1 eligibility verification and direct data entry billing requirements february 2013 1 department...
TRANSCRIPT
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1www.vita.virginia.gov
Eligibility Verification and Direct Data Entry Billing Requirements
February 2013
www.dmas.virginia.gov 1
Department of Medical Assistance Services
Intellectual Disability Community Waiver
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www.vita.virginia.gov
• This presentation is to facilitate training of the subject matter in the Virginia Medicaid manuals.
This training contains only highlights of the manual and is not meant to substitute for or take the place of the manual.
Providers are responsible for reviewing and adhering to all Medicaid manual requirements.
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Agenda• DMAS Web Portal• Eligibility Verification Options• Patient Pay Information• Important Contacts• Direct Data Entry Billing
Guidelines• Timely Filing
www.vita.virginia.govwww.dmas.virginia.gov 3
Department of Medical Assistance Services
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DMAS Web Portal
www.vita.virginia.govwww.dmas.virginia.gov 4
Department of Medical Assistance Services
• Current, most up-to-date information on Virginia Medicaid programs:– Provider Memos Available for Review– Access to Medicaid Manuals– Provider Forms– Provider Profile Maintenance– Automated Response System– Direct Data Entry (DDE)
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal
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DMAS Web Portal
• Current, most up-to-date information on Virginia Medicaid programs:– Provider Memos Available for Review– Access to Medicaid Manuals– Provider Forms– Provider Profile Maintenance– Automated Response System– Direct Data Entry (DDE)
www.vita.virginia.govwww.dmas.virginia.gov 5
Department of Medical Assistance Services
• https://www.virginiamedicaid.dmas.virginia.gov/wps/portal
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As a participating Provider You Must
• Determine the patients 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.
www.vita.virginia.govwww.dmas.virginia.gov 6
Department of Medical Assistance Services
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COMMONWEALTH OF VIRGINIADEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
9 9 9 9 9 9 9 9 9 9 9 9V I RG I N I A J. R E C I P I E N T
DOB: 05/09/1994 F CARD# 00001
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8www.vita.virginia.govwww.dmas.virginia.gov 8
Department of Medical Assistance Services
Medicaid Eligibility Verification Options
MediCall/Automated Response System
(ARS)
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9www.vita.virginia.govwww.dmas.virginia.gov 9
Department of Medical Assistance Services
MediCall/Automated Response System (ARS)
• Available 24 hours a day, 7 days a week• Medicaid Eligibility Verification• Claim Status• Patient Pay Information• Prior Authorization Information• Primary Payer Information• Managed Care Organization Assignments
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10www.vita.virginia.govwww.dmas.virginia.gov 10
Department of Medical Assistance Services
MediCall
800 - 884 - 9730800 - 772 - 9996800 - 965 - 9732800 - 965 - 9733
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11www.vita.virginia.govwww.dmas.virginia.gov 11
Department of Medical Assistance Services
Automated Response System (ARS)• Web based eligibility verification
option–Free of Charge–Information received in “real time”
–Secure–Fully HIPPA compliant
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12www.vita.virginia.govwww.dmas.virginia.gov 12
Department of Medical Assistance Services
ARS Registration Process
• First Time Users– Go to
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Webregistration
– Establish an user ID and password– By registering you are acknowledging
yourself as a staff member with administrative rights for the organization
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13www.vita.virginia.govwww.dmas.virginia.gov 13
Department of Medical Assistance Services
ARS Web Support Call Center• Questions regarding new user registration,
temporary password or password resets, call:
1-866-352-0496 Available 8 am – 5 pm
Monday – Friday (No Holidays)
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Patient Pay Information• The local department of social services (LDSS) will
enter data regarding the individual’s patient pay obligation into the Medicaid Management Information System (MMIS) at the time action is taken on a case:– Result of application for long term care services– Time of the annual re-determination of eligibility– Change in the enrollee’s situation is reported
• Medicaid patient pay information is available via MediCall and ARS.
