beginning billing workshop cms 1500 - colorado.gov · xerox state healthcare medicaid ... 12...

Colorado Department of Health Care Policy and Financing

1

Beginning Billing WorkshopCMS 1500

Colorado Medicaid2015


Xerox State HealthcareXerox State Healthcare

Medicaid/CHP+ Medical ProvidersMedicaid/CHP+ Medical Providers

Department of Health Care Policy and Financing

Department of Health Care Policy and Financing

Centers for Medicare & Medicaid Services

Centers for Medicare & Medicaid Services

2

MedicaidMedicaid


3

Training Objectives

Billing Pre‐Requisites National Provider Identifier (NPI)

What it is and how to obtain one

Eligibility How to verify Know the different types

Billing Basics How to ensure your claims are timely When to use the CMS 1500 paper claim form How to bill when other payers are involved


4

National Provider Identifier Unique 10‐digit identification number issued to U.S. health care providers by CMS All HIPAA covered health care providers/organizations must use NPI in all billing transactions Are permanent once assigned

Regardless of job/location changes

What is an NPI?


5

What is an NPI?

How to Obtain & Learn Additional Information: CMS web page (paper copy)‐

www.dms.hhs.gov/nationalproldentstand/

National Plan and Provider Enumeration System (NPPES)‐ www.nppes.cms.hhs.gov

Enumerator‐ 1‐800‐456‐3203 1‐800‐692‐2326 TTY


NEW! Department Website

www.colorado.gov/hcpfwww.colorado.gov/hcpf

1.1.

For Our ProvidersFor Our Providers2.2.

6


7

NEW! Provider Home Page

Find what you need here

Find what you need here

Contains important information regarding Colorado Medicaid & other topics of interest to providers & billing professionals

Contains important information regarding Colorado Medicaid & other topics of interest to providers & billing professionals


8

Provider Enrollment

Question:What does Provider Enrollment do?

Question:What does Provider Enrollment do?

Answer:Enrolls providers into the Colorado Medical Assistance Program, notmembers

Answer:Enrolls providers into the Colorado Medical Assistance Program, notmembers

Question:Who needs to enroll?Question:Who needs to enroll?

Answer:Everyone who provides services for Medical Assistance Program members

Answer:Everyone who provides services for Medical Assistance Program members


9

Rendering Versus BillingRendering Provider

Billing Provider

Individual that provides services to a Medicaid member

Entity being reimbursed for service


Always print & save copy of eligibility verifications Keep eligibility information in member’s file for auditing purposesWays to verify eligibility:

10

Verifying Eligibility

Web Portal Fax Back 1‐800‐493‐0920

CMERS/AVRS 1‐800‐237‐0757

Medicaid ID Card with Switch Vendor


Eligibility Dates Co‐Pay Information Third Party Liability (TPL) Prepaid Health PlanMedicare Special Eligibility BHOGuarantee Number

11

Eligibility Response Information


Eligibility Request Response (271)

12

Information appears in sections:• Requesting Provider, Member Details,

Member Eligibility Details, etc. • Use the scroll bar to the right to view

more details

Information appears in sections:• Requesting Provider, Member Details,

Member Eligibility Details, etc. • Use the scroll bar to the right to view

more details

Successful inquiry notes a Guarantee Number:• Print a copy of the response for the

member’s file when necessary

Successful inquiry notes a Guarantee Number:• Print a copy of the response for the

member’s file when necessary

Reminder:• Information received is based on what

is available through the Colorado Benefits Management System (CBMS)

• Updates may take up to 72 hours

Reminder:• Information received is based on what

is available through the Colorado Benefits Management System (CBMS)

• Updates may take up to 72 hours


13

Both cards are valid Identification Card does not guarantee eligibility

Medicaid Identification Cards


Most members= Regular Colorado Medicaid benefits Some members= different eligibility type

Modified Medical Programs Non‐Citizens Presumptive Eligibility

Some members= additional benefits Managed Care Medicare Third Party Insurance

14

Eligibility Types


15

Eligibility Types

Modified Medical ProgramsModified Medical Programs

• Members are not eligible for regular benefits due to income• Some Colorado Medical Assistance Program payments are reduced

• Providers cannot bill the member for the amount not covered• Maximum member co‐pay for OAP‐State is $300• Does not cover:

Long term care services Home and Community Based Services (HCBS) Inpatient, psych or nursing facility services

• Members are not eligible for regular benefits due to income• Some Colorado Medical Assistance Program payments are reduced

• Providers cannot bill the member for the amount not covered• Maximum member co‐pay for OAP‐State is $300• Does not cover:

Long term care services Home and Community Based Services (HCBS) Inpatient, psych or nursing facility services


16

Eligibility Types

Non‐CitizensNon‐Citizens

• Only covered for admit types: Emergency = 1 Trauma = 5

• Emergency services (must be certified in writing by provider) Member health in serious jeopardy Seriously impaired bodily function Labor / Delivery

• Member may not receive medical identification care before services are rendered

• Member must submit statement to county case worker• County enrolls member for the time of the emergency service only

• Only covered for admit types: Emergency = 1 Trauma = 5

• Emergency services (must be certified in writing by provider) Member health in serious jeopardy Seriously impaired bodily function Labor / Delivery

• Member may not receive medical identification care before services are rendered

• Member must submit statement to county case worker• County enrolls member for the time of the emergency service only


17

Sudden, urgent, usually unexpected occurrence or occasion requiring immediate action such that of: Active labor & delivery Acute symptoms of sufficient severity & severe pain‐

Severe pain in which, the absence of immediate medical attention might result in:

– Placing health in serious jeopardy– Serious impairment to bodily functions– Dysfunction of any bodily organ or part

What Defines an “Emergency”?


