Using PES Billing Professional Services Arkansas Medicaid © Copyright 2012 Hewlett-Packard Development Company, L.P. The information contained herein is

Using PES Billing Professional Services Arkansas Medicaid

© Copyright 2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.


Agenda

Claim formsThird Party Liability Eligibility5010 ChangesTransmitting data


Claim forms

4 © Copyright 2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

Primary Care Physician (PCP)

Arkansas Medicaid operates as a Primary Care Case Management Program. Most beneficiaries are required to have a PCP, and most services require PCP referral.

Beneficiaries that are not required to enroll with a PCP include:

Beneficiaries with Medicare coverage

Residents of an Intermediate Care Facility for the Mentally Retarded

Residents of Long Term Care facilities

Beneficiaries on spend down aid categories

Retroactive eligible beneficiaries


Header 1

Header 1 contains 2 main pieces of information:

• Who is getting paid?

–This is who is billing for services that will be paid by Arkansas Medicaid

• Who are we billing services for?

–This is who actually received the services that is an Arkansas Medicaid beneficiary



Provider ID

This is the provider who will be paid for this claim.

When submitting claims electronically, ALWAYS USE YOUR NPI


Beneficiary ID

Account # - We recommend using the patient’s last name unless using a vendor for electronic posting. Use the Last Name, First Name, and DOB that Arkansas Medicaid has on file for this beneficiary.

SSN not Required


Omit Attachment Section



Header 2

Header 2 relates to diagnosis codes, auths, etc.

• Diagnosis Codes

–Do not enter the decimal in the DX code.

Example: if DX is 111.11; enter 11111

• Referring Provider

–If a PCP referral is required, PCP info must be entered

• Facility Provider ID

–Where was the patient located for these services?


Prior Auth: Only if required (one PA per Claim)Hospital Admit Date: Facility admit date (required if POS is 21, 22, or 23)Date Last Seen/Onset of Current Illness (not required)


Referring Provider or Facility



Header 3

Header 3 relates to the services that are provided

• Related Causes

–If services were provided due to accident; workers comp, auto accident, etc.

• Special Program Code

–Indicates if an EPSDT screening was performed

• EPSDT Referral

–Indicates if an EPSDT Referral was given

–Referral Status

• Therapy Service

–See section 262.310 of the OT, PT, and speech manual


Header 3 (cont)

• School District

–School’s LEA Code

• TPL stands for Third Party Liability

–This is for patients who have commercial insurance coverage

• Crossover

–This is for patients who have Medicare or a Medicare Replacement Plan coverage

• NET

–Non Emergency Transportation


Third Party Liability


TPL Indicator

If beneficiary has commercial insurance change the TPL indicator to “Y”. This will add another tab at the top to enter the commercial insurance payment information.



TPL Information

Claim Filing Indicator Code

• ALWAYS USE COMMERCIAL INSURANCE (CI)

Paid Amount and Denial Date

• If the claim was paid on by commercial insurance, then enter that amount here

• If the claim was TOTALLY denied, then enter the date from EOB here

Policy Holder Information

• This information can be found on eligibility strip that ran for the patient


How to Read TPL Information----------------------------------------------E L I G I B I L I T Y I N F O R M A T I O N

ELIGIBILITY/BENEFIT: 1 ACTIVE COVERAGEPLAN DESCRIPTION: 01ARKIDS 1STELIGIBILITY PERIOD: 01/01/2010-07/01/2010COUNTY: 731 WHITE

ELIGIBILITY/BENEFIT: R TPLINSURANCE TYPE: C1 COMMERCIALTPL MEMBER #: xxxxxxxxxxTPL POLICY #: 7777777TPL GROUP #: 666666PLAN NAME: ACME INSURANCEELIGIBILITY PERIOD: 01/01/2010 – 07/01/2010COVERAGE 1: FULL COVERAGELAST/ORG NAME: ACME INSURANCECOMPANY CODE: ABCADDRESS LINE 1: P.O. BOX 1000CITY: LITTLE ROCKSTATE: ARZIP: 72201

(continued next)

Shows coverage

TPL information

Aid category

Dates of eligibility

County of residence

Type of TPL

Member number

Policy number

Group number

Plan name

Type of coverage

Dates of coverage

Name of insurer

Company code

Address


To get the additional information you will need to check the supplemental eligibility information for the beneficiary.

The supplemental eligibility information can be obtained through the Medicaid website or PES.


Eligibility


Supplemental Eligibility

website

PES software


------------------------------------------SUPPLEMENTAL ELIGIBILITY BATCH RESPONSE

BENEFICIARY ID: XXXXXXXXXXPLAN CODE: 01PLAN DESCRIPTION 1: ARKIDS 1ST ELIGIBILITY BEGIN DATE: 1/01/2005ELIGIBILITY END DATE: 7/01/2005COUNTY CODE: 731COUNTY: WHITE

TPL SEGMENT COUNT 1

TPL COMPANY CODE D02TPL SUBSCRIBER NAME JOHN DOE

Beneficiary ID for this eligibility segment…up to 4 segments returned

Plan code and description

Dates of eligibility in this aid category

Number of TPL segments

TPL carrier code

Name of policy holder


Arkansas Medicaid does not return the Policy Holder’s DOB, Gender, Address, or Relationship to the Beneficiary through the eligibility response. You will need to obtain this information from the patient.



