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Billing Basics

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Billing Basics

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    1. The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide] The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide]

    2. April 2006 LTC Seminar 2

    3. April 2006 LTC Seminar 3

    4. April 2006 LTC Seminar 4 COMING ATTRACTIONS!

    5. April 2006 LTC Seminar 5 MARCH 1, 2006 Claim Scanning (rather than microfilming). This will speed up claims processing and eliminate the waiting period for pulling claims.

    6. April 2006 LTC Seminar 6 On-Line Claims Inquiry will allow providers to check claim status on the Web. This is a FREE service! On-Line Eligibility Inquiry client eligibility, and prior authorization information. This is a FREE service! Check your RA Newsletter for more information. COMING IN SPRING 2006

    7. April 2006 LTC Seminar 7 On-Line PA allows providers to check their PAs on file with ACS. These will be free services to providers. Check your RA Newsletter for more information. COMING IN SPRING 2006

    8. Electronic versus Paper Billing

    9. April 2006 LTC Seminar 9 Advantages of Billing Electronically Control over data entry Claim processed in as little as a week Payment in as little as a week Confirmed receipt of the submitted claims Eliminates expense of mailing claims

    10. April 2006 LTC Seminar 10 Electronic or Paper? Paper or Electronic - claims within 120 days from the 1st date of service on the claim may be submitted electronically or on paper (UB-92). Paper Only - claims more than 120 days from the 1st date of service on the claim must be submitted on paper (UB-92) with attachments/proof of timely filing.

    11. April 2006 LTC Seminar 11

    12. April 2006 LTC Seminar 12

    13. April 2006 LTC Seminar 13 Electronic – Billing Requirements LTC providers: HIPAA regulations require that client address, admitting and principal diagnosis codes, and attending provider information be included. LTC providers may use their facility’s address as the resident’s address.

    14. April 2006 LTC Seminar 14 Electronic – Billing Requirements Diagnosis Codes on HIPAA electronic claims (837I or PayerPath) The following are generic diagnoses in lieu of a client specific diagnosis - Nursing facilities use V70.3 ICF-MRs use 319

    15. April 2006 LTC Seminar 15 Electronic – Billing Requirements Reserve Bed Days Reserve bed days can now be billed on the 837I or on Payerpath along with regular, in-facility days.

    16. April 2006 LTC Seminar 16 Electronic – Billing Requirements Payerpath Tips Remember – Payerpath must send a HIPAA compliant electronic claim. The fields that Payerpath requires are to meet HIPAA requirements. Payerpath required fields do not include all fields where information is required by NM Medicaid in order to pay the claim.

    17. April 2006 LTC Seminar 17 Electronic – Billing Requirements Payerpath Tips Key fields not required by Payerpath include covered and non-covered days, and the admission date.

    18. April 2006 LTC Seminar 18 Claims Processing Effective 3/1/2006, claims submitted using the ACE$ electronic billing software or another NSF electronic claims submission software were no longer accepted by NM Medicaid. Effective 3/1/2006, NM Medicaid only accepts HIPAA compliant electronic claims (the 837I.)

    19. April 2006 LTC Seminar 19 Claims Processing If Medicare pays a claim and the EOB indicates that it has been sent to Medicaid, please wait four weeks for Medicaid to process the crossover. If after four weeks Medicaid has not processed the crossover, submit it on paper.

    20. April 2006 LTC Seminar 20 Claims Processing Nursing facility crossover claims (claims from nursing facilities submitted for Medicare clients) have the client’s patient liability (medical care credit) automatically deducted from the claim.

    21. April 2006 LTC Seminar 21 Claims Processing Exception 0783 - ACS currently denies an LTC claim when a PCO or waiver claim has paid for the same or overlapping dates of service. You may contact Merri @ the LTC helpdesk if you believe you have received this denial incorrectly. (505) 246-9988 ext. 191

    22. Billing Basics

    23. April 2006 LTC Seminar 23 The following items MUST be in place before ACS can pay a claim: Client’s Medicaid eligibility for the dates of service must be on file with ACS The client must not be enrolled in SALUD! A long term care span (the abstract) for the dates of service and your provider number must be on file with ACS.

    24. April 2006 LTC Seminar 24 Timely Filing Limits Original Claims - 120 days from the initial date of service. (For DRG hospital inpatient claims ONLY – 120 days from last date of service.)

    25. April 2006 LTC Seminar 25 Timely Filing Limits Resubmissions - 6 months from the date of the previous denial (include a copy of the page of the RA where the claim denied and/or other proof of timely filing.) Adjustments – 6 months from the date of the incorrect payment (include a copy of the page of the RA(s) where the claim paid).

    26. April 2006 LTC Seminar 26 Timely Filing Limits TPL - 365 days from the initial date of service (remember to include a copy of the EOB from the insurance carrier, plus a copy of the explanation page). Medicare - 6 months from the date that Medicare either paid or denied the claim (remember to include a copy of the EOMB along with the explanation page)

    27. April 2006 LTC Seminar 27 Timely Filing Limits Final Limit - all payments must be finalized within 2 years of the date of service.

