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CMS-1500 Workshop. Presented by: Xerox State Healthcare, LLC Provider Relations. Resources . When online use: Ask Service Representative HIPAA.Desk.NM@xerox.com NMPRSupport@xerox.com Call Center 505-246-0710 or 800-299-7304 New Mexico Web Portal Provider Information section

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slide1

CMS-1500 Workshop

Presented by:

Xerox State Healthcare, LLC

Provider Relations

resources
Resources
  • When online use: Ask Service Representative
  • HIPAA.Desk.NM@xerox.com
  • NMPRSupport@xerox.com
  • Call Center 505-246-0710 or 800-299-7304
    • New Mexico Web Portal
      • Provider Information section
      • Links and FAQ section
      • Provider Login section
important state websites
Important State Websites

STATE WEBSITE:

PROGRAM POLICY MANUAL

    • http://www.hsd.state.nm.us/mad/policymanual.html
  • BILLING INSTRUCTIONS
    • http://www.hsd.state.nm.us/mad/billinginstructions.html
  • REGISTERS AND SUPPLEMENTS:
    • http://www.hsd.state.nm.us/mad/registers/2012.html
purpose of workshop
Purpose of workshop

Provide information on filling out the CMS-1500 paper claims for:

  • Claim Form Instructions
  • Primary Medicaid
  • Medicaid secondary to a Third Party Liability (TPL)
  • HMO/PPO copayments
  • Medicare Replacement Plans
  • Medicare Crossovers
  • Medicaid Tertiary
where to get a copy of claim form instructions
Where to get a copy of claim form instructions

Click Forms , Publications, and Instructions under Provider Information

slide9

111223333

Patient, Petunia

11 11 90

X

If a referring provider is required in order to be paid or if you simply wish to enter this information on the claim, enter the referring provider’s name in box 17 and the referring provider’s NPI in box 17b.

Doe, John

1223334444

slide10

RENDERING PROVIDER’S NPI/Taxonomy

43310

2722

QUALIFIER

25000

ZZ

273R00000X

99214

25

123

78 01

1

05 30 07

05 30 07

11

1234567890

  • Health care providers:
    • If you are a health care provider, you must submit your NPI.
    • The NPI goes in Box 33a.
    • If the NPI is not submitted, the claim will deny.

Optional

Optional

78 01

X

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ363LF0000X

  • Taxonomy: If you wish to submit rendering provider taxonomy code, it goes in Box 33b preceded by the qualifier “zz”.
  • Do not enter a space between the qualifier and the taxonomy code. An example of a correctly submitted taxonomy code is: zz103T00000X.
slide11

12345678X01

99509

UA

15 20

1

05 30 07

05 30 07

12

  • Non-Health care providers:
    • Legacy Medicaid Number: If you wish to submit your Legacy ID, enter Qualifier 1D directly preceding your Legacy ID Do not enter a space between the qualifier and the Legacy ID.

Optional

Optional

15 20

X

Joe Provider 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1D000D1111

If your Medicaid ID is less than 8 digits, enter enough zeroes in front of it to make it 8 digits long.

slide12

What is a Transaction Control Number (TCN)?

The twelfth digit in an adjustment/ void TCN will either be:

1= Debit

2= Credit

91308700085000001

The first digit indicates what the claim “media” is:

2 = electronic crossover

3 = other electronic claim

4 = system generated claim or adjustment

8 = paper claim

9 = Web portal claim entry

Batch number

The last two digits of the year the claim was received

The claim number within the batch.

The numeric day of the year.

This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87th day of 2013, or March 28, 2013

timely filing denials
Timely Filing Denials
  • Re-filing Claims and Submitting Adjustments
  • CMS 1500 form: Put the TCN in block 22 on the paper form. Leave the “Code” blank, and put the TCN in the “Original Reference No.” field.
ncci national corrective coding initiative
NCCI (National Corrective Coding Initiative)
  • Is a CMS program that consists of coding policies and edits.  Medicaid NCCI Edits consist of two types: 
  • NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and
  • (2) Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas).
ncci national corrective coding initiative1
NCCI (National Corrective Coding Initiative)
  • RA EOB Codes:
  • 6501 or 6502 - Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service.
  • 6503 through 6505 - Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit.
  • Please visit the link below for any additional information:
  • http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html
third party liability tpl tips
Third Party Liability (TPL) Tips
  • TPL is commercial insurance
  • TPL must be billed primary to Medicaid
  • Medicaid does not consider Medicare TPL
slide18

111223333

Patient, Petunia

11 11 90

X

Patient, Petunia

010203

Check YES in box 11d

X

09 22 90

ABC, Inc.

