “Continued. Page __ of __” in Field 28. For example, when 10 procedures were provided for the same beneficiary on the same date of service enter, “Continued. Page 1 of 2.” 4) Enter the total charge in Field 28 of the last page of the claim form page 2. According to the example above, the total charge would be in Field 28 on page 2.

Field 29 Amount Paid:

Enter any amount paid by insurance or other third party sources known at the time the claim is submitted on the last claim page submitted. If the amount shown in this field is the result of other insurance, documentation of the payment must be attached. (Field 11 must identify the other insurance source.) Refer to Sections 3200 and 3300 of the General Third Party Payment Provider Manual for more specific information. Do not enter co-payment or spenddown payment amounts. They are deducted automatically. Note: Retain proof of other insurance payment in the beneficiary’s file.

Field 30 Balance Due:

Subtract block 29 from 28 and enter the balance on the last claim page submitted.

Field 31 Signature of Physician or Supplier:

Read statement on back of claim form, sign and date. • Phrase "signature on file" is acceptable. • Provider’s name typed/stamped is acceptable.

Field 32 Name and Address of Facility Where Services Rendered:

Enter name and address of facility (if other than patient's home or provider's facility).


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5800. Updated 10/07

Field 32A Provider’s NPI: Enter the provider’s NPI.

Field 32B KMAP Provider ID or Taxonomy Code:

Enter either a 10-digit KMAP provider ID or a taxonomy code.

Field 33 Billing Provider Info & Ph #: This information regarding the group number corresponds with the provider information provided in fields 33A and 33B.

Field 33A Provider’s NPI:

Enter the provider’s NPI.

Field 33B KMAP Provider ID or Taxonomy Code: Enter qualifier ‘1D’ and the 10-digit KMAP provider ID or qualifier ‘ZZ’ and a taxonomy code.

Submission of Claims:

Send completed first page of each claim and any necessary attachments to:

Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, KS 66601-3571


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5900. COMPLIANCE WITH SECTION 6032 OF FEDERAL DEFICIT REDUCTION ACT Updated 10/07 Any KMAP provider, including any KMAP managed care organization, that receives or makes $5 million in annual KMAP payments, must comply with Section 6032 of the Deficit Reduction Act of 2005 (DRA) as a condition of receiving payment under KMAP. The $5 million amount, for KMAP purposes, is based on paid claims, net of any adjustments to those claims. It is the responsibility of providers or provider entities to make the determination as to whether they meet the $5 million threshold.

To comply with Section 6032, the provider must ensure that no later than January 1, 2007, it has implemented all of the following requirements:

1. The provider must establish written policies that provide detailed information about the federal laws identified in Section 6032(A) and any Kansas laws imposing civil or criminal penalties for false claims and statements, or providing whistleblower protections under such laws.

2. In addition to the detailed information regarding the federal and state laws, the provider’s written policies must contain detailed information regarding the provider’s own policies and procedures to detect and prevent fraud, waste, and abuse in federal healthcare programs, including Medicare and KMAP.

3. The provider must provide a copy of its written policies to all of its employees, contractors, and agents of the vendor.

4. If the provider maintains an employee handbook, the provider must include in its employee handbook a specific discussion of the federal and state laws described in its written polices; the provider’s policies and procedures for detecting and preventing fraud, waste, and abuse; and the right of its employees to be protected from discharge, demotion, suspension, threat, harassment, discrimination, or retaliation in the event the employee files a claim pursuant to the Federal False Claims Act or otherwise makes a good faith report alleging fraud, waste, or abuse in a federal healthcare program, including Medicare and KMAP, to the provider or to the appropriate authorities.

Any KMAP provider that receives or makes annual payments of $5 million or more under KMAP must certify annually that it complies with Section 6032 of the DRA. Specifically, each year, providers must complete and submit the form attesting compliance with Section 6032 of the DRA to KHPA. This form may be downloaded from the KMAP Web site. For federal fiscal year 2006, providers must submit their initial annual attestation form no later than October 1, 2007. In future years, including federal fiscal year 2007, this form must be submitted in the quarter following the end of each federal fiscal year (October to December), but before January 1 of the following year.