    28. April 2006 LTC Seminar 28 Timely Filing Limits The following slides explain how the LTC 120-day filing limit is applied when an abstract is added retroactively.

    29. April 2006 LTC Seminar 29 Timely Filing Limits The 120-day filing limit is counted from the add date of an LTC span (abstract) ONLY if the client also had retroactive eligibility. “Retro-eligibility” occurs when the eligibility add date is AFTER the eligibility span’s begin date and when the last DOS on the claim is BEFORE the eligibility span’s add date.

    30. April 2006 LTC Seminar 30 Timely Filing Limit In these cases, a provider has 120 days from the add date of the LTC span to file the claim. In these cases, the system calculates the 120-days from the LTC span’s add date. A paper claim is not required.

    31. April 2006 LTC Seminar 31 Timely Filing Limit This DOES NOT apply if the client’s eligibility for the claim’s DOS was added PRIOR to the last DOS on the claim. Providers are advised that in the event an abstract has not been added, but the client’s eligibility is on file, the claim should be submitted so as to keep within timely filing.

    32. April 2006 LTC Seminar 32 Revenue Codes Revenue Codes: All revenue codes MUST be billed using four digits regardless of the date of service.

    33. April 2006 LTC Seminar 33 Revenue Codes Revenue Codes: All NFs, ICF-MRs, RTCs and TFCs: Bill revenue code 0190 for in-facility days.

    34. April 2006 LTC Seminar 34

    35. April 2006 LTC Seminar 35 Covered and Non-Covered Days Total covered days must equal total days billed (in-facility days plus any reserve days). The total of covered days plus non-covered days must equal the number of days indicated by the “from” and “to” dates of service.

    36. April 2006 LTC Seminar 36 Value Codes Value Codes for reserve bed days are no longer used. This information is now included within the revenue code. D3 is the value code used to indicate a patient liability amount, but we recommend leaving the patient liability off the claim.

    37. April 2006 LTC Seminar 37 Reserve Bed Days Billing both facility and reserve bed days on the same claim: One line is for in-facility days, billed with rev code 0190. Another line is for reserve bed days, billed with rev code 0185 or 0182 for Nursing facilities; 0184 for ICF/MR facilities.

    38. April 2006 LTC Seminar 38

    39. April 2006 LTC Seminar 39

    40. April 2006 LTC Seminar 40 Level of Care The level of care code is no longer required on the claim, as the level of care is taken from the LTC abstract. This applies to NFs, ICF-MRs, RTCs and TFCs.

    41. April 2006 LTC Seminar 41 Level of Care Providers are responsible for being sure abstracts are up-to-date when a resident’s level of care changes.

    42. April 2006 LTC Seminar 42 Level of Care If a resident’s level of care changes, but the existing abstract is not updated, or a new abstract is not issued and sent to ACS, the claim may be paid incorrectly (overpaid or underpaid.)

    43. April 2006 LTC Seminar 43 If this happens, the provider is responsible for filing an adjustment AFTER the abstract has been updated and received by ACS. Level of Care

    44. April 2006 LTC Seminar 44 The Abstract Claims are edited to ensure that: An abstract is on file with ACS. The billing provider is the provider authorized by the abstract. The dates of service being billed are covered by the abstract

    45. April 2006 LTC Seminar 45

    46. April 2006 LTC Seminar 46 Patient Liability ( aka: Medical Care Credit) “D3” is the value code used to indicate a patient liability amount, but we recommend leaving the patient liability off the claim. The Patient Liability is not withheld when the patient status is “20” or “01”. Do not put the patient liability on claim.

    47. April 2006 LTC Seminar 47 Patient Liability If the patient dies or goes home permanently, call the ISD case worker so that the patient’s files can be updated.

    48. April 2006 LTC Seminar 48 ACS recommends the Patient Liability not be entered on the claim, unless you know the amount is greater than what ACS has on file. The system will automatically deduct the patient liability when necessary.

    49. April 2006 LTC Seminar 49 The Patient Liability is not withheld on the initial month if the admit date is not the first of the month. Do not put the Patient Liability on the claim if this is the case.

    50. April 2006 LTC Seminar 50 If ACS has an incorrect Patient Liability amount in the system, attach a copy of the 200p form to a paper claim and send to the attention of the LTC Coordinator. If you wish to bill electronically, mail the form to the LTC coordinator to update. Once updated, you can transmit your claim.

    51. April 2006 LTC Seminar 51

    52. April 2006 LTC Seminar 52

    53. April 2006 LTC Seminar 53

    54. April 2006 LTC Seminar 54 3RD DIGIT - FREQUENCY 3 - Interim – Continuing Claim - “From” date of service does not match admit date and status code = still a patient 4 - Interim – Last Claim - “From” date of service does not match admit date and status code = discharged The frequency digit of the Type of Bill code MUST agree with the patient status code in order to avoid a denial. Type of Bill

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