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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.

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    DISCHARGE STATUS

    This field identifies the discharge status of the patient at the statement through date. This is a two-position alphanumeric field. The valid values are:

    Value Description

    01 Discharged to home or self-care (routine discharge)
    02 Discharged/transferred to another short-term general hospital
    03 Discharged/transferred to SNF
    04 Discharged/transferred to an ICF
    05 Discharged/transferred to another type of institution
    06 Discharged/transferred to home under care of organized home health service organization
    07 Left against medical advice
    08 Discharged from outpatient care to be admitted to the same hospital from which the patient received outpatient services
    09 Discharged from outpatient care to be admitted to the same hospital from which the patient received outpatient services
    20 Expired (Or did not recover – Christian Science Patient)
    30 Still a patient
    40 Expired at home. For use only on Medicare hospice care claims.
    41 Expired in a medical facility, i.e., hospital, SNF, ICF or freestanding hospice
    42 Expired – place unknown. For use only on Medicare hospice care claims
    50 Hospice – home
    51 Hospice – medical facility
    61 Discharged/transferred to a hospital based Medicare approved swing bed
    62 Discharged/transferred to inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital.
    63 Discharged/transferred to a Medicare certified long term care hospital (LTCH).
    64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare.
    64 Discharged/transferred to a psychiatric hospital or psychiatric distinct part of a hospital (effective for discharges on or after April 1, 2004).

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    Maternity Room and Board Revenue Codes;


    Molina is finding that some maternity claims have either denied or paid zero. Upon researching the claims, Molina discovered that the claims in question were billed without maternity room and board revenue codes. Please keep in mind that although there may be some circumstances when you do not need a maternity revenue code, the claims will process more efficiently if you are billing the appropriate maternity room and board revenue code when applicable.


     NDC Billing Instructions

    Molina EDI Help Desk is reporting claims are being rejected because more than one NDC code is being billed on one service line. Below you will find instructions on billing multiple NDC codes for the same drug on a claim. For more detailed information on billing NDC codes, please see the
    BMS website at www.wvdhhr.org/bms. On this site, you will find a listing of drug codes and whether or not they require a NDC, Frequently Asked Questions, a provider notice and a list of manufacturers that participate in the rebate program.


    Multiple NDCs

    At times, it may be necessary for providers to report multiple NDCs for a single procedure code. For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code, NDC qualifier, NDC, NDC unit qualifier and NDC units. The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line. The second line item with the same procedure
    code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.
     
    Split Billing

    Reminder: Molina updates the hospital contracts every July 1st and October 1st. If you are billing an outpatient claim that extends from June to July or September to October, it is important for you to split the claim into two claims, one date ending on June 30th or September 30th, and the next claim beginning on July 1st or October 1st.

    Please Note: Inpatient acute care claims cannot be split billed; must be billed upon discharge only.

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    Non-Par Non-Assigned Claim No EHR/PQRS Adjustment:

    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    Adjustment Total $5.00
    MPFS Allowed Amount $100-$5.00= $95.00
    Limiting Charge Allowed= $95.00 x 115%= $109.25

    Non-Par Non-Assigned Claim with EHR Adjustment:
    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    1% EHR negative adjustment $.95 (95 x.01)
    Adjustment Total $5.95
    MPFS Allowed Amount $100-$5.95= $94.05
    Limiting Charge Allowed= $94.05 x 115%= $108.16

    Non-Par Non-Assigned Claim with PQRS Adjustment:

    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    1.5% PQRS negative adjustment $1.43 (95 x.015)
    Adjustment Total $ 6.43
    MPFS Allowed Amount $100-$6.43= $93.57
    Limiting Charge Allowed= $93.57 x 115%= $107.61

    Non-Par Non-Assigned Claim with EHR + e-prescribing:

    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    2% EHR negative adjustment $1.90 (95 x.02)
    Adjustment Total $ 6.90
    MPFS Allowed Amount $100-$6.90= $93.10
    Limiting Charge Allowed= $93.10 x 115%= $107.07

    Non-Par Non-Assigned Claim with EHR without 2014 e-Prescribing Adjustment + PQRS:

    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    1% EHR negative adjustment $.95 (95 x .01)
    EHR Adjustment Total $5.95
    MPFS Allowed Amount $100-$5.95= $94.05
    1.5% PQRS negative adjustment $1.41 ($94.05 x .015)
    PQRS Adjustment Total $94.05-$1.41=$92.64
    MPFS Allowed Amount $92.64
    Limiting Charge Allowed= $92.64 x 115%= $106.54

