CMS-1450 Billing Guidelines for Hospitals

1. CMS-1450 Billing Guidelinesfor Hospitals December 2009 www.dmas.virginia.gov

3. Objectives

4. Participating Providers Must- Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid by Virginia Medicaid. Bill any and all other third party carriers.

5. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

6. MediCall/Automated Response System (ARS) Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Patient Pay Information Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

7. MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

8. Automated Response System (ARS) Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

9. ARS Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Select the ARS tab on FHSC ARS Home Page Choose “User Administration” Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’ Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process. Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process.

10. ARS – Users ARS User’s Guide http://www.dmas.virginia.gov/prclaims_billing.htm Web Support Helpline- 800-241-8726 You are required to enroll and begin using the new Web Site by May 23, 2007. You are required to enroll and begin using the new Web Site by May 23, 2007.

11. Important Contacts Provider Call Center Provider Enrollment Electronic Claims Coordinator

12. Provider Helpline Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

13. Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

14. Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

15. Billing on the CMS-1450

16. MAIL CMS-1450 FORMS : DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Facility P. O. Box 27443 Richmond, Virginia 23261-7443

17. TIMELY FILING ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive/Delayed Eligibility Denied Claims NO EXCEPTIONS Accidents Other Primary Insurance

18. TIMELY FILING Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

20. Locator 1:Provider’s Name, Address and Phone Number Enter the provider’s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. NOTE: DMAS will need to have the 9 digit zip code on line four, left justified for adjudicating the claim.

22.  3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters. 3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters.

23. Enter the code as appropriate. Claims submitted without the required four digit bill type will be denied. Enter the code as appropriate. Claims submitted without the required four digit bill type will be denied.

24. 0111- Original Inpatient Hospital Invoice 0112- Interim Inpatient Hospital Invoice* 0113- Continuing Inpatient Hospital Invoice* 0114- Last Inpatient Hospital Invoice * 0117- Adjustment Inpatient Hospital 0118- Void Inpatient Hospital Invoice Only “APROVED” claims can be adjusted or voided

26. Locator 6: Statement Covered Period For hospital admissions, the billing cycle for general medical surgical services has been expanded to a minimum of 120 days for both children and adults, except for psychiatric services. Interim claims (bill types 0112 or 0113) submitted with less than 120 days will be denied. Bill types 0111 or 0114 submitted with greater than 120 days will be denied. These guidelines also apply to SLH claims. These guidelines also apply to SLH claims.

32. Locator 12: Admission/Start of Care The start date for this episode of care. For inpatient services this is the date of admission. For all other services, the date the episode of care began: IP- Day admitted OP- Day episode of care began

33. 

35. Appropriate PRIORITY TYPE codes accepted by DMAS are:

37. Source of Referral for Admission or Visit Appropriate codes accepted by DMAS are:

38. For TDO and ECO claims, your admission source should be 8.For TDO and ECO claims, your admission source should be 8.

39. TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing. SLH-Enter the hour the patient was discharged from inpatient care. TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing. SLH-Enter the hour the patient was discharged from inpatient care.

40. Locator 17:Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:

41. Locator 17:Patient Discharge Status

42. Locator 17:Patient Discharge Status

43. Locator 17: Patient Status

45. Locators 18-28:Condition Codes These codes are used by DMAS in the adjudication of claims:

46. Locators 18-28:Condition Codes These codes are used by DMAS in the adjudication of claims:

52. DMAS will capture the number of covered or non-covered day (s) or units for outpatient services with these required value codes: 80 Enter the number of covered days for inpatient hospitalization or the number of days for re-occurring outpatient claims. 81 Enter the number of non-covered days for inpatient hospitalization Locators 39-41:Value Codes and Amounts

53. Locators 39-41: Value Codes and Amount Enter the appropriate code (s) to relate amounts or values to identify data elements necessary to process this claim. One of the following codes must be used to indicate coordination of third party insurance carrier benefits No Other Coverage Billed and Paid (Enter Amount Paid by Primary Carrier) 85 Billed Not Covered/No Payment (Documentation Required)

54. Locators 39-41: Value Codes and Amount For Part A Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes: A1 Deductible from Part A A2 Coinsurance from Part A Other codes may be used if applicable.

