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DMAS Division of Health Care Services New Billing Instructions for Emergency Air Ambulance, Emergency Ground Ambulance, and Neonatal Ambulance Services. Instructions include Medicare Cross Over Claims. Two Code Methodology to Begin with Dates of Service November 1, 2009 and After.

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DMAS Division of Health Care Services

New Billing Instructions for Emergency Air Ambulance, Emergency Ground Ambulance, and Neonatal Ambulance Services. Instructions include Medicare Cross Over Claims.

Two Code Methodology to Begin with Dates of Service November 1, 2009 and After.


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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


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Health Insurance Claim Form CMS 1500

  • What’s Changed?

    • Beginning with Date of Service (DOS) November 1, 2009 and forward, Emergency Air, Emergency Ground Ambulance, and Neonatal Ambulance claims will be will be processed using the two CPT/HCPCS code payment methodology. This includes Medicare cross-over claims as well.

    • Two CPT/HCPCS codes meaning “service” with corresponding “mileage” code.

    • When Medicare “total payment” for both service and mileage added together exceed DMAS maximum rate, crossover claims will be paid at $0.00 with the claims edit 364 “Exceeds Medicaid Allowed Amount”.

    • All Emergency Ground and Air Ambulance claims will no longer require attachments.

    • No longer use Modifier “22” in block 24D. Except for claims that are over 200 miles and more than one transport on same day service. (see billing instructions)

    • All Emergency Air and Emergency Ground Ambulance claims will be subject to post review.

    • Emergency Air Ambulance Claims will change to a Post Review for Medical Necessity.

    • CMS 1500 requires Font size 10 or larger

    • Adjustments must be submitted for only one line of the pair.

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


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Health Insurance Claim Form CMS 1500

  • Most Common Mistakes

    • Claims with DOS October 30, 2009 and before still require one code billing.

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

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

    • Third party liability claims – if primary insurance pays at $00.00 make sure block 11d is marked “yes” and block 24a shaded area has TPL00.00. This needs to be entered for each CPT code line. If primary insurance pays, make sure 11d is marked “yes” and block 24a shaded area has dollar amount paid for each CPT code line example: TPL53.69

    • Make sure providers NPI number match for blocks 24j and 33a. DO NOT use a physicians NPI in block 24j.

    • Do not bill DMAS for regular non-emergency service codes A0426, A0428, A0434 and corresponding A0425.However, DMAS is responsible for all emergency and non-emergency Medicare cross-over claims (see billing instructions for cross over claims).


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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.


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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.



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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


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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


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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


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TIMELY FILING

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


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Block 1

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


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Block 1

TRICARE

MEDICAID

1.MEDICARE

CHAMPUS

(Medicare#)

(Medicaid#)

(Sponsor'sSSN)

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

MEDICAID CLAIM

12


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Block 1a: Recipient ID Number

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

123456789014

Be sure to include all

12 digits of the VA Medicaid ID.

13


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Block 2: Patient's Name

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

Smith, Sam

5.PATIENT'SADDRESS(No.,Street)

14


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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’


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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


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Block 10d

If Applicable

10d.RESERVEDFORLOCALUSE

*ATTACHMENT

*Emergency Ground Ambulance trips 200 miles and over, and more than one transport with same service day MUST use the word "ATTACHMENT"

  • Trips over 200 miles must have Pre-Hospital Patient Care Report (PPCR) attached

  • More than one transport per day, attach statement “This is second/third/forth transport”.

17


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Block 11c - Insurance Plan Name or Program Name

c. INSURANCE PLAN NAME OR PROGRAM NAME

Other Insurance Name

18


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Is There Another Health Benefit Plan?Block-11d

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

  • If Medicare pays $00.00 mark this block “yes” and follow instructions for shaded area block 24A.


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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


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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


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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


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TPL Information Block 24A

  • Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier

  • No spaces between the qualifier and dollars and no $ symbol used (TPL00.00 or TPL payment amount: TPL123.45)

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

  • Must be left justified

  • Enter dollar amount paid for each CPT Code line


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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


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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


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Block 24A: Dates of Service

(TPL example added if applicable)

24.A.

DATE(S)OFSERVICE

From

To

MMDDYY

MMDDYY

TPL27.08

09

09

01

11

11

01

1

TPL8.60

11

01

09

11

01

09

2

BothFROMandTOdates

must be completed

26

Dates must be within same calendar month


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Block 24B: Place of Service

B.

Place

41- Ambulance – Land

Or

42-Ambulance – Air or Water

“Not both”

of

Service

41

41

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

27


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Emergency Indicator-24C

  • This locator will be used to indicate whether the procedure was an emergency

  • DMAS will only accept a ‘Y’ for yes in this locator

  • Make sure and mark ‘Y’ on both service and mileage lines


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Block 24C: EMG

C.