    Non-Par Non-Assigned Claim with EHR with 2014 e-Prescribing Adjustment + PQRS:

    Original Fee Schedule Amount: $100
    5% non-PAR status: $5 (100 x .05)
    2% EHR negative adjustment $1.90 (95 x .02)
    EHR Adjustment Total $6.90
    MPFS Allowed Amount $100-$6.90= $93.10
    1.5% PQRS negative adjustment $1.40 (93.10 x .015)
    PQRS Adjustment Total $93.10-$1.40=$91.70
    MPFS Allowed Amount $91.70


    Limiting Charge Allowed= $91.70 x 115%= $105.46

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    Q: Does the 2 percent payment reduction under sequestration apply to the payment rates reflected in Medicare fee-for-service fee schedules or does it only apply to the final payment amounts?

    A: Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare secondary payment adjustments. All fee schedules, Pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced.


    Q: How is the 2 percent payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?
    A: Claim adjustment reason code (CARC) 253 is used to report the sequestration reduction on the ERA and SPR.



    Q: What is the verbiage for CARC 253?
    A: “Sequestration - reduction in federal payment.”


    Q: Will the 2 percent reduction be reported on the remittance advice in a separate field?
    A: For institutional Part A claims, the adjustment is reported on the remittance advice at the claim level. For Part B physician/practitioner, supplier, and institutional provider outpatient claims, the adjustment is reported at the line level.


    Q: How will the payments be calculated on the claims?
    A: The reduction is taken from the calculated payment amount, after the approved amount is determined and the deductible and coinsurance are applied.
    Example: A provider bills a service with an approved amount of $100.00, and $50.00 is applied to the deductible. A balance of $50.00 remains. We normally would pay 80 percent of the approved amount after the deductible is met, which is $40.00 ($50.00 x 80 percent = $40.00).
    The patient is responsible for the remaining 20 percent coinsurance amount of $10.00 ($50.00 - $40.00 = $10.00). However, due to the sequestration reduction, 2 percent of the $40.00 calculated payment amount is not paid, resulting in a payment of $39.20 instead of $40.00 ($40.00 x 2 percent = $0.80).


    Q: How are unassigned claims affected by the 2 percent reduction under sequestration?
    A: Though beneficiary payments toward deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The non-participating physician who bills on an unassigned basis collects his/her full payment from the beneficiary, and Medicare reimburses the beneficiary the Medicare portion (e.g., 80 percent of the reduced fee schedule amount.

    Note: The “reduced fee schedule” refers to the fact that Medicare’s approved amount for claims from non-participating physicians/practitioners is 95 percent of the full fee schedule amount). This reimbursed amount to the beneficiary would be subject to the 2 percent sequester reduction just like payments to physicians on assigned claims. Both are claims payments, but to different parties. If the limiting charge applies to the service rendered, providers cannot collect more than the limiting charge amount from the beneficiary.

    Example: A non-participating provider bills an unassigned claim for a service with a limiting charge of $109.25. The beneficiary remains responsible to the provider for this full amount. However, sequestration affects how much Medicare reimburses the beneficiary. The non-participating fee schedule approved amount is $95.00, and $50.00 is applied to the deductible. A balance of $45.00 remains. Medicare normally would reimburse the beneficiary for 80 percent of the approved amount after the deductible is met, which is $36.00 ($45.00 x 80 percent = $36.00). However, due to the sequestration reduction, 2 percent of the $36.00 calculated payment amount is not paid to the beneficiary, resulting in a payment of $35.28 instead of $36.00 ($36.00 x 2 percent = $0.72).

    We encourage physicians, practitioners, and suppliers who bill unassigned claims to discuss with their Medicare patients the impact of the sequestration reductions to Medicare payments.


    Q: Is this reduction based on the date of service or date of receipt?

    A: In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME competitive bidding program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.


    Q: If a durable medical equipment capped rental period started before April 1, 2013, are the rental payments for months after April 1, 2013, subject to the 2 percent reduction?

    A: Any claims for rental payments with a “FROM” date of service on or after April 1, 2013, will be subject to the 2 percent reduction, regardless of when the rental period began. For example, if a capped rental wheelchair was provided in February 2013, the monthly rental payment for May 2013 would be subject to the 2 percent sequestration reduction. The initial and subsequent monthly rental payments billed with a “FROM” date of service beginning on or prior to March 31, 2013 would not be affected by the 2 percent reduction.