56. Locator 42: Revenue Code Enter the appropriate revenue code (s) for the service provided. Note: Multiple services for the same item, providers should aggregate the service under the assigned revenue code and then total the number of units that represent those services DMAS has a limit of five pages for one claim The Total Charge revenue code (0001) should be the last line of the last page of the claim

58. ** Effective 07/01/08 **  Outpatient Hospital Setting Billing Requirements for NDC CMS requirements related to the Deficit Reduction Act (DRA) of 2005, mandate DMAS to require hospital providers who bill drug products administered in an outpatient hospital setting to include the National Drug Code (NDC) information of the drug dispensed on all claim submissions.

59. NDCOutpatient Hospital Setting Requirements The NDC information will be required on all electronic (ASC X12N:837I) and paper (Universal Billing “UB”) claim submissions. This requirement also applies to Medicare Crossover claim submissions. Outpatient hospital claims submitted without a valid NDC will have the revenue code line reduced to a non-covered service line.

60. NDC Outpatient Hospital Setting Providers billing for compound medication with more than one NDC included in the medication dispensed, each applicable NDC must be submitted on a separate claim line to include both prescription and over-the-counter ingredients. Each claim line submitted with pharmacy revenue codes 0250-0259 and 0630-0639 will require the NDC information.

61. NDC Outpatient Hospital Setting Effective 07/01/08, a valid NDC will be required for all drug products administered in an outpatient hospital setting. By definition, a valid NDC is a formatted number using the 5-4-2 format, i.e., 5-digits, followed by 4-digits, followed by 2-digits: 99999888877 Each NDC must be an 11-digit code unique to the manufacturer of the specific product administered to the patient.

62. Outpatient Hospital SettingLocator 43: NDC Requirements Form Locator 43 must have N4 modifier as the first indicator in this field, the corresponding 11-digit NDC number, followed by the Unit of Measure Qualifier and the NDC unit quantity. Billing for the same medication dispensed in different packages, each package size MUST be listed separately using N4 modifier, the revenue code, and all the required information on separate lines. The DMAS system will not consider these drugs as duplicates.

63. NDC Outpatient Hospital Setting If available, providers should enter the HCPCS code in Locator 44 (HCPCS/Rate/HIPPS Code) and the HCPCS units in Locator 46 (Serv Unit). DMAS will validate all HCPCS codes. Submission of an invalid HCPCS code will cause denial of the entire claim. The NDC number submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.

71. Locator 50: Payer Name A-C Enter the payer from which the provider may expect some payment for the bill. When Medicaid is the only payer, enter “Medicaid” on line A. If Medicaid is the secondary or tertiary payer, enter on lines B or C.

75. Note: appropriate codes accepted by DMAS are:

79. Locator 64:Document Control Number This locator is to be used to list the original Internal Control Number (ICN) for APPROVED claims that are being submitted to adjust or void the original claim.

82. Locator 67 Principal Diagnosis CodeLocators 67A-Q Present on Admission (POA) Indicator The eighth digit of the Principal, Other and External Cause of Injury Codes are to indicate if: the diagnosis was know at the time of admission, or the diagnosis was clearly present, but not diagnosed, until after the admission took place or was a condition that developed during an outpatient encounter

83. Locator 67 A-Q (POA) Indicator The POA indicator should be listed in the shaded area. This field is required for hospitals, (05/20/09 Memo). Reporting codes are: CODE DEFINITION Y YES N NO U No information in the record W Clinically undetermined

88. Locator 74: Principal Procedure Code and Date Note: for outpatient claims, a procedure code must appear in this locator when revenue codes 0360-0369, 0420-0429, 0430-0439, and 0440-0449 (if covered by Medicaid) are used in Locator 42 or the claim will be rejected. For inpatient claims, a procedure code or one of the diagnosis codes of V64.1 through V64.3 must appear in this locator (or Locator 67) when revenue codes 0360-0369 are used in Locator 42 or the claim will be rejected.

93. Locators 78-79:Other Provider Name and Identifiers This field will be used to list the NPI for the Primary Care Physician (PCP) who authorized the inpatient stay or outpatient visit. For MEDALLION patients referred to an outpatient clinic, enter the NPI for the PCP who authorized the outpatient visit. This information is required for all MEDALLION patients treated for non-emergency services.

94. Locators 78-79:Other Provider Name and Identifiers For Client Medical Management (CMM) patients referred to the emergency room by the PCP or admitted for non-emergency inpatient stay, enter the provider’s ID number and attach the Practitioner Referral Form (DMAS-70).

