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DMAS Division of Health Care Services. Billing for Emergency and Non-Emergency Transportation Services With Dates of Service October 31, 2009 and Before. Presentation Outline. Health Insurance Claim Form - 1500 Emergency Ground & Neonatal Ambulance Transportation

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Dmas division of health care services

DMAS Division of Health Care Services

Billing for Emergency and Non-Emergency Transportation Services

With Dates of Service October 31, 2009 and Before


Presentation outline
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


Health insurance claim form cms 1500
Health Insurance Claim Form CMS 1500

  • What’s Changed?

    • We want to remind everyone that this is not a change in policy.

    • Effective April 1, Cross Over claims will be processed using the correct manner.

    • Medicaid reimbursement for these services is less than 80% of the Medicare payment level, Medicare crossover claims will be paid at $0.00 with the claims edit 364 (“Exceeds Medicaid Allowed Amount.”)

    • Use Font size 10 or larger

    • Mail all Ground Ambulance claims to First Health, address at end of presentation

  • Most Common Mistakes

    • Using a 2-code system (One code for base rate and second code for mileage)

    • Trying to bill using CPT/HCPCS mileage codes with:

      • A0425

      • A0435

      • A0436

  • Block 10b, make sure and check yes for auto accidents

  • Block 10c, make sure to mark for other accidents


Eligibility and claims status information
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.


Transportation for managed care organizations mco
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.



Printing
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


Printing1
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


Timely filing
TIMELYFILING

  • ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE

  • EXCEPTIONS

    • Retroactive/Delayed Eligibility

    • Denied Claims

  • NO EXCEPTIONS

    • Accident Cases

    • Other Primary Insurance


Timely filing1
TIMELY FILING

  • Submit claims with documentation attached explaining the reason for delayed submission

  • You must have the word “Attachment” in Locator 10d and use modifier “22” in Locator 24D (Attachments include: Run sheets, Call sheets, Pre-hospital Patient Care Report (PPCR)


Block 1
Block 1

  • Enter an ‘X’ in the MEDICAID box for the Medicaid Program


Block 1

TRICARE

MEDICAID

1.MEDICARE

CHAMPUS

(Medicare#)

(Medicaid#)

(Sponsor'sSSN)

2.PATIENT'SNAME(LastName,FirstName,MiddleInitial)

MEDICAID CLAIM

12


Block 1a: Recipient ID Number

1a.INSURED'SI.D.NUMBER(FORPROGRAMINITEM1)

123456789014

(Be sure to include all 12 digits)

13


Block 2: Patient's Name

2.PATIENT'SNAME(Lastname,FirstName,MiddleInitial)

Smith, Sam

5.PATIENT'SADDRESS(No.,Street)

14


Is patient s condition related to block 10a 10b 10c
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.ISPATIENT'SCONDITIONRELATEDTO:

a.EMPLOYMENT?(CURRENTORPREVIOUS)

YES

NO

PLACE(State)

b.AUTOACCIDENT?

WV

YES

NO

c.OTHERACCIDENT?

NO

YES

You MUST check YES or NO for a, b & c

16


Block 10d

10d.RESERVEDFORLOCALUSE

ATTACHMENT

You MUST use the word "ATTACHMENT"

if documents are attached to the HCFA form.

17


Block 11c insurance plan name or program name
Block 11c - Insurance Plan Name or Program Name

c. INSURANCE PLAN NAME OR PROGRAM NAME

Other Insurance COPAY

18


Is there another health benefit plan block 11d
Is There Another Health Benefit Plan?Block-11d

  • Providers should only check yes if there is another third party carrier


Block 11d is there another health benefit plan
Block 11d - Is There Another Health Benefit Plan?

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

If yes, return to and complete item 9 a-d.

NO

YES

20


Block 21: Diagnosis Codes

21.DIAGNOSISORNATUREOFILLNESSORINJURY

31100

1.

3.

30130

2.

4.

May enter up to 4 codes

Omit decimals (List of frequently used diagnosis codes are in the Transportation Manual)

21


Blocks 24a thru 24j
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


Tpl information block 24a
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

  • Decimal between dollars and cents is required to read paid amount correctly

  • Must be left justified


Tpl information block 24a1
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 2

    • No, 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


Tpl information block 24a2
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


Block 24A: Dates of Service

24.A.

DATE(S)OFSERVICE

From

To

MMDDYY

MMDDYY

TPL27.08

06

06

03

01

03

01

1

2

BothFROMandTOdates

must be completed

26

Dates must be within same calendar month


Block 24B: Place of Service

B.