EMG

Y

Y

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

29


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Block 24D: Procedure Codes

Neonatal Transport with “U1” Modifier

D. PROCEDURES,SERVICES,ORSUPPLIES

(ExplainUnusualCircumstances)

CPT/HCPCS

MODIFIER

DMAS Recognizes the

Following codes:

A0225 w/A0425 “U1”

A0427 w/A0425

A0429 w/A0425

A0433 w/A0425

A0430 w/A0435

A0431 w/A0436

A0225

A0425

U1

“U1” Modifier is for Neonatal Mileage Only

30


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Block 24D: Procedure Codes

Service and Mileage CPT Codes

One CPT Code on Each Line

D. PROCEDURES,SERVICES,ORSUPPLIES

(ExplainUnusualCircumstances)

CPT/HCPCS

MODIFIER

DMAS Recognizes the

Following codes:

A0225 w/A0425 “U1”

A0427 w/A0425

A0429 w/A0425

A0433 w/A0425

A0430 w/A0435

A0431 w/A0436

A0427

A0425

No Modifier is required

30


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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.

1,2

1,2

31


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Block 24 F: Charges

F.

$CHARGES

1500

00

500

00

Enter the usual and customary

charges for each CPT code

32


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Block 24G: Days or Units

G.

DAYS

OR

UNITS

Enter “1” for one unit of service.

Enter the number of “loaded miles” of transport.

1

31

33


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ID.QUALBlock-24I – Shaded Area

  • Qualifier ‘ZZ’ is to be used to indicate the taxonomy code-only when the NPI is used and only if necessary to adjudicate the claim.

  • Make sure to follow these instructions for each line.

  • Taxonomy code must be used for each CPT code line.


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If Taxonomy codes are usedBlock-24J

  • If needed the shaded red area will contain the Taxonomy codes

  • If Taxonomy codes are used in shaded area, NPI number must be provided in the open area.

  • Make sure and follow these instructions for both lines.


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Fill in only if Taxonomy codes are needed

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

3416A0800X

Or

3416L0300X

ZZ

3416A0800X is Taxonomy code for Air Transport

3416L0300X is Taxonomy code for Land Transport

If taxonomy codes are used, make sure and use same codes for each line.

36


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Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

J.

RENDERING

PROVIDER ID. #

I.

ID.

QUAL

Taxonomy # (if needed)

ZZ

12345647890

NPI

Make sure and use ZZ and same taxonomy code for each line.

37


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Block 26: Patient’s Account Number

(Optional)

26.PATIENTACCOUNTNUMBER

12345678918765

Can not exceed 17

alphanumeric digits

38


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Total ChargeBlock 28

  • DMAS now requires this locator to be completed

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


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Block 28: Total Charges

28.TOTALCHARGE

$

40


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Block 29: Amount Paid

(By Other Insurance)

29.AMOUNTPAID

$

41


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Block 30: Balance Due

(Block 28 minus Block 29)

30.Balance Due

$

42


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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


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Service Facility Location InformationBlock-32

  • Enter information for the location where recipient was dropped off - services were rendered

    • First line-Name

    • Second line-Address

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

  • The zip code must reflect the hospital/facility location where services were rendered

  • No punctuation in the address

  • Space between city and state

  • Include hyphen for the 9 digit zip code



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Block 32: Service Facility Location Information

Drop off location - Local Hospital or Facility Name

XXXX Anywhere St.

Your Town, ST 12345-1456

32. SERVICE FACILITY LOCATION INFORMATION

Leave Blank

a.

Leave Blank

b.

46


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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


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Billing Provider Info Block-33a-b

  • 33a - Enter the 10 digit NPI number of the service location in 33a. (This is required on all claims).

  • 33b – If applicable, Enter ‘ZZ’ qualifier with the taxonomy code in 33b (example – ZZ3416L0300Z).

  • NOTE: 33a and 33b - NPI number and taxonomy codes must match information in blocks 24I and 24J


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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


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Block 22: Adjustments and Voids

Send in Adjustment for MILEAGE CODE ONLY with mileage ICN number.

22.MEDICAIDRESUBMISSION

CODE

ORIGINALREF.NO.

1032

xxxxxxxxxxxxxxxx

From Original

Adjustment or

Void

Remittance

Resubmission Code

Chap. V, Medicaid Transportation Manual has code list.

50


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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 mileage code paid on the claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted. Only one claim can be adjusted on each CMS-1500 (08-05) submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim.)

