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DMAS Division of Health Care Services

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  1. 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.

  2. 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

  3. 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

  4. 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).

  5. 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.

  6. 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.

  7. Billing on the CMS-1500 6

  8. 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

  9. 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

  10. 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

  11. TIMELY FILING • Submit claims with documentation attached explaining the reason for delayed submission

  12. Block 1 • Enter an ‘X’ in the MEDICAID box for the Medicaid Program

  13. Block 1 TRICARE MEDICAID 1.MEDICARE CHAMPUS (Medicare#) (Medicaid#) (Sponsor'sSSN) 2.PATIENT'SNAME(LastName,FirstName,MiddleInitial) MEDICAID CLAIM 12

  14. 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

  15. Block 2: Patient's Name 2.PATIENT'SNAME(Lastname,FirstName,MiddleInitial) Smith, Sam 5.PATIENT'SADDRESS(No.,Street) 14

  16. 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’

  17. 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

  18. 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

  19. Block 11c - Insurance Plan Name or Program Name c. INSURANCE PLAN NAME OR PROGRAM NAME Other Insurance Name 18

  20. 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.

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. Block 24C: EMG C. EMG Y Y Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency 29

  31. 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

  32. 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

  33. 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

  34. Block 24 F: Charges F. $CHARGES 1500 00 500 00 Enter the usual and customary charges for each CPT code 32

  35. 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

  36. 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.

  37. 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.

  38. 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

  39. 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

  40. Block 26: Patient’s Account Number (Optional) 26.PATIENTACCOUNTNUMBER 12345678918765 Can not exceed 17 alphanumeric digits 38

  41. Total ChargeBlock 28 • DMAS now requires this locator to be completed • Enter the total charges together for the services in 24F lines 1-6.

  42. Block 28: Total Charges 28.TOTALCHARGE $ 40

  43. Block 29: Amount Paid (By Other Insurance) 29.AMOUNTPAID $ 41

  44. Block 30: Balance Due (Block 28 minus Block 29) 30.Balance Due $ 42

  45. 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

  46. 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

  47. Service Facility Location InformationBlock-32a-b Leave Blank

  48. 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

  49. 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

  50. 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