    Q: How long is the 2 percent reduction to Medicare fee-for-service claim payments in effect?
    A: The sequestration order covers all payments for services with dates of service or dates of discharge (or a start date for rental equipment or multi-day supplies) April 1, 2013, through March 31, 2016.


    Q: Are drugs excluded from the 2 percent reduction?


    A: No. All fee-for-service Medicare claim payments are subject to the 2 percent reduction. There are no exemptions provided in the law for drugs or any other health care item or service provided under the fee-for-service program.

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    SCHs are paid under the OPPS. Therefore, the new OPPS packaging policies apply to SCHs as to other OPPS hospitals for laboratory and other services furnished on or after January 1, 2014. However, SCHs with qualified laboratories continue to be eligible for the 62 percent CLFS payment amount described in the “Medicare Claims Processing Manual” (Pub. 100-04 Chapter 16, Section 40.3) when they furnish outpatient lab tests that are separately payable under exceptions (2) or (3) listed above. The 014X TOB does not provide differential CLFS payment rates for SCHs with qualified laboratories and other OPPS hospitals. Qualified SCHs must submit a 013X TOB with the new modifier appended to separately payable outpatient lab services in order to obtain the 62 percent CLFS payment amount provided in current manual instructions. CMS recognizes that these providers may wish to cancel or adjust claims that are submitted without the new modifier prior to July 1, 2014, and submit a new 013x claim with the appended modifier after July 1, 2014, in order to receive corrected reimbursement or for other reasons when the new modi
    fier is implemented in July.

    CMS will be reviewing claims data for CY 2014 for potential inappropriate unbundling of laboratory services under the new OPPS packaging policy. As stated in the OPPS final rule, CMS does not expect changes in practice patterns under the new policy. Hospitals may not establish new scheduling patterns in order to provide laboratory services on separate dates of service from other hospital services for the purpose of receiving separate payment under the CLFS.

    Billing Scenarios for the New Modifier (on or after July 1, 2014): 

    1)A patient goes to hospital and the hospital only collects the specimen and furnishes only laboratory services on that date of service. No other services are rendered on this date of
    service. It is generally appropriate to append the new modifier to the laboratory services (see example 2).

    2)A beneficiary has a pre-surgery exam in a provider-based clinic for an outpatient cataract surgery that is scheduled in two weeks with the ophthalmologist. On the same day, while at the hospital the beneficiary goes to the hospital lab to have blood drawn for long-term psychiatric medication monitoring, by order of a community psychiatrist. In this situation, the hospital can use the new modifier to bill Medicare for separate payment under the CLFS of the lab test to monitor the patient’s psychiatric medication level. However, any lab tests run by the hospital lab that day upon the order of the ophthalmologist or another physician in the ophthalmologist’s group practice in preparation for the cataract surgery cannot be billed for separate payment.

    3) The beneficiary in example 2 goes to the hospital lab to have blood drawn for long-term psychiatric medication monitoring, by order of a community psychiatrist, and has no other
    hospital services that day. The hospital can use the new modifier to bill Medicare for separate payment under the CLFS of the lab test to monitor the patient’s psychiatric medication level.

    4) The beneficiary in example 2 has the pre-surgery exam in the ophthalmologist’s free-standing physician office. The ophthalmologist refers the beneficiary to the hospital lab located across the street for diagnostic lab tests in preparation for the upcoming out
    patient surgery. The beneficiary has to immediately return to work and chooses to have the lab work done at the hospital 2 days later. The hospital can use the new modifier to bill Medicare for separate payment under the CLFS.

    5) The beneficiary in example 3 goes to the hospital lab the same day to have the pre-surgical labs drawn. The hospital can use the new modifier to bill Medicare for separate payment under the CLFS.



    As a reminder, for claims received on or after July 1, 2014, OPPS providers are instructed to submit “specimen only” services on the 014x TOB. OPPS providers are instructed not to use the new modifier on 014x TOB.

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    Your NPI and Tax ID are required on all claims, in addition to your provider taxonomy and specialty type codes (CMHCs, FQHCs, RHCs and PCCs) using the required claim type format (CMS – 1500, UB-04 or Dental ADA) for the services rendered. Please note, for Community Mental Health Centers (CMHCs) billing on a CMS 1500, the rendering and billing NPI information cannot match. As of October 1, 2013, Kentucky Department for Medicaid Services (KDMS) requires that all NPIs, billing and rendering addresses and taxonomy codes be registered and appear on their master provider list (MPL). Claims submitted without these numbers or information that is not consistent with the MPL will be rejected.