Crossover Indicator

If beneficiary has Medicare change the Crossover indicator to “Y”. This will add another tab at the top to enter the Medicare payment information. If Medicare denied the claim it cannot be filed electronically.



Crossover

This information is obtained from the Medicare EOB

• The Medicare ICN is the claim number assigned by Medicare–When entering this information, you must use a 13

digit/alpha claim number. If the Medicare ICN is not 13 digits/alpha characters, use zeros to make 13 digits/alpha characters long.




Service 1

What DOS or range of DOS are we billing for?

What Procedure Code for this DOS(s) are we billing for?

What is the total units we provided for this Procedure Code on this DOS(s)?

What is the total charge for all of these units (NOT FOR EACH UNIT) on this DOS(s) for this Procedure Code?


5010 Changes


5010 Changes for PES

The drug codes above are for a compound drug. Even though it is the same drug code, two different NDC numbers will be used so the drug code will have to be on two different service lines.



A drug code is listed on the Service tab 1. To enter the NDC number for the drug code being billed click the RX Indicator button on Service tab 2 and select Y for YES. The RX tab will appear.



A drug code is listed on Service line 2, so the NDC number for this line will be entered here. Providers will use the RX/Link # for the compound drug. The RX/Link # will indicate which NDC numbers on the claim need to be linked together for the compound drug



A drug code is listed on Service line 3, so the NDC number for this line will be entered here. Providers will use the RX/Link # for the compound drug. The RX/Link # will indicate which NDC numbers on the claim need to be linked together for the compound drug


Do not enter the Place of Service on this tab

Modifiers (only if required)


Use the Copy Service button to easily enter multiple DOS or Procedure codes!



Service 2

Were the services due to an Emergency, EPSDT, or Family Planning?

Does the procedure code require an NDC number?


If procedure code requires an NDC # change the RX Indicator to “Y”. This will add an RX tab to enter the NDC #.


NDC must be 11 digits

Click Save when all items have been entered.


Your claim(s) is now ready to submit!Click Close to proceed to next step to submit claims


How to Submit Claims

Once you are ready to submit your claim(s) for processing, click on the Communication Tab at the top of the main screen.

This will open a drop down menu where you will now select Submission.


Sending/Receiving

Files to Send

• Do this step first• Select the files you want to send and then click Submit.

It is recommended to select all so you do not miss any files that you may need to send.

Files to receive

• Select ALL files to receive and then click Submit.


Claim Status Reports

Once a claim has been submitted electronically, it takes about 3-4 minutes per claim to get a response. So if you submit 10 claims, you will need to wait approximately 30-40 minutes to receive a response (Time may vary).

When requesting to receive files, ALWAYS SELECT ALL!

There are 2 main reports we want to look at. The Batch Response and 997s and the Rejected Response Report.


Batch Response and 997s

This report is basically a “Yes” or “No” answer to if your claim was successfully submitted for processing by Arkansas Medicaid.• If the claim was accepted, you will see that an ICN number is

assigned to your claim for tracking.• If the claim was rejected, you will see that there is NOT an ICN

number assigned to your claim.


Rejected Response Report

This report will go into detail of claims that were not accepted for processing.• It will tell you how many errors were on your claim• Where these errors are located (Header/Detail)• Detail about the actual error such as invalid diagnosis (Did you

use decimal point in diagnosis field?)


How to Fix Rejected Claims

You may resubmit any rejected claim very easily.• Find your claim that was rejected and select it with your mouse

–You will receive an error that reads, “Record with status of F cannot be updated.”

–Click “OK”


Select the “Copy” button


Corrected Claim

By selecting “Copy”, this generates an exact duplicate of the claim previously submitted.• Keep in mind that this function is also copying any error on

your claim that was previously submitted also

Find the error on your claim in the appropriate Header/TPL/Crossover/Service Tab• Correct the error, save and then submit again!


Build Lists

When you are on the main screen when logged into PES, you can build a list for different beneficiaries, providers, revenue codes, diagnosis codes, etc.• This will help make things faster by already having this

information saved on your computer so that building claims becomes quicker


Additional Information

Go to www.medicaid.state.ar.us

Click on Provider

Click Free Software

Click HP Enterprise Services Provider Electronic Solutions

Scroll to the bottom; click on PES Handbook


Questions?


Thank you

Documents

Using PES Billing Professional Services Arkansas Medicaid © Copyright 2012 Hewlett-Packard Development Company, L.P. The information contained herein is