41- Ambulance – Land

Or

42-Ambulance – Air or Water

“Not both”

Place

of

Service

41

Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare.

27


Emergency indicator 24c
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


Block 24C: EMG

C.

EMG

Y

Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency

29


Block 24D: Procedure Codes

D.

PROCEDURES,SERVICES,ORSUPPLIES

(ExplainUnusualCircumstances)

CPT/HCPCS

MODIFIER

DMAS Recognizes the

Following codes:

A0225

A0427

A0429

A0430

A0431

A0225

22

All Claims must have modifier 22

30


Block 24E: Diagnosis Code

21.DIAGNOSISORNATUREOFILLNESSORINJURY

34431

1.

3.

2963

2.

4.

E.

DIAGNOSIS

POINTER

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.

1

1,2

31


Block 24 F: Charges

F.

$CHARGES

500

00

Enter the usual

and customary charges

32


Block 24G: Days or Units

G.

DAYS

OR

Enter the number of “loaded miles” of transport.

The 31 is an example that shows loaded miles.

UNITS

31

33


Id qual block 24i shaded area
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.


If taxonomy codes are used block 24j
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.


Fill in only if Taxonomy codes are needed

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

3416A0800X

Or

3416L0300X

ZZ

3416A0800X is Air

3416L0300X is Land

36


Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

J.

RENDERING

PROVIDER ID. #

I.

ID.

QUAL

Taxonomy # (if needed)

ZZ

12345647890

NPI

37


Block 26: Patient’s Account Number

(Optional)

26.PATIENTACCOUNTNUMBER

12345678918765

Can not exceed 17

alphanumeric digits

38


Total charge block 28
Total ChargeBlock 28

  • DMAS now requires this locator to be completed

  • Enter the total charges for the services in 24F lines 1-6.


Block 28: Total Charges

28.TOTALCHARGE

$

40


Block 29: Amount Paid

(By Other Insurance)

29.AMOUNTPAID

$

41


Block 30: Amount Paid

(By Other Insurance)

30.Balance Due

$

42


Block 31: Signature & Date

31.SIGNATUREOFPHYSICIANORSUPPLIER

INCLUDINGDEGREESORCREDENTIALS

(Icertifythatthestatementsonthereverse

applytothisbillandaremadeapartthereof.)

SIGNED

DATE

If there is a signature waiver

on file, you may stamp, print,

or computer-generate the signature.

43


Service facility location information block 32
Service Facility Location InformationBlock-32

  • Enter information for the location where services were rendered

    • First line-Name

    • Second line-Address

    • Third line-City, State, 9 digit zip code

  • The zip code must reflect the office location where services were rendered

  • No punctuation in the address

  • Space between city and state

  • Include hyphen for the 9 digit zip code



Block 32 service facility location information
Block 32: Service Facility Location Information

Your Local Hospital

XXXX Anywhere St.

Your Town, ST 12345-1456

32. SERVICE FACILITY LOCATION INFORMATION

Leave Blank

a.

Leave Blank

b.

46


Billing provider info ph block 33
Billing Provider Info & PH #-Block-33

  • 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


Billing provider info ph block 33a b
Billing Provider Info & PH #-Block-33a-b

  • Enter the 10 digit NPI number of the service location in 33a.

  • Enter ‘ZZ’ qualifier with the taxonomy code if needed, when using the NPI in 33a (example – ZZ3416L0300Z)


Block 33 billing provider info ph
Block 33: Billing Provider Info & PH #

Your Local Hospital

XXXX Anywhere St.

Your Town, ST 12345-1456

33. BILLING PROVIDER INFO & PH #

(123) 456-7890

a.

1234567890

ZZ3416L0300X (If needed)

b.

49


Block 22: Adjustments and Voids

22.MEDICAIDRESUBMISSION

CODE

ORIGINALREF.NO.

1032

xxxxxxxxxxxxxxxx

From Original

Adjustment or

Void

Remittance

Resubmission Code

Chap. V, Medicaid Transportation Manual has code list.

