HP Provider Relations October 2011 CMS-1500 Billing Medicare Replacement Plans.
1 CMS-1500 (08-05) Billing Guidelines Department of Medical Assistance Services February 2010 .
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Transcript of 1 CMS-1500 (08-05) Billing Guidelines Department of Medical Assistance Services February 2010 .
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1
CMS-1500 (08-05)Billing Guidelines
Department of Medical Assistance Services
February 2010www.dmas.virginia.gov
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This presentation is to facilitate training of the This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid subject matter in Chapter V of the Virginia Medicaid
Physicians Manual.Physicians Manual.
This training contains only highlights of this manual This training contains only highlights of this manual and is not meant to substitute for or take the place of and is not meant to substitute for or take the place of
the the PhysiciansManual. PhysiciansManual.
Providers are responsible for reviewing and adhering Providers are responsible for reviewing and adhering to the to the Physicians ManualPhysicians Manual requirements. requirements.
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Objectives
To familiarize the providers with the billing guidelines of the CMS-1500 claim form.
To give the providers clear instructions on the requirements of DMAS for the completion of the CMS-1500 claim form.
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Participating Providers Must
Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid
by Virginia Medicaid. Bill any and all other third party carriers.
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DOB: 05/09/1994 F CARD# 00001
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
COMMONWEALTH OF VIRGINIA
V I RG I N I A J. R E C I P I E N T
9 9 9 9 9 9 9 9 9 9 9 9
002286
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MediCall/Automated Response System (ARS)
Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Patient Pay Information Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment
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MediCall
800-884-9730
800-772-9996
804-965-9732
804-965-9733
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Automated Response System (ARS)
Web-based eligibility verification optionFree of Charge.Information received in “real time”.SecureFully HIPAA compliant
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ARS Registration Process
https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Select the ARS tab on FHSC ARS Home PageChoose “User Administration”Follow the on-screen instructions for help with
registration, this is a 3-step process to request, register and activate a new account
Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’
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ARS – Users
ARS User’s Guide
http://www.dmas.virginia.gov/prclaims_billing.htm
Web Support Helpline-
800-241-8726
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Important Contacts
Provider Call Center Provider Enrollment Electronic Claims Coordinator
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Provider Helpline
Claims, covered services, billing inquiries:
800-552-8627
804-786-62738:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)
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Provider Enrollment
New provider enrollment, Electronic Fund Transfer (EFT) or change of address:
First Health – PEU
P. O. Box 26803
Richmond, VA 23261
888-829-5373
804-270-5105
804-270-7027 - Fax
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Electronic Billing
Electronic Claims Coordinator
Mailing Address
First Health Services CorporationVirginia Operations
Electronic Claims Coordinator4300 Cox Road
Glen Allen, VA 23060
E-mail: [email protected]
Phone: (800) 924-6741
Fax: (804) 273-6797
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Claim Attachment FormDMAS-3
The DMAS-3 form is to be used by Electronic Data Interchange (EDI) billers only to submit a non-electronic attachment to an electronic claim. See Chap. V Exhibits pg. 5
Attachment Control Number (ACN) should be indicated on the electronic claim submitted.
The ACN number is the combined information from: Patient Account Number Date of Service Sequence Number
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Claim Attachment FormDMAS 3 – Sample ACN#
Patient Account Number 123456789
Date of Service 09/11/2009
Sequence Number 12345
ACN number listed on form will be- 1234567890911200912345
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Billing on the CMS-1500
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MAIL CMS-1500 FORMS TO:
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
PRACTITIONERP. O. Box 27444
Richmond, Virginia 23261
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TIMELY FILING
ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE
EXCEPTIONSRetroactive/Delayed EligibilityDenied Claims
NO EXCEPTIONSAccident CasesOther Primary Insurance
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TIMELY FILING
Submit claims with documentation attached to the back of the claim form, explaining the reason for delayed submission
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Block 1
The locator will now be used to indicate if the claim is Medicaid, TDO, or ECO.