    To avoid delay or disruption of claims payments, please share this information with individuals involved in claims and billing for your organization, billing vendors and/or electronic claims clearinghouses. When submitting an electronic claim to one of our clearinghouses, be sure to include the Humana – CareSource electronic payer ID number KYCS1.

    To submit a paper claim, please mail a completed form to:
    Humana – CareSource Claim Submissions
    P.O. Box 824
    Dayton, OH 45401-0824

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    How to print NPI and referring provider name in box 17 and 17a with example. Also in some cases we need to print Taxanomy code with modifiers



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    Under the Health Insurance Portability and Accountability Act (HIPAA), claims for reimbursement by the Medicare Program must be submitted electronically, except where waived, even for claims with attachments. The process for accepting medical documentation and attaching it to the electronic claim has been improved due to our imaging system. The Claim Supplemental Information segment (PWK) is used whenever paper documentation has been sent for an electronic claim. When sending an electronic claim that contains an attachment, follow these rules to submit the attachment for your electronic claim:

    Maintain the appropriate medical documentation on file for electronic (and paper) claims.
    Complete the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * form. For accurate processing of your claim(s), please complete all requested information in capital letters and avoid contact with the edge of the boxes.
    Important tips to keep in mind when faxing medical records for electronic claims:
    •    Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
    •    The narrative field on the claim is to be utilized in situations where sufficient information for the documentation of a procedure/modifier can be provided without sending the medical records. When additional information cannot be contained in the narrative of the claim, additional documentation (medical records) may be submitted via mail or fax.
    •    Only fax documentation for one patient per cover sheet. The cover sheet is for Part A or B electronic claims.
    •    Clearly write the: Attachment Control Number, Internal Control Number (ICN/DCN), Patient Name, Health Insurance Claim (HIC) Number, Date of Service, Total Claim Billed Amount, National Provider Identification (NPI) Number, Contact Information, and State Where Services Were Provided on the cover sheet.  Failure to submit all items requested will result in documentation being returned and could delay claim processing.
    •    The fax/mail cover sheets are not to be modified.
    •    Only the first iteration of the PWK, at either the claim level and/or line level, will be considered for adjudication.
    •    Submitters must send ALL relevant PWK data at the same time for the same claim.
    •    After submitting the electronic claim, locate the ICN/DCN number on the 277CA claims acknowledgement report.  The ICN/DCN is located in the 2200D REF segment.
    •    Fax the cover sheet and medical documentation to (877) 439-5479. You may fax documentation any time after claim submission, including the same day. Faxing is available 24 hours a day, 7 days a week. Faxes should be sent within seven calendar days of your electronic claim submission.
    Novitas Solutions strongly recommends faxing your medical documentation. If you are not able to fax your documentation, mail the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * and all pertinent medical documentation within ten calendar days of your electronic claim submission to:


    Jurisdiction L Part A Jurisdiction L Part B Jurisdiction H Part A Jurisdiction H Part B
    Novitas Solutions Novitas Solutions Arkansas, Louisiana, Mississippi: Novitas Solutions
    PO Box 3385 PO Box 3065 Medical Review JH Part A PO Box 3094
    Mechanicsburg, PA 17055-1840 Mechanicsburg, PA 17055-1807 Novitas Solutions Mechanicsburg, PA 17055-1812


    PO Box 3103


    Mechanicsburg, PA 17055-1819


    Colorado, J04911, New Mexico, Texas:


    Medical Review JH Part A


    Novitas Solutions


    P.O. Box 3113


    Mechanicsburg, PA 17055-1828






    Oklahoma:


    Medical Review JH Part A


    Novitas Solutions


    P.O. Box 3114


    Mechanicsburg, PA 17055-1829
    In the Claim Supplemental Information Segment (PWK) of the electronic claim:

    •    Select the appropriate Report Type Code for the medical documentation. For information on what codes are needed in the PWK segment.
    •    Use the By Fax or By Mail option for the Attachment Transmission Code
    •    Enter AC for the Identification Code Qualifier
    •    Report the Attachment Control Number - This number may be assigned by your software or can be any number you chose including the patient account number or other identifying number.
    Note: Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.