50


Block 22: Medicaid Resubmission Codes

  • Medicaid Resubmission of Adjustment Codes

  • Primary Carrier has made additional payment

  • Primary Carrier has denied payment

  • Accommodation charge corrected

  • Patient payment amount charged

  • Correcting service periods

  • Correcting procedure/service code

  • Correcting diagnosis code

  • Correcting charges

  • Correcting units/visits/studies/procedures

  • IC reconsideration of allowance, documented

  • Correcting admitting, referring, prescribing,

  • provider ID

  • 1041 Incorrect Amount paid

  • 1053 Adjustment reason is in the Misc. Category

  • Medicaid Resubmission of Void Invoice Codes

  • Original claim has multiple incorrect items

  • Wrong provider identification number

  • Wrong enrollee eligibility number

  • Primary carrier has paid DMAS maximum

  • allowance

  • 1047 Duplicate carrier has paid full charge

  • 1048 Primary carrier has paid full charge

  • 1051 Enrollee is not my patient

  • Miscellaneous

  • 1060 Other insurance is available

Original Reference Number/ICN - Enter the claim reference number/ICNof the paid 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.)

51


More than one emergency air or ground claim with same day service
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. 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 attachments and mail to:

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219


Mailing address for emergency air ambulance claims
Mailing Address for Emergency Air Ambulance Claims Service

  • Emergency Air Ambulance Claims with Attachments

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219

  • Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.


Air ambulance claim procedure and claim reconsideration
Air Ambulance Claim Procedure and Claim Reconsideration Service

  • All air ambulance claims are reviewed for medical necessity of using an emergency air ambulance. Claims submitted that do not establish air ambulance medical necessity will be paid at 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:

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219

  • If reconsideration is denied, then please use the formal appeal process.


Mailing address for emergency ground ambulance services
Mailing Address for Emergency Ground Ambulance Services Service

  • Emergency Ground and Neonatal Ambulance Claims with Attachments

    DMAS-Transportation

    P. O. Box 27447

    Richmond, Virginia 23261-7447

  • Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.



Title xviii common mistakes
Title XVIII Common Mistakes Service

  • 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)


Changes
CHANGES Service

  • Locator 01-Billing Provider Number

  • Locator 06-Rendering Provider Number

  • Locator 08-Type of Coverage


Title xviii block 01
Title XVIII- Block 01 Service

01 Billing Provider Number

Enter the billing provider NPI number

59


Title xviii block 06
Title XVIII- Block 06 Service

06 Rendering Provider Number

Enter the rendering provider NPI number

60


Title xviii block 7
Title XVIII – Block 7 Service

07

Primary Carrier Information Other ThanMedicare

2 No Other Coverage

5 Billed No Coverage

3 Billed and Paid


Title xviii block 08
Title XVIII – Block 08 Service

08

Type OfCoverageMedicare

Type CoverageMedicare- Mark type of coverage “B”.

B

6


Title xviii block 17
Title XVIII- Block 17 Service

17

Charges To Medicare

Block 17: Charges to Medicare- Enter the total charges submitted to Medicare.


Title xviii block 18
Title XVIII- Block 18 Service

Allowed By Medicare

18

Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare.


Title xviii block 19
Title XVIII- Block 19 Service

19

Paid By Medicare

Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the EOB).


Title xviii block 20
Title XVIII- Block 20 Service

Deductible

20

Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB).


Title xviii block 21
Title XVIII- Block 21 Service

Co-Insurance

21

Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare EOB).


Title xviii block 22
Title XVIII- Block 22 Service

Paid By Carrier Other Than

Medicare

22

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.)


Title xviii block 23
Title XVIII- Block 23 Service

23

Patient Pay Amt. LTC Only

Block 23: Patient Pay Amount, LTC Only- Leave Blank.


Title xviii adjustment invoice dmas 31
TITLE XVIII- ServiceAdjustment InvoiceDMAS-31

  • Block 1Adjustment/VoidCheck the appropriate block

  • Block 2Billing Provider Number Enter the NPI of the billing provider

  • Block 6Rendering Provider Number

    Enter the NPI of the rendering provider

  • Block 2AReference NumberEnter the ICN number taken from the Remittance Voucher for the line of payment needing adjustment.


Title xviii adjustment invoice
TITLE XVIII- ServiceAdjustment Invoice

  • Blocks 3-20Refer 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.


Reminders
REMINDERS Service

  • Xeroxed copies 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


Logisticare contact telephone number for a0428 non emergency ambulance non emergency services
LogistiCare Contact Telephone Number For A0428 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 A0428 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.


Resources
Resources Ambulance Non-Emergency Services

  • 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


Help line

HELPLINE Ambulance Non-Emergency Services

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.

Help Line


Questions
Questions? Ambulance Non-Emergency Services


Thank you

THANK YOU Ambulance Non-Emergency Services


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