Enter an ‘X’ in the MEDICAID box for the Medicaid Program
Enter an ‘X’ in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO)
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MEDICAID
(Medicaid #)
Block 1
CHAMPUS
(Sponsor's SSN)
1. MEDICARE
(Medicare #)
MEDICAID CLAIM
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
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TRICARE
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GROUP
(SSN or ID)
Block 1
BKL LUNG(SSN)
CHAMPVA
(Member ID#)
TDO or ECO CLAIM14
FECAHEALTH PLAN
OTHER
(ID)
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1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
Block 1a: Recipient ID Number
(Be sure to include all 12 digits)
123456789014
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Block 2: Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle Initial)
Smith, Sam5. PATIENT'S ADDRESS (No., Street)
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Is Patient’s Condition Related To? Block-10
If the condition is related to an auto accident, and you have this information, place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.
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Block 10: Accident-Related
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
YES NO
PLACE (State)
YES
YES
NO
NO
You MUST check YES or NO for a, b & c18
WV
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Insurance Plan Name or Program NameBlock-11c
Providers that are billing for non-Medicaid Managed Care Organizations (MCO) co-pays please insert ‘HMO COPAY’
The amount billed to Medicaid in 24F (Charges) must represent only the enrollees co-payment amount for the HMO, and the Explanation of Benefits (EOB) must be attached.
Use the CPT or HCPCS procedure code that was billed as the primary procedure to the HMO.
This does not apply to enrollees in a Medicaid HMO, e.g., Medallion II.
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Block 11c - Insurance Plan Name or Program Name
c. INSURANCE PLAN NAME OR PROGRAM NAME
HMO COPAY
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CHANGE – Is There Another Health Benefit Plan?
Block-11d
Providers should always check ‘YES’ if there is verification of Third Party Liability
If there is no other coverage check no or leave blank
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Block 11d - Is There Another Health Benefit Plan?
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.
23
DMAS does not require items 9 a-d to be completed.
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Blocks 17 and 17b- Conditional
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17- Name of the Recipient’s PCP17b- PCP’s NPI
17a.
17b. NPI 1234567890
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Block 19- Conditional Use
19. RESERVED FOR LOCAL USE
Clinical Laboratory Improvement Amendment (CLIA) Number of the physician office laboratory (POL)
performing the service.
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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
3441
Block 21: Diagnosis Codes
May enter up to 4 codes
Omit decimals
2963
29
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Prior Authorization NumberBlock-23
If service requires prior authorization, enter the eleven digit PA number assigned by KePRO
Enter the number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO.
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23. PRIOR AUTHORIZATION NUMBER
Block 23: Prior Authorization Number - Conditional
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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-shaded red area
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
Decimal between dollars and cents is required to read paid amount correctly
Must be left justified
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24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
12 01 09 12 01 09
12 01 09 12 31 09
1
2
TPL27.08amount paid by primary carrier $27.08
68TPL Information
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TPL Billing Scenarios
No other insurance Check ‘NO’ in Locator 11d or leave blank Do not document any information in the
shaded red area of 24A Primary Carrier pays covered service
Provider receives Explanation of Benefits (EOB)
Check ‘YES’ in Locator 11d Document primary payment information in the
shaded red area of 24A on claim form
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TPL Billing Scenarios
Primary carrier does not pay Payment applied to deductible/claim denied Provider receives EOB Check ‘YES’ in Locator 11d Attach copy of EOB showing non-payment to
the back of the DMAS claim form Do not document any information in the shaded
red area of 24A
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TPL Billing Scenarios
Primary carrier does not pay Service not covered Check ‘YES’ in Locator 11d Attach EOB documenting that services are
not covered or, attach letter verifying the service is not covered
Do not document any information in the shaded red area of 24A
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TPL Billing Scenarios
Primary carrier does not pay Provider not enrolled with carrier Check ‘YES’ in Locator 11d Attach letter documenting the provider is not
enrolled with the primary carrier Do not document any information in the shaded
red area of 24A
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TPL Billing Scenarios
Primary carrier does not pay Policy is no longer active/coverage
terminated Check ‘YES’ in Locator 11d Attach EOB verifying that the policy is not
active or, attach letter verifying the policy is not active
Do not document any information in the shaded red area of 24A
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NDC Information Block-24A
Qualifier ‘N4’ is used followed by the National Drug Code (NDC) whenever a HCPCS J-code is submitted in 24D.