    Technically Speaking, Claim Supplemental Information (PWK) is reported as follows:
    Data Element    Segment
    Attachment Report Type Code    2300 or 2400 - PWK01
    Attachment Transmission Code    2300 or 2400 - PWK02
    Identification Code Qualifier    2300 or 2400 - PWK05
    Attachment Control Number    2300 or 2400 - PWK06

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    21 (A-L)
    Diagnosis or Nature of Illness or Injury

    At least one Required
    Enter the appropriate ICD-9-CM/ICD-10-CM codes (up to 12).
    Enter the primary diagnosis in 21(A). If applicable, B, C, and other diagnosis in 21 (A-L).
    Always enter the entire diagnosis code including the decimal point.
    Enter a 9 for ICD-9-CM or a zero for ICD-10-CM codes in the ICD Ind. field.
    Note: External Cause of Injury/Morbidity codes are not billable as the primary diagnosis on CMS 1500 claims.


    24E
    (unshaded)

    Diagnosis Pointer
    Required if diagnosis code in block 21 is present
    Use A-L for the corresponding diagnosis code entered in field 21.


    24H (unshaded)
    EPSDT Family Plan
    Required if applicable
    Not required unless applicable. If the services performed constitute an EPSDT program screen, refer to the instructions for EPSDT claims in the provider handbook.

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    24A (shaded top)
    NDC code
    Required if appropriate
    Enter N4 followed by the 11 digit NDC code



    24B (shaded top)
    NDC Unit of measure
    Required if NDC code is present in 24A
    Enter appropriate 2 digit NDC unit of measure
    Valid values:
    F2 - International Unit
    GR – Gram
    ME - Milligram
    ML - Milliliter
    UN - Unit


    24C-D (shaded top)
    NDC number of Units
    Required if NDC code is present in 24A
    Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may precede the decimal point and three numbers may follow the decimal.



    24D
    (shaded top modifier section)
    NCD Unit Price
    Required if NDC code is present in 24A
    Enter unit price corresponding to NDC code.


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    Answer is Yes, read below

    32 Line 1
    Service Facility Name

    Required if Service Facility Location is present in 32a
    Enter name of service facility only if Service Location is different than Billing Provider name in box 33, otherwise leave box 32 blank. If this is included the service facility must be affiliated with the billing facility.

    32 Line 2
    Service Facility Address line 1
    Required if Service Facility Location ID is present in 32a
    Enter Street Address of Service Facility, only if Service Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank.

    32 Line 3
    Service Facility Address line 2
    Not Required
    Enter additional service facility address line if needed and service location if different than billing provider address in box 33, otherwise leave box 32 blank.


    32 Line 3 or 4
    Service Facility City, State and Zip Code
    Required if Service Facility Location is present in 32a
    Enter Service Facility city, state, and zip code, only if Service Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank.


    32a
    Service Facility Location ID (NPI)
    Required, if applicable
    If you bill with an NPI, enter the 14-digit service location identifier only if the services were rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32a. For example, 1234567890-001. If this is included the service facility must be a part of your billing facility.


    32b
    Service Facility Location ID (blank)

    Required, if applicable
    If you bill with an Idaho proprietary number (not an NPI) enter the 12-digit service location identifier only if rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32b. For example, M1234567-001 or A1234567-001. If this is included the service facility must be a part of your billing facility.

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    Note: Tufts Health Plan has identified that the following Revenue Codes will be accepted when submitted electronically without a corresponding CPT and/or HCPCS procedure code if one cannot be found (however, EDI acceptance does not guarantee payment):

    0250 – Pharmacy
    0525 – RHC/FQHC visit to facility (not 4)
    0251 – Generic
    0527 – Visit Nurse to Home HH short area
    0252 – Non-Generic
    0528 – RHC/FQHC visit to other (not 4, 5)
    0258 – IV Solutions
    0621 – Incident to Radiology
    0259 – Pharmacy — Other
    0622 – Incident to other Diagnostics
    0270 – M&S Supplies
    0656 – Hospice — Inpatient General Care
    0271 – Non-sterile Supplies
    0659 – Hospice — Other
    0272 – Sterile Supplies
    0663 – Daily Respite Care
    0274 – Prosthetic/ Orthopedic Devices
    0681 – Level I Trauma Response
    0275 – Pacemaker Supplies
    0682 – Level II Trauma Response
    0276 – Intraocular Lens
    0683 – Level III Trauma Response
    0278 – Other Implants
    0684 – Level IV Trauma Response
    0279 – M&S Supplies – Other
    0689 – Other Trauma Response
    0370 – Anesthesia
    0710 – Recovery Room
    0371 – Incident to Radiology
    0719 – Recovery Room — Other
    0372 – Incident to Other Diagnostic
    1000 – General Classification - Behavioral Health
    0379 – Anesthesia — Other
    1001 – Residential Psychiatric
    0392 – Processing and Storage
    1002 – Residential Chemical
    0524 – RHC/FQHC visit to SNF (Part A)