• Providers responsible for collecting the patient pay amount should review the information prior to billing each month.
www.vita.virginia.govwww.dmas.virginia.gov 14
Department of Medical Assistance Services
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Patient Pay Information
Begin-End(Date Time Period)
Patient Pay Status
06/01/2012- 06/30/2012
06/01/2012 - 06/30/2012
658.00
488.00 A
V
ARS Patient Pay Information
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Provider Call Center
www.vita.virginia.govwww.dmas.virginia.gov 16
Department of Medical Assistance Services
Claims, covered services, billing inquiries:
800-552-8627
804-786-6273
8:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)
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Provider Enrollment
www.vita.virginia.govwww.dmas.virginia.gov 17
Department of Medical Assistance Services
New provider enrollment, Electronic Fund Transfer (EFT) or change of address:
Xerox– PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax
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18www.vita.virginia.govwww.dmas.virginia.gov 18
Department of Medical Assistance Services
Direct Data Entry
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19www.vita.virginia.govwww.dmas.virginia.gov 19
Department of Medical Assistance Services
Accessing DDE• Once registered for the Web Portal, the
Primary Account Holder (PAH) and Organization Administrator (OrgAdmin) will automatically have access to DDE
• Other users identified as Authorized Staff, will need to be assigned a new role called Authorized Staff-Claims to have access to DDE
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20www.vita.virginia.govwww.dmas.virginia.gov 20
Department of Medical Assistance Services
Direct Data Entry (DDE) of Claims• DDE allows the submission of professional
claims by entering the information at the required locators as detailed in the billing instructions within the User Guide– http://www.virginiamedicaid.dmas.virginia.gov– Under Provider Resources tab select Claims
Direct Data Entry (DDE)– Provides access to DDE User Guide, Tutorial
and FAQs
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Direct Data Entry (DDE) of Claims
www.vita.virginia.govwww.dmas.virginia.gov 21
Department of Medical Assistance Services
• Through the DDE process providers will have the ability to – create a new initial claim– create templates – request an adjustment or void
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Accessing the Claims DDE• https://www.virginiamedicaid.dmas.virginia.gov
www.vita.virginia.govwww.dmas.virginia.gov 22
Department of Medical Assistance Services
• Upon successful login, you will be directed to the secure Provider Welcome Page• Navigational tabs will direct you to Claims DDE and Automated Response System functions
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23www.vita.virginia.govwww.dmas.virginia.gov 23
Department of Medical Assistance Services
Claims Menu-Access
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24www.vita.virginia.govwww.dmas.virginia.gov 24
Department of Medical Assistance Services
Claims Main Page
• DDE functions can be accessed here
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Create New Professional Claim
www.vita.virginia.govwww.dmas.virginia.gov 25
Department of Medical Assistance Services
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Void/Replacement Claim
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• Is this a void/replacement (adjustment) of a paid claim: System defaults to ‘No’ and requires no Claim
Resubmission Information fields related to a prior claim
If ‘Yes’ is selected, the system requires Claim Resubmission Information fields be entered as well as the original paid claim except areas changing for adjustment.
• Claim Resubmission Information section has the following required fields: Resubmission Type Code (required) Select the 4 digit
code identifying the reason for adjusting or voiding an individual claim
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28www.vita.virginia.govwww.dmas.virginia.gov 28
Department of Medical Assistance Services
Resubmission Type Options- Adjustments• 1023- Primary carrier
has made additional payment
• 1024- Primary carrier denied payment
• 1025- Accommodation charge correction
• 1026- Patient payment amount changed
• 1027- Correcting service periods
• 1028- Correcting procedure/service code
• 1029- Correcting diagnosis code
• 1030- Correcting charges• 1031- Correcting units/
visits/studies/procedures• 1032-IC reconsideration of
documented allowance• 1033- Correcting
admitting/referring/ prescribing Provider Identification Number
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Resubmission Type Options – Voids
www.vita.virginia.govwww.dmas.virginia.gov 29
Department of Medical Assistance Services
• 1042- Original claim has multiple incorrect items
• 1044- Wrong provider identification number
• 1045- Wrong enrollee eligibility number
• 1046- Primary carrier paid DMAS max allowance
• 1047- Duplicate payment was made
• 1048- Primary carrier has paid full charge
• 1051- Enrollee not my patient
• 1052-Miscellaneous• 1060- Other insurance
available
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Submitter Information
• Submitter ID- this field defaults to the User ID used to login into the portal
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Patient and Insured Information
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• Patient's Last Name (REQUIRED) – Enter the Last Name of the member receiving the service.