X

UnitedHealthcare Community plan

When filling out a Medicaid claim where TPL is primary payer, be sure to fill in all required primary and secondary payer information.

slide19

65663

V283

ZZ

1234567890

273R00000X

05 30 07

05 30 07

11

76811

TC

12

400 00

1

12

05 30 07

05 30 07

11

76820

TC

170 00

1

Attach a copy of the EOB

along with the explanation

of denials page

Always enter the amount the insurance has paid in Box 29 on the CMS-1500.

X

Optional

Optional

570 00

120 00

450 00

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ363LF0000X

hmo co pay tips
HMO Co-Pay Tips
  • Write “HMO Co-pay Due” on the claim. Attach the EOB.
  • In the “amount paid” field (Box 29), enter the difference between the billed amount and the co-payment.
  • Enter the co-payment amount in the “est. amount due” field (Box 30).
slide22

HMO CO-PAY DUE

Write “HMO Co-pay Due” in the upper left hand side of the claim form next to the “1500” and attach the EOB.

111223333

Patient, Petunia

11 11 1990

X

Patient, Petunia

010203

X

09 22 90

ABC, Inc.

UnitedHealthcare Community Plan

X

slide23

Attach a copy of the EOB

along with the explanation

of denials page

65663

V283

ZZ

1234567890

273R00000X

05 30 07

05 30 07

11

76811

TC

12

400 00

1

05 30 07

05 30 07

11

12

170 00

76820

TC

1

In the “amount paid” field, enter the difference between the billed amount and the co-payment.

Enter the co-payment amount in the “balance due” field.

Optional

Optional

570 00

520 00

50 00

X

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ363LF0000X

slide25

Write “Medicare Replacement Plan” in the upper left hand side of the claim form next to the “1500”. Attach the EOB.

MEDICARE REPLACEMENT PLAN

111223333

Patient, Petunia

11 11 1990

X

slide26

Attach a copy of the EOB

along with the explanation

of denials page

65663

V283

ZZ

273R00000X

1234567890

76811

TC

12

400 00

1

05 30 07

05 30 07

11

76820

TC

170 00

1

12

05 30 07

05 30 07

11

In the “amount paid” field, enter the difference between the billed amount and the co-payment.

Enter the co-payment amount in the “net due” field.

Optional

Optional

570 00

120 00

450 00

X

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ363LF0000X

medicare primary claims crossovers
Medicare Primary Claims (Crossovers)
  • When billing for clients covered by Medicare for which Medicare has paid something on the claim and the claim DID NOT automatically crossover from Medicare to Xerox, submit those claims via paper to Xerox with the Medicare EOMB attached.
slide29

111223333

Patient, Petunia

11 11 1990

X

NM Medicaid does not consider Medicare to be TPL, so be certain that you do not fill in any of the TPL information blocks.

slide30

7213

05 30 07

05 30 07

24

64483

RT

1

1683 00

1

05 30 07

05 30 07

24

64484

RT

1

906 00

1

Attach a copy of the EOMB

along with the explanation

of denials page

Don’t fill out boxes 29 and 30. We’ll key this info directly from the EOMB.

2589 00

Optional

Optional

X

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ273R00000X

medicaid tertiary claims
Medicaid Tertiary Claims

Medicaid tertiary claims are submitted in the following order:

  • Medicare primary
  • TPL secondary
  • Medicaid tertiary
slide33

111223333

Patient, Petunia

11 11 1990

X

  • Fill out the TPL information

Patient, Petunia

010203

X

09 22 90

ABC, Inc.

X

UnitedHealthcare Community Plan

slide34

7213

Fill out claim form as if you were billing secondary to a TPL.

05 30 07

05 30 07

24

64483

RT

1

1683 00

1

24

64484

RT

1

1

05 30 07

05 30 07

906 00

Attach a copy of the Medicare EOMB

and the TPL EOB, along with the

explanation of denials page.

The claim must match the EOBs

Only amount paid by TPL is entered in box 29. Medicare payment is keyed directly from EOMB.

Optional

Optional

2589 00

640 00

1949 00

X

Provider Med Gp 505 333-4444

1234 Rocky Road

Mountain View, NM 8888

Situational

Required

1234567890

ZZ273R00000X

did you remember to
Did you remember to?
  • Ensure the line item charges are correct and match the total charge.
  • If you’re a for profit organization, make sure gross receipts tax is included in the line items, if applicable.
  • Procedure and diagnosis codes are entered correctly
  • Sign and date the claim.
did you remember to1
Did you remember to?
  • Include your NPI or provider number.
  • Include all appropriate EOB’s for TPL, HMO, Medicare, etc.
  • Attach proof of timely filing/TCN if needed
  • Keep a copy of the correspondence for your records.
resources1
Resources
  • When online use: Ask Service Representative
  • HIPAA.Desk.NM@xerox.com
  • NMPRSupport@xerox.com
  • Call Center 505-246-0710 or 800-299-7304
    • New Mexico Web Portal
      • Provider Information section
      • Links and FAQ section
      • Provider Login section