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    MEDICARE CROSSOVER CLAIMS

    Medicare/MO HealthNet (crossover) claims that do not automatically cross from Medicare to MO HealthNet must be filed through the MO HealthNet billing Web site, www.emomed.com or through the 837 electronic claims transaction. It is advised providers wait sixty (60) days from the date of Medicare’s explanation of benefits (EOMB) showing payment before filing an electronic claim. This will avoid possible duplicate payments from MO HealthNet.

    Claims may not cross over from Medicare to MO HealthNet for various reasons. Two of the most common reasons are as follows:

    • Invalid participant information on file causes many claims to not cross over electronically from Medicare. Participants not going by the same name with Medicare as they do with MO HealthNet will not cross over electronically. Additionally, the participant’s Medicare Health Insurance Claim number (HIC) in the MO HealthNet eligibility file must match the HIC number used by the provider to submit to Medicare. It is the responsibility of the participant to keep this information updated with their Family Support Division Eligibility Specialist.

    • MO HealthNet enrolled providers who have not provided their National Provider Identifier (NPI) used to bill Medicare to the Missouri Medicaid Audit Compliance (MMAC), Provider Enrollment Section, also causes claims to not cross over electronically from Medicare. Providers in doubt as to what NPI is on file should contact Provider Enrollment by e-mail at mmac.providerenrollment@dss.mo.gov.

    Providers who have not submitted their Medicare NPI may fax a copy of their Medicare approval letter showing their NPI, provider name and address to Provider Enrollment at 573-526-2054.



    Following are tips to assist you in successfully filing crossover claims on the MO HealthNet billing Web site at www.emomed.com:

    • From Claim Management choose the Medicare CMS-1500 Part B Professional format under the ‘New Xover Claim’ column.

    • Providers must submit claims to MO HealthNet with the same NPI they used to bill Medicare.

    • There is a ‘Help’ feature available by clicking on the question mark in the upper right hand corner of the screen.

    • Select MB-Medicare as the ‘Filing Indicator’ from the drop down box.

    • On the Header Summary screen, the ‘Other Payer ID’ is a unique identifier on the other payer remittance advice. If not provided, it is suggested using a simple, easy to remember ID. This field may contain numeric and/or alpha-numeric data up to 20 characters.

    • All fields with an asterisk are required and should be completed with the same information submitted to Medicare. Data entered should be taken directly from your Medicare EOB with the exception of the participant’s name and HIC; these should be stated as they appear in the MO HealthNet eligibility file.

    • The Other Payer Detail Summary must contain the same number of line items as detail lines that were entered. Do not check the ‘Payer at Header Level’ box on the Header Summary for Medicare crossover claims.


    MEDICARE ADVANTAGE/PART C CROSSOVER CLAIMS FOR QMB OR QMB PLUS PARTICIPANTS

    Medicare Advantage/Part C plans do not forward electronic crossover claims to MO HealthNet, therefore providers must submit these claims through the MO HealthNet billing Web site, www.emomed.com. The following tips will assist you in successfully
    filing your Medicare Advantage/Part C crossover claims:

    • From Claim Management choose the CMS-1500 Part C Professional format under the ‘New Xover Claim’ column.

    • Select 16-Medicare Part C Professional as the ‘Filing Indicator’ from the drop down box on the Header Summary screen.

    • Always verify eligibility either through the ‘Participant Eligibility’ link on www.emomed.com or access the Interactive Voice Response (IVR) at

    • 573-751-2896 to see if the participant is a Qualified Medicare Beneficiary (QMB) on the date of service. Eligibility needs to be checked for each date of service. The Part C format can only be used if the participant is QMB eligible on the date of service.


    Providers are not to submit crossover claims for participants enrolled in a Medicare Advantage/Part C plan who are non-QMB. These services are to be filed as Medical claims.



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    Completing a claim correctly when a member has primary coverage with Medicare and secondary coverage (Medicare Supplement) from another Blue Plan will decrease your chance of receiving claim denials. The following instructions apply to items on the CMS-1500 form or its electronic counterpart that require specific Medicare Supplement information:

    Item 9

    • Enter the last name, first name and middle initial of the member if it is different from that shown in Item 2. Otherwise, you may enter the word “SAME”. If no Medigap benefits are assigned, leave blank.