No spaces between the qualifier and the NDC number
Must be left justified
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24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
12 01 09 12 01 09
12 01 09 12 16 09
1
2
37
N400026064871
NDC Information
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24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
12 01 09 12 01 09
12 01 09 12 31 09
1
2
TPL and NDC information31
TPL27.08N400026064871
If both NDC andTPL apply to a
single procedureboth must be placed on the
same line, it doesnot matter which
comes first
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24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
12 01 09 12 01 09
12 01 09 12 16 09
1
2
Both FROM and TO datesmust be completed
Dates must be within same calendar month36
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B.Place
ofService
Block 24B: Place of Service
11
11-Office location
21- Inpatient
Medicaid accepts the same 2 digit CMS Place of Service codes as
Medicare.37
Note: Type of Serviceis no longer required
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Emergency IndicatorBlock 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
If there was no emergency leave blank
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C.
EMG
Block 24C: EMG
Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an
emergency 39
Y
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D.
Block 24D: Procedure Codes
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
2299254
40
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J Code Mandate: Block 24D When billing a J Code the red shaded area
must have the unit of measurement (UOM) qualifier.
Valid qualifiers:F2: international unitML: milliliterGR: gramUN: unit
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J-Code Mandate: Block 24D
Enter the actual metric decimal quantity (units) administered to the patient
If reporting a fraction of a unit, use the decimal point
The maximum number of bytes allowed for the quantity is 13, including the decimal point.
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D.
Block 24D: Procedure Codes
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
J0881
GR0.0004
J0881 constitutes 1mcg of a drug, the quantity given was 400 mcg which converts to 0.0004 grams
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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
34431
Block 24E: Diagnosis Code
E.
DIAGNOSISPOINTER
1
2963
1,2
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.
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F.
$ CHARGES
Block 24 F: Charges
Enter the usualand customary charges
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G.DAYS
ORUNITS
Block 24G: Days or Units
1
Enter the number of times or hours the procedure, service, or item was provided during the service period.
31
43
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H.
Block 24H: EPSDT/Family Plan
44
1
EPSDTFamilyPlan
1-EPSDT2-Family Planning Service
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CHANGE – ID.QUALBlock-24I
Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (API).
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.
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61
CHANGE – Rendering Provider ID #
Block-24J
The shaded red area will contain the current Atypical Provider Identifier (API) or;
The open area will contain the NPI of the provider rendering the service
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Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
48
I.ID.
QUAL
J.RENDERING
PROVIDER ID. #
NPI
ID 9876543210
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Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
49
I.ID.
QUAL
J.RENDERING
PROVIDER ID. #
NPI
ZZ Taxonomy (if needed)
12345647890
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26. PATIENT ACCOUNT NUMBER
Block 26: Patient’s Account Number
(Optional)
12345678918765
50
Can not exceed 17 alphanumeric digits
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Total ChargeBlock 28
DMAS now requires this locator to be completed
Enter the total charges for the services in 24F lines 1-6.
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28. TOTAL CHARGE
Block 28: Total Charges
52
$
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Amount Paid(Personal/Waiver Services ONLY)
Block 29 Patient pay amount is taken from
services billed on 24A – line 1 If multiple services are provided on
the same date of service another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service
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28. AMOUNT PAID
Block 29: Amount Paid
(Personal and Waiver Services ONLY)
54
$
Enter the Patient Pay amount as indicated on the DMAS-122
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31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverseapply to this bill and are made a part thereof.)
SIGNED DATE
Block 31: Signature & Date
If there is a signature waiveron file, you may stamp, print,
or computer-generate the signature.55
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Service Facility LocationInformationBlock-32
Enter information for the location where services were renderedFirst line-NameSecond line-AddressThird line-City, State, 9 digit zip code
Physicians with multiple offices-the zip code must reflect the office 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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Service Facility Location InformationBlock-32a-b
Enter the 10 digit NPI number of the service provider in 32a OR;
Enter ‘1D’ qualifier with the API in 32b
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Block 32: Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a. b.NPI
58
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Billing Provider Info & PH #Block-33
Enter the information to identify the provider that is requesting to be paidFirst line-NameSecond line-AddressThird 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 & PH #Block-33a-b
Enter the 10 digit NPI number of the service location in 33a OR;
Enter ‘1D’ qualifier with the API in 33b
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Block 33: Billing Provider Info & PH #
33. BILLING PROVIDER INFO & PH #
a. b.NPI
( )
61
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22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
Block 22: Adjustments and Voids
1032 xxxxxxxxxxxxxxxxAdjustment
or
Resubmission Code
From originalremittanc
eVoid
Chap. V, Medicaid Physician’s Manual has code list.64
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77
THANK YOUDepartment of Medical
Assistance Services
www.dmas.virginia.gov