CMS 1500 Billing Instructions Susan J. Tucker Executive Director, Office of Health Services Maryland Dept. of Health and Mental Hygiene April 14, 2010
Prerequisites for Billing an MCO • Be certified to provide SA services by the Office of Health Care Quality (OHCQ) • Have a National Provider Identifier (NPI) number • Have a Maryland Medical Assistance (MA) provider number • Submit information to be an MCO self-referred provider to Maryland Medicaid • Follow HIPAA regulations • Follow authorization procedures • Bill appropriate party for services rendered
CMS 1500 Form Instructions Please Note • These instructions only apply to PAC-insured patients who do not have any other third party insurance!! • Only those blocks/boxes that are required for submitting a clean claim for patients without third party insurance (HealthChoice and PAC) are presented here.
CMS 1500 Billing Form • When filing a paper claim, programs must use original CMS 1500 forms • Forms are available from the Government Printing Office at 202-512-1800, the American Medical Association, and major medical-oriented printing firms. • See the following website for more information: http://www.cms.hhs.gov/electronicbillingeditrans/16_1500.asp.
Before Getting Started Important Reminders: For Medical Assistance claims processing, the TOP RIGHT SIDE of the form MUST be BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed. The Medical Assistance Program is the “payer of last resort.” If a patient is covered by other insurance or third party insurance (e.g., Workers Comp), the provider must first bill the other insurance company.
CMS 1500 Form – General Information Make sure to complete the following boxes: • 1. Check the “MEDICAID” box. 1a. Enter the patient’s unique MCO number. MedStar, United and Priority Partners have unique numbers. Other MCOs use the recipient’s MA ID number.
CMS 1500 Form – Blocks 2 and 3 • 2. Enter patient’s last name, first name, middle initial as it appears on the HealthChoice or PAC card. • 3. Enter patient’s date of birth (month/day/year) and check the appropriate sex.
CMS 1500 Form – Block 5 • 5. Enter patient’s complete mailing address with zip code and telephone number.
CMS 1500 Form – Block 8 • 8. Check the patient’s marital and employment/ student status.
CMS 1500 Form – Block 9a • 9a. Enter the 11-digit Maryland Medical Assistance number.
CMS 1500 Form – Blocks 10a – 10c • 10a, 10b, 10c. Check “YES” or “NO” to indicate if employment, auto accident, or other accident are related to the patient’s condition and to the services listed in Block 24. If unknown, leave blank.
CMS 1500 Form – Block 12 • 12. Signature of the patient or signature of authorized person. If Signature is on File, write Signature on File and the date.
CMS 1500 Form – Blocks 14 and 15 • 14. Enter start date of illness/substance abuse symptoms. • 15. Enter first date of when patient had same or similar illness/substance abuse symptoms (enter a date or write “N/A”).
CMS 1500 Form – Block 17 • 17. Enter the name of the referring physician/ provider if there is one. • Enter “N/A” if patient was not referred by a physician/provider.
CMS 1500 Form – Block 21 • 21. Enter the 3, 4, or 5 ICD-9 code that is related to the procedures, services, or supplies in Block 24d. • List the primary diagnosis in Line 1 and the secondary diagnosis in Line 2. • Lines 3 and 4 can be used for other diagnoses.
CMS 1500 Form – Block 23 • 23. Enter the prior-authorization number only if a prior-authorization is required for the service provided. Otherwise leave blank.
CMS 1500 Form – Block 24a • 24a. Enter each separate date of service as a 6-digit numeric date under the “FROM” heading. • Leave the space under the “TO” heading blank. • Each date of service must be listed on a separate line. • Date ranges are not accepted on this form. Do not enter a date range!
CMS 1500 Form – Block 24b • 24b. For each date of service, enter the place of service code. • Substance abuse treatment programs must enter code “11” here.
CMS 1500 Form – Block 24d • 24d. Enter the 5-character H code that describes the service provided.
CMS 1500 Form – Block 24e • 24e. Enter a single or combination of diagnosis from Block 21 on each line. • Write the number (1, 2, 3, or 4) rather than the actual diagnosis code in this box.
CMS 1500 Form – Block 24f • 24f. Enter the usual and customary charge. • Do not enter the Maryland Medicaid maximum fee unless that is your usual and customary charge. • If there is more than one unit of service on a line, the charge for that line should be the total of all units.
CMS 1500 Form – Block 24g • 24g. Enter the total number of units of service for each procedure. • The number of units must be for a single visit or day. • Multiple, identical services rendered on different days need to be billed on separate lines.
CMS 1500 Form – Block 24j • 24j. Enter the NPI number of the substance abuse treatment clinic/program. • Do not enter the individual clinician’s NPI number.
CMS 1500 Form – Block 25 • 25. Enter the federal tax I.D. number for the “pay-to” provider entered in Block 33.
CMS 1500 Form – Blocks 26 and 27 • 26. Enter patient account identifier (up to 13 characters) used by the provider’s office. • 27. For payment of Medicare coinsurance and/or deductibles, the “YES” box must be checked. Providers agree to accept assignment as a condition of participation.
CMS 1500 Form – Blocks 28-30 • 28. Enter the sum of the charges shown on all lines of Block 24f of the invoice. • 29. Enter the amount of any collections received from any third party payer, except Medicare. • If there is no third party payer, this will likely be $0.00 • 30. Enter the balance due to your program.
CMS 1500 Form – Block 31 • 31. Write “Signature on File”. • Include the date of submission.
CMS 1500 Form – Blocks 32, 32a, 32b • 32. Enter complete name and address for the substance abuse treatment program. • 32a. Enter the substance abuse treatment program’s group NPI number (same as Block 24j). • 32b. Enter the substance abuse treatment program’s 9-digit Maryland Medicaid provider number.
CMS 1500 Form – Blocks 33, 33a, 33b • 33. Enter the name and complete address to which payment and/or incomplete claims should be sent. • 33a. Enter NPI number of the “pay-to” billing provider named in Block 33. • 33b. Enter the 9-digit MA provider number of the “pay-to” provider named in Block 33.
Additional Tips for Successful Completion of a Claim Enter the appropriate pay-to provider information in Blocks 31 and 33. Block 24J and Block 32 should contain information for the SA program; and Block 25 and Block 33 should contain information for the sponsoring/pay-to provider if it is different from the rendering program information.
Additional Tips for Successful Completion of a Claim Establish provider and/or patient eligibility on the dates of services. Verify that you did not bill for services provided prior to or after your program enrollment dates by calling EVS on the day you render the service; and Verify that you entered the correct dates of service in the Block #24a of the claim form.
Additional Tips for Successful Completion of a Claim Make sure the medical services are covered/ authorized for the provider and/or recipient. Procedure must be appropriate for the recipient based on gender, age, prior procedure or other medical criteria conflicts; and Services must be covered for the recipient’s coverage type. For example, since hospital-based services are not covered under PAC, a claim with this information would not be paid.
Rejected Claims Rejected fee-for-service claims will be listed on your Remittance Advice along with an Explanation of Benefits (EOB) code. Common reasons a claim may be rejected: Data was incorrectly keyed or was unreadable on the claim; and The claim is a duplicate, has previously been paid or should be paid by another party. For MCO Rejected Claims: Each MCO sets its own rules for rejection of claims and provides varying information on the EOB. See MCO Provider manuals for further information.
Common Errors HANDWRITING!! MCO number vs. MA number Substance Abuse Program MA number vs. “Pay-to” Provider MA number
CMS 1500 Forms Questions? More information available at: http://dhmh.maryland.gov/mma/healthchoice/html/subabuse.htm