    Item 9a

    • Enter the Medicare Supplement member’s policy and/or group number preceded by MEDIGAP, MG, or MGAP.

    • Item 9d must be completed if you enter a policy and/or group number in 9a.


    Item 9b

    • Enter the birth date (MM/DD/YYYY) and gender of the member.

    Item 9c

    • Leave this field blank if the Blue Plan secondary payer’s name is entered in 9d.

    • Enter the correct Blue Plan name as the secondary carrier in 9c. For example, if the member has a Medicare Supplement with Blue Cross and Blue Shield (BCBS) of Michigan, then BCBS of Michigan should be indicated as the secondary carrier, not Blue Cross and Blue Shield of Florida (BCBSF). Use an abbreviated street address, two letter postal code, and zip code copied from the member’s Medicare Supplement ID card. For example: 1234 Anywhere St, MD 12345.

    Item 9d

    • Enter the correct Blue Plan name as the secondary carrier.

    Note: All information must be complete and accurate in items 9, 9a, 9b, 9c and 9d of the CMS-1500 form in order for the Medicare carrier to be able to forward claim information. If prior arrangements have been made with the private insurer, the carrier will forward the Medicare information electronically. Otherwise, the carrier will forward a hard copy of the claim to the private insurer.

    Item 11d

    • If you submit a claim with a Medicare Remittance Notice attached, always mark “YES” in 11d.

    • If you mark “NO” in 11d, the claim will pass through the system but attachments will not be reviewed.

    • If your billing system is hard-coded to mark “NO” automatically in 11d, please manually override your system to mark “YES” when submitting a claim with the Medicare Remittance Notice attached.


    Item 13

    • The signature in this item authorizes payment of mandated Medigap benefits to a participating physician or supplier if required Medicare Supplement information is included in items 9 through 9d.

    • The member or member’s representative must sign this item or the signature must be on file as a separate Medigap authorization.

    • The Medigap assignment on file in the participating physician or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.


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    (UB-04)

    Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:

    Form Locator 50 – Payer

    • Enter “Medicare” as the primary payer on line A.

    • Enter the appropriate Blue Plan name as the secondary payer on line B.

    o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.

    o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.


    Form Locator 53 – ASG BEN

    • A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.

    • This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.

    • The member or representative’s signature must be on file as a separate Medigap authorization.

    • The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.



    Form Locator 54– Prior Payments

    • Enter the amount you have received toward payment of this bill from Medicare on line A.


    Form Locator 58 – Insured’s Name

    • Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.

    Form Locator 59 – P. Rel

    • Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).


    Form Locator 60 – Insured’s Unique ID

    • Enter the patient’s Medicare HIC number as shown on the ID card on line A.

    • Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
    Form Locator 61 – Group Name

    • Enter the name of the group or plan through which the insurance is provided to the member.

    Form Locator 62 – Insurance Group No.

    • Enter the group number as identified on the ID card.



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    Box 19 If Applicable Reserved for Local Use - 

    Use this area for procedures that require additional information, justification or an Emergency Certification Statement.

    • This section may be used for an unlisted procedure code when explanation is required and clinical review is required.

    • If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section.

    All applicable modifiers for each line item should be listed.

    • Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits.

    • All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.

    • Anesthesia start and stop times.

    • Itemization of miscellaneous supplies, etc.



    Box 2. Services rendered to an infant may be billed with the mother’s ID for the month of birth and the month after only. Enter “Newborn using Mother’s ID”/ “(twin a) or (twin b)” in the Reserved for Local Use field (Box 19).






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    The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for
    medical services. The form is used by Physicians and Allied Health Professionals to submit
    claims for medical services. All items must be completed unless otherwise noted in these

    instructions. A CMS 1500 with field descriptions and instructions is included in the link below:

    Box 18 If Applicable Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank.

    Box 20 If Applicable Outside Lab? - Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory.

    Box 24H If Applicable EPSDT Family Plan - Enter code “1” or “2” if the services rendered are related to family planning (FP). Enter code “3” if the services rendered are Child Health and Disability Prevention (CHDP) screening related

    Box 26 optional Patient's Account Number -Enter the patient’s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated

    Box 29 If Applicable Amount Paid - Enter the amount of payment received from the Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals.

    Box 30 If Applicable Balance Due - Enter the difference between the Total Charges and the Amount Paid in full dollar amount and cents. Do not enter decimals.