97. TAXONOMYLocator 81: Code-Code Field DMAS will be using this field to capture a taxonomy code for claims that are submitted for one NPI with multiple business types or locations (e.g., Rehabilitative or Psychiatric units within an acute care facility, Home Health Agency with multiple locations).

98. TAXONOMYLocator 81: Code-Code Field The taxonomy code will be required for providers who do not have a separate NPI for each different service billed to VA Medicaid. The taxonomy code will also be required for providers who have one NPI for multiple business locations. Code B3 is to be entered in the first small space and the provider taxonomy code is to be entered in the second large space. The third space should be blank.

100. DMAS Service Types That May Require a Taxonomy Codes

101. Outpatient Surgery For elective outpatient surgical procedures which require Preauthorization (PA) by Medicaid Medical Support (Physician’s Manual, Appendix B), submit paper claim. Contact the surgeon and request a copy of his PA letter ( the facility services do not required preauthorization). Attach a copy of the PA letter to the back of your claim form. Do not put the Physician’s PA # on your claim.

102. Medicare PrimaryCrossover Claims&Medicare Exhaust Claims

103. Medicare Primary  Billing Instructions for CMS-1450 The word “CROSSOVER” must be entered in Block 30 of the UB-04 to identify Medicare crossover claims. Coordination of Benefits (COB) codes 83 and 85 must be accurately printed in Blocks 39-41 of the UB-04.

104. Medicare Primary  In addition to Value Code 80- covered days and/or services, the following information is required for Medicare primary claims: The first occurrence code 83 indicates that Medicare paid and there should always be a dollar value associated with this code. The A1 indicates Medicare deductible and code A2 indicates Medicare coinsurance

105. Blocks 39-41 Line a 83 = Billed and Paid (enter amount paid by Medicare or other insurance). Line a A1 = Deductible Payer A. (enter Medicare Deductible Amount listed on the EOMB). Line a A2 = Co-Insurance Payer A. (enter Medicare Co-Insurance amount listed on the EOMB).

106. Medicare Primary  Note: Complete all information in Locators 39a through 41a first (payments by Medicare or payments by other insurance) before entering information in 39b through 41b locators etc. COB code 85 is to be used when another insurance carrier is billed and there is no payment from that carrier. For the deductibles and co-insurance due from any other carrier(s) (not Medicare) the code for reporting the amount paid is B1 for the deductibles and B2 for the coinsurance.

107. Medicare Exhaust Days MEDICARE PRIMARY/Days Exhausted Preauthorization from the Medicaid Prior Authorization Contractor is required. Proof of exhausted Medicare days must be submitted with preauthorization.

108. Medicare Exhaust Days All days must be billed. Initial stay less than 120 days, bill type 0111. First 120 days bill type 0112 – next 120 days bill type 0113 – continue bill type 0113 for any additional 120 day periods. Final bill type 0114.

109. Medicare Exhaust Days Providers should list the amount Medicare paid on the 0112 bill type (less than 120 days list payment on 0111 bill type). Medicare payment should be listed in Block 39a and use COB code 83 (billed and paid).

110. Medicare Exhaust Days DO NOT WRITE the word CROSSOVER in Block 30 (Medicare is exhausted and the days billed to Medicaid were not paid by Medicare) Block 80- providers MUST put write a statement MEDICARE DAYS EXHAUSTED and attach something showing Medicare are exhausted (Medicare EOB).

111. Medicare Exhaust Days If Medicaid has considered a crossover claim for deductible and coinsurance on days Medicare paid or any Part B charges- If the provider keeps all charges on the claim submitted for Medicare Exhaust days, all payments must be listed. If the provider deletes Part B charges, do not list any Part B payment amounts.

112. Special Note If the Medicaid recipient does not have Part A coverage, the COB code should be 82 (No Other Coverage).

113. REMITTANCE VOUCHERSections of the Voucher APPROVED for payment. PENDING for review of claims. DENIED no payment allowed. DEBIT (+) Adjusted claims creating a positive balance. CREDIT (-) Adjusted/Voided claims creating a negative balance.

114. REMITTANCE VOUCHERSections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS

115. THANK YOU Department of Medical Assistance Services www.dmas.virginia.gov