• First Name (REQUIRED) – Enter the First Name of the member receiving the service.
• MI (optional) – Enter the member's middle initial.
• Insured's I.D. Number (REQUIRED) – Enter the 12 digit Virginia Medicaid Identification number for the member receiving the service.
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• Is Patient's Condition Related To: (REQUIRED)• Related Cause 1– Select whether or not the member’s
condition is the result of an employment accident.• Drop down options:
– Not Related To Employment– Related To Employment
• Related Cause 2– Select whether or not the member’s condition is related to an auto accident.
• Dropdown options:– Not Related To An Auto Accident– Related To An Auto Accident
• If ‘Related to an Auto Accident’, the system requires you to enter the state where the auto accident occurred.
• Related Cause 3– Select whether or not the member’s condition is related to an accident other than auto or employment.
• Drop down options:– No Accident– Accident
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• Is there another Health Benefit Plan? (REQUIRED) – This field always defaults to ‘No’ but if other third party coverage exists, select ‘Yes’ and enter Other Coverage Information.
• If ‘Yes’ is entered and other insurance pays this must be listed as Supplemental Data
• If ‘Yes’ is entered and other insurance does not pay standard TPL guidelines must be followed– Attachments must be indicated in Service
Location section
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Physician or Supplier Information
This is notrequired
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CLIA #
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• Date of Current (optional/situational) – Select the reason from drop down options and enter the date in the format MM/DD/YYYY– Illness(First Symptom)-Waiver services providers will enter
the date care began from the DMAS-93 (PA Letter)
• Diagnosis or Nature of illness or Injury (REQUIRED) – Enter the appropriate diagnosis code, which describes the nature of the illness or injury for which the service was rendered. You have to enter at least one diagnosis code out of four.
• Service Authorization # (optional/situational) - Enter the Service Authorization Number for approved services that require a service authorization.
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Service Line ItemClick on ‘Add Service Line Item’Button to add additional Line items
After entering informationYou must Save, Reset, or Cancel
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Note: Taxonomy Code isentered here if applicable
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• Service Date Begin (REQUIRED) – Enter the date on which the service was first rendered. Format is MM/DD/YYYY
• Service Date End (REQUIRED) – Enter the date on which the service was last rendered. Format is MM/DD/YYYY.
• Place of Service (REQUIRED) – Select the two digit code which best describes where the services were rendered.– 12 – Home
• Procedure Code (REQUIRED) – Enter the code that describes the procedure rendered or the service provided.
• Modifiers (optional/situational) – Enter the appropriate modifiers if applicable.
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• Diagnosis Pointers (REQUIRED) – Select the diagnosis pointer related to the date of service and the procedure performed for the primary diagnosis. The system requires you to enter at least one diagnosis pointer value out of four.– Drop down options:
• 1• 2• 3• 4
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Saved Service Line Items
After entering informationYou must Save, Delete, or Cancel
Click on Service Line Item to view
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Save/Reset/Cancel• After entering information in identified
sections, you will have the following options: Save- saves the data as part of your DDE
claim Reset- clears the data entered allowing you to
start again Cancel- will exit or close the current data field
• Data will be required to be saved to be included as part of the DDE claim submission
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• After saving the data, each line item will be displayed
• Additional information can be entered by selecting the ‘Add’ link
• To correct or delete a saved line item, you must first select the line to be amended by clicking on it
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• After selecting the saved line item, you will have the following options: Correcting the information and
save by clicking the Save link Remove the entry from the claim
by clicking on the Delete link Keep the original data as listed by
clicking on the Cancel link
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Service Location and Attachments
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• The Amount Paid field is for Personal Care and Waiver services only– Enter the patient pay amount that is due from
the patient.– NOTE: The patient pay amount is taken from
services billed. – Providers rendering more than one service will
need to send another DDE submission for charges not subject to the Patient Pay.