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5900. Updated 10/07 The KHPA and partner agencies Kansas Department of Social and Rehabilitation Services and Kansas Department on Aging have the responsibility to ensure compliance with the requirements. In addition to the annual certification, compliance is determined through retrospective reviews by the fiscal agent and contractors and through other State audits. Providers must be prepared to submit the following items within 10 days of the request of the fiscal agent, contractor, or State agency:

• Copies of written or electronic policies that meet the federal requirements • Written description of how the policies are made available and disseminated to all employees

and to all employees of any contractor agent for each provider or provider entity • Copies of any employee handbook, if the provider maintains a handbook

Compliance with these requirements is mandatory. Any provider or provider entity that fails to comply with the annual attestation or the submission of information will be subject to sanction, including suspension of Medicaid payments or termination from participation in the Kansas Medical Assistance Program.

FORMS

• Individual Adjustment Form • CMS-1500 • Attestation of Compliance with Section 6032 of the

Federal Deficit Reduction Act

Kansas Medical Assistance Program Individual Adjustment Form

This facsimile transmission and attachments contains protected health information (PHI) from EDS and is covered by the Electronic Communications Privacy Act, 18 U.S.C § 2510-2521 and the Standards for Privacy of Individual Identifiable Health Information, 45 CFR Parts 160 and 164, which is intended only for the use of the individual or entity named in the e-mail. Any unintended recipient is hereby notified that the information is privileged and confidential, and any use, disclosure, or reproduction of this information is prohibited. Any unintended recipient should contact EDS by telephone at 785-274-4205 immediately and delete the original message. Form Updated 5/15/2007

To facilitate processing, please attach the following: • Claim copy • Remittance Advice copy

Total Claim Recoupment Claim Adjustment

Underpayment Overpayment

Section I – Billing and Beneficiary Information 1. Name – Billing Provider .

2. Billing Provider’s KMAP Provider ID

3. Name – Beneficiary

4. Beneficiary’s ID Number

5. NPI

Section II – Claim Information 6. Internal Control Number

7. Remittance Advice Date

Section III – Adjustment Detail Information (enter corrected information only) 8. Claim Detail(s) Delete Add

9.

Claim Detail To Be Adjusted

10.

Date(s) of Service

From To

11.

POS

12. Procedure/NDC/ Revenue Code

13. Modifiers 1-4

14. Billed Amount

15. Units/ Qty.

16. Performing Provider

17. NPI

18. Third Party Liability (TPL) Please attach explanation of benefits.

19. Remarks Section

Attachment(s) with adjustment Mail To:

Contact Name: ___________________________ Kansas Medical Assistance Program Attn: Adjustment Unit Contact Phone Number: ____________________ P.O. Box 3571 Topeka, KS 66601

Fax: (785) 274-4296 20. Provider Signature: _________________________________________ 21. Date: ____________________________

Attestation of Compliance with Section 6032 of the Federal Deficit Reduction Act

Provider/Entity Name: _________________________________________________________________ KMAP Provider Number or NPI: _________________________________________________________ Address: ___________________________________________________________________________ Street City State ZIP Code I hereby attest that, as a condition for receiving payments, I have read Section 6032 of the Deficit Reduction Act of 2005 (the Act), and have examined the above-named provider/entity’s policies and procedures. Based on that review, the provider/entity is in compliance with the requirements of the Act to educate employees and contractors concerning the Federal False Claims Act established under sections 3729 through 3733 of Title 31, United States Code, administrative remedies for false claims and statements established under Chapter 38 of Title 31, United States Code, State laws pertaining to Medicaid fraud, abuse, civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste and abuse in Federal health care programs. Furthermore, the provider/entity will continue to comply with these provisions to remain eligible for payment under the Kansas Medical Assistance Program. I declare that the Provider or Contractor must continue to comply with these provisions to remain eligible for payment under the Kansas Medical Assistance Program. I understand that if any statements in this declaration are false, they may be subject to prosecution under the Kansas perjury law, K.S.A. 21-3805, as well as the laws cited in this declaration. I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. Executed on (date) ______________________ For Federal Fiscal Year _________ _______________________________________________ _________

Signature of Chief Executive Officer/President/Vice President Date _______________________________________________

Print or Type Name and Title _______________________________________________ _________

Signature of Corporate Secretary/Treasurer Date _______________________________________________

Print or Type Name and Title Mail or fax the completed form to:

Kansas Health Policy Authority Fax: 785-296-4813 Attention: Tamara Demmitt Landon State Office Building 900 SW Jackson, Room 900 Topeka, KS 66612