51


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More than One Emergency Air or Ground Claim with Same Day Service

  • Please complete second/third claim using the same billing instructions as the first plus in block 10d add the word “ATTACHMENT” and add modifier “22” in block 24d. Please provide a cover letter explaining this claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of second claim with PPCR/run/call sheets and mail to:

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219


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Air Ambulance Claim Procedure and Claim Reconsideration Service

  • All air ambulance claims with a date of service November 1, 2009 and after are subject to a post claim review. Claims submitted that do not establish air ambulance medical necessity will be adjusted to DMAS emergency ground ambulance rates.

  • In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be reconsidered if the original claim was missing attachments or other medical information. For reconsideration please write a brief description or explanation on why the claim needs to be reconsidered.

  • Please mail the letter, a new original CMS 1500 with attachment to:

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219

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


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Mailing Address for Emergency Ground Ambulance, Emergency Air Ambulance, and Neonatal Ambulance Service Claims

  • Emergency Air, Emergency Ground and Neonatal Ambulance Claims with a Date of Service on or after November 1, 2009 mail to:

    DMAS-Transportation

    P. O. Box 27447

    Richmond, Virginia 23261-7447

  • Note: Emergency ground ambulance claims with 200 miles and over and/or multiple emergency transports on the same day must be mailed to:

    DMAS

    Transportation Unit, Suite 1300

    600 East Broad Street

    Richmond, Virginia 23219


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Billing on the DMAS 30 & 31 Air Ambulance, and Neonatal Ambulance Service Claims

56


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Title XVIII Common Mistakes Air Ambulance, and Neonatal Ambulance Service Claims

  • 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)


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CHANGES Air Ambulance, and Neonatal Ambulance Service Claims

  • Locator 01-Billing Provider Number

  • Locator 06-Rendering Provider Number

  • Locator 08-Type of Coverage


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Title XVIII- Block 01 Air Ambulance, and Neonatal Ambulance Service Claims

01 Billing Provider Number

Enter the billing provider NPI number

59


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Title XVIII- Block 06 Air Ambulance, and Neonatal Ambulance Service Claims

06 Rendering Provider Number

Enter the rendering provider NPI number

60


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Title XVIII – Block 7 Air Ambulance, and Neonatal Ambulance Service Claims

07

Primary Carrier Information Other ThanMedicare

2 No Other Coverage

5 Billed No Coverage

3 Billed and Paid


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Title XVIII – Block 08 Air Ambulance, and Neonatal Ambulance Service Claims

08

Type OfCoverageMedicare

Type CoverageMedicare- Mark type of coverage “B”.

B

6


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Title XVIII- Block 17 Air Ambulance, and Neonatal Ambulance Service Claims

17

Charges To Medicare

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


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Title XVIII- Block 18 Air Ambulance, and Neonatal Ambulance Service Claims

Allowed By Medicare

18

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


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Title XVIII- Block 19 Air Ambulance, and Neonatal Ambulance Service Claims

19

Paid By Medicare

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


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Title XVIII- Block 20 Air Ambulance, and Neonatal Ambulance Service Claims

Deductible

20

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


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Title XVIII- Block 21 Air Ambulance, and Neonatal Ambulance Service Claims

Co-Insurance

21

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


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Title XVIII- Block 22 Air Ambulance, and Neonatal Ambulance Service Claims

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.)


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Title XVIII- Block 23 Air Ambulance, and Neonatal Ambulance Service Claims

23

Patient Pay Amt. LTC Only

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


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TITLE XVIII- Air Ambulance, and Neonatal Ambulance Service ClaimsAdjustment 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.


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TITLE XVIII- Air Ambulance, and Neonatal Ambulance Service ClaimsAdjustment 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.


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REMINDERS Air Ambulance, and Neonatal Ambulance Service Claims

  • Xeroxed copies of DMAS forms are still unacceptable

  • Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid recipients who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid

  • Use the same CPT/HPCS codes that were billed to Medicare (this means using the two code system)

  • Make sure and attach Medicare EOB to 30-R & 31-R


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LogistiCare Contact Telephone Number For A0426, A0428, and A0434 Non-Emergency Ambulance Non-Emergency Services

  • LogistiCare’s Medicaid recipients toll-free reservation line: 1-866-386-8331 - This line is intended for recipients, facilities, and hospitals to schedule trips

  • All A0426, A0428, and A0434 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.


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Resources A0434 Non-Emergency 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


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HELPLINE A0434 Non-Emergency 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


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Questions? A0434 Non-Emergency Ambulance Non-Emergency ServicesOr email question(s) to: [email protected]


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THANK YOU A0434 Non-Emergency Ambulance Non-Emergency Services