Patient Pay Amount
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• If the claim has any attachments, you must select ‘Yes’ and enter the following information: Patient Account Number (required) –
Enter up to 20 alphanumeric characters Date of Service (required) – Enter from
date of service the attachment applies to in the MM/DD/YYYY format
Sequence Number (required) – Enter the provider generated sequence number – maximum of 5 digits
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• A ‘Claim Submitted’ confirmation page will be generated by the system
• Print the Claim Submitted page • Staple documents to a copy of the
confirmation page and mail to DMAS• Attachment “documentation” must be
received by Xerox (DMAS Fiscal Agent) within 21 days of the DDE submission or claim will deny
• NOTE: Confirmation page must be the first page of the mailed submitted documents
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• Mailing Address – Claims Submission page and required documents should be mailed within 21 days to:
Department of Medical Assistance ServicesP. O. Box 27444
Richmond, VA 23261-7444
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Service Facility Location Information
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Billing Provider Information
• This section details information about the provider requesting payment for services rendered.
• Billing Provider Information section has both required and optional/situational fields
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Claim Submitted Page
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• You will not be able to access the Claim Submitted page anywhere else on the Portal
• It is strongly recommended you always save a file copy or print this page for your records by clicking on the ‘Print Submission Page’
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• Claim Information- review the following: ICN – Displays the ICN number of the
submitted claim Attachment Control Number (ACN) – Displays
the ACN number if the ATTACHMENT option has been selected for this claim
Date of Service Provider # Member ID Member Name Total Charge Submitted Date/Time (this information will be
accepted as Proof of Timely Filing)
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Create a Professional Template CMS 1500
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• Templates are a mechanism for the user to establish a baseline claim that can be reused as needed.
• They can :– be used to eliminate the need for having to
rekey static data with every submission (i.e. billing provider information).
– be established for common submissions (i.e. infant well care, immunizations, etc)
– be stored for reuse
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• To establish a template for a professional claim, select Create Professional Template from the Claims drop down menu.
• You will be transferred to the Create New Professional Template page for template creation
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Template Name
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• All the fields utilized in the Create Professional Template will be the same as the fields in the Create Professional Claim Except for the buttons below
• From this template page you can
– save the template by clicking on ‘Save Template’ button
– reset all the entered fields by clicking on the ‘Reset’ button or;
– navigate to the ‘Create New Professional Template’ page by clicking on the ‘Cancel’ button.
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• When saving the template, the system only validates the format of the data entered.
• After clicking 'Save Template' button, the system displays a successful save message by directing you to the ’Save Template‘ portlet.
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Save Template
• From this Save Template page you can– navigate to the ’Claims Main Page’ in order to
access other claims options by clicking on the 'Claims Main Page’ button or;
– create a new professional template by clicking on the 'Create Another Template' button.
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View/Manage/DeleteTemplates
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View/Edit/Delete Template
• Once a selection is made, you will be transferred to the request page
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View/Edit/Delete Request Page
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View/Edit/Delete Template –Search Results
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• Results that match the search criteria entered, will be displayed in the ‘Search Results’ section
• Clicking on the individual search result record will direct you to the response page containing detailed information for the selected template
• Except for the buttons above, all of the fields in the Template Response page will be the same as the fields in Create Professional Claim
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• After clicking on the ‘Delete Template’ button, the system deletes the template and displays a successful deletion message by directing you to the ‘Template Deleted’ portlet shown above
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DDE Tips
• Recommend using 6.0 or higher Internet Explorer
• Web-based cursor must be placed in correct location
• Templates limited to 100• Be as specific as possible when naming
templates-they are to be shared• Data entry only-no edits• When adjustments and/or voids of
claims are required, you must wait until the next business day to submit this information 67
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DDE Tips
• Print or save confirmation-Claim Submitted Page
• You will not receive prompts to submit required Supplemental Data
• Don’t worry about capitalization, punctuation, or symbols (except for TPL Supplemental Data)
• 3 year limit for adjustments and voids• Claims for Medallion II members enrolled
in Managed Care Organizations will continue to be submitted to the MCO’s according to their guidelines 68
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TIMELY FILING
www.vita.virginia.govwww.dmas.virginia.gov 69
Department of Medical Assistance Services
• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS– Retroactive/Delayed Eligibility– Denied Claims
• NO EXCEPTIONS– Other Primary Insurance– Accidents
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TIMELY FILING• Claims documentation can be submitted
with DDE• Provider must indicate documentation will
be submitted during the data entry claims process
• Documentation should be attached to the claims confirmation page and mailed to the DMAS fiscal agent – Xerox State Health Plans
www.vita.virginia.govwww.dmas.virginia.gov 70
Department of Medical Assistance Services
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Thank You