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    MEDICARE/MEDICAL ASSISTANCE CROSSOVER CLAIMS

    When a Medical Assistance provider bills Medicare Part B for services rendered to a MA recipient, and the provider accepts assignment on the claim (Block #27), Medical Assistance pays the provider the Medicare coinsurance and/or deductible amount(s) in full less any other third party payments (i.e., Medigap). In order for claims to be accurately cross-referenced to your Medicaid provider number, be sure to advise the Claims Processing/Medicare Crossover Unit of your Medicare provider number and NPI number so that all provider numbers can be properly linked in the Medicaid system. Requests to add, change, or delete information on the Medicare crossover file must be sent in writing to the address below Attention: Jack Collins or call 410-767-5559.


    PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS

    Billing a CMS-1500 with a Medicare EOMB:

    On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines.

    • When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB.

    o Dates of service must match

    o Procedure codes must match

    o Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB.

    • When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. In order for MA to pay for co-insurance and deductibles, the CMS-1500 and the Medicare EOMB must be submitted. Claims
    should be sent to the original claims address:

                                                   Maryland Medical Assistance
                                                       Claims Processing
                                                         P.O. Box 1935
                                                     Baltimore, MD 21203



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       Medicaid requires an EOMB for all Medicare crossover claims filed on a paper claim.

    ** NOTE: Medicaid will reimburse Medicare Advantage Plans co-payments, coinsurance and deductibles, with the following exceptions:

    We will not reimburse Medicare Advantage Plan claims for recipients deemed eligible for the Specified Low Income Medicare Beneficiaries (SLMB) Program. Combined co-payments and coinsurance may not exceed 20%. In order to ensure that claims are processed appropriately, the following information is required on the EOMB:


    Requirements for EOMB Header:

    ** In the absence of identifying Medicare information on the EOMB, the provider must label the EOMB attachment “MEDICARE EOMB” to assure proper
    processing of the claim.
    ** Provider Name
    ** Provider Medicare Legacy Number
    ** Provider NPI number
    ** Medicare Payment Date
    ** Column Headings (title)

    Requirements for individual claim lines CMS-1500 Part B:

    ** Date of service
    ** Procedure code plus modifiers (up to 4 spaces for modifiers when applicable)
    ** Charged amount for each procedure
    ** Allowed amount for each procedure
    ** List deductible amounts (if any)
    ** List co-insurance amounts (co-pay amounts not payable)
    ** Patients Medicare ID number
    ** Total deductible amounts (if any)
    ** Total co-insurance amount
    ** Total Medicare payment (even if zero)

    Note: If Medicare denies a service or claim, a written description of the reason/remark code(s) is required for all code(s).

    Failure to comply with the above requirements will result in a denial of the claim and further delay in processing of the claim for payment. You may contact the Medicare Liaison Unit at 410-767-5559 for further assistance.

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    CLAIM TROUBLESHOOTING

    This section provides information about the most common billing errors encountered when providers submit claims to the Medical Assistance Program. Preventing errors on the claim is the most efficient way to ensure that your claims are paid in a timely manner.
    Each rejected claim will be listed on your remittance advice along with an Explanation of Benefits (EOB) code that provides the precise reason a specific claim was denied. EOB codes are very specific to individual claims and provide you with detailed information about the claim. The information provided below is intended to supplement those descriptions and provide you with a summary description of reasons your claim may have been denied. Claims commonly reject for the following reasons:


    1. The appropriate provider and/or recipient identification is missing or inaccurate.'

    ?? Verify that your NPI and 9-digit Medical Assistance provider numbers are entered in Blocks #33a/b. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. Do not use your PIN or tax identification number.

    ?? Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

    ?? Verify that the NPI and 9-digit rendering Medical Assistance provider number you entered in Block #24j. is in fact, a rendering provider. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. If you enter a group NPI and provider number in the block for the rendering provider, the claim will deny because group provider numbers cannot be used as rendering provider
    numbers.

    ?? Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

    ?? Verify that the recipient’s name is entered in Block #2, last name first.


    2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.

    ?? Verify that you did not bill for services provided prior to or after your provider enrollment dates.

    ?? Verify that you entered the correct dates of service in the Block #24a of the claim form. You must call EVS on the day you render service to determine if the recipient is eligible on that date. If you have done this and your claim is denied because the recipient is ineligible, double-check that you entered the correct dates of service.

    ?? Verify that the recipient is not part of the Medical Assistance HealthChoice Program. If you determine that the recipient is in HealthChoice, contact the appropriate Managed Care Organization (MCO).



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