18

Eligibility Types

Presumptive EligibilityPresumptive Eligibility

• Temporary coverage of Colorado Medicaid or CHP+ services until eligibility is determined Member eligibility may take up to 72 hours before available

• Medicaid Presumptive Eligibility is only available to: Pregnant women

Covers DME and other outpatient services Children ages 18 and under

Covers all Medicaid covered services Labor / Delivery

• CHP+ Presumptive Eligibility Covers all CHP+ covered services, except dental

• Temporary coverage of Colorado Medicaid or CHP+ services until eligibility is determined Member eligibility may take up to 72 hours before available

• Medicaid Presumptive Eligibility is only available to: Pregnant women

Covers DME and other outpatient services Children ages 18 and under

Covers all Medicaid covered services Labor / Delivery

• CHP+ Presumptive Eligibility Covers all CHP+ covered services, except dental


19

Presumptive Eligibility

Presumptive EligibilityPresumptive Eligibility

• Verify Medicaid Presumptive Eligibility through: Web Portal Faxback CMERS

May take up to 72 hours before available• Medicaid Presumptive Eligibility claims

Submit to the Fiscal Agent Xerox Provider Services‐ 1‐800‐237‐0757

• CHP+ Presumptive Eligibility and claims Colorado Access‐ 1‐888‐214‐1101

• Verify Medicaid Presumptive Eligibility through: Web Portal Faxback CMERS

May take up to 72 hours before available• Medicaid Presumptive Eligibility claims

Submit to the Fiscal Agent Xerox Provider Services‐ 1‐800‐237‐0757

• CHP+ Presumptive Eligibility and claims Colorado Access‐ 1‐888‐214‐1101


20

Managed Care Options

Types of Managed Care options: Managed Care Organizations (MCOs) Behavioral Health Organization (BHO) Program of All‐Inclusive Care for the Elderly (PACE) Accountable Care Collaborative (ACC)


21


Managed Care Organization (MCO)Managed Care Organization (MCO)

• Eligible for Fee‐for‐Service if: MCO benefits exhausted

Bill on paper with copy of MCO denial Service is not a benefit of the MCO

Bill directly to the fiscal agent MCO not displayed on the eligibility verification

Bill on paper with copy of the eligibility print‐out

• Eligible for Fee‐for‐Service if: MCO benefits exhausted

Bill on paper with copy of MCO denial Service is not a benefit of the MCO

Bill directly to the fiscal agent MCO not displayed on the eligibility verification

Bill on paper with copy of the eligibility print‐out


22


Behavioral Health Organization (BHO)Behavioral Health Organization (BHO)

Community Mental Health Services Program State divided into 5 service areas

Each area managed by a specific BHO Colorado Medical Assistance Program Providers

Contact BHO in your area to become a Mental Health Program Provider

Community Mental Health Services Program State divided into 5 service areas

Each area managed by a specific BHO Colorado Medical Assistance Program Providers

Contact BHO in your area to become a Mental Health Program Provider


23


Accountable Care Collaborative (ACC)Accountable Care Collaborative (ACC)

Connects Medicaid members to: Regional Care Collaborative Organization (RCCO) Medicaid Providers

•Helps coordinate Member care Helps with care transitions

Connects Medicaid members to: Regional Care Collaborative Organization (RCCO) Medicaid Providers

•Helps coordinate Member care Helps with care transitions


24

Medicare

MedicareMedicare

Medicare members may have: Part A only‐ covers Institutional Services

Hospital Insurance Part B only‐ covers Professional Services

Medical Insurance Part A and B‐ covers both services Part D‐ covers Prescription Drugs

Medicare members may have: Part A only‐ covers Institutional Services

Hospital Insurance Part B only‐ covers Professional Services

Medical Insurance Part A and B‐ covers both services Part D‐ covers Prescription Drugs


25

Medicare

Qualified Medicare Beneficiary (QMB)Qualified Medicare Beneficiary (QMB)

Bill like any other TPL Members only pay Medicaid co‐pay Covers any service covered by Medicare

QMB Medicaid‐members also receive Medicaid benefits QMB Only‐members do not receive Medicaid benefits

Pays only coinsurance and deductibles of a Medicare paid claim

Bill like any other TPL Members only pay Medicaid co‐pay Covers any service covered by Medicare

QMB Medicaid‐members also receive Medicaid benefits QMB Only‐members do not receive Medicaid benefits

Pays only coinsurance and deductibles of a Medicare paid claim


26

Eligible for both Medicare & Medicaid Formerly known as “Dual Eligible”Medicaid is always payer of last resort

Bill Medicare first for Medicare‐Medicaid Enrollee members

Retain proof of: Submission to Medicare prior to Colorado Medical Assistance Program

Medicare denials(s) for six years

Medicare‐Medicaid Enrollees


27

Third Party Liability

Third Party LiabilityThird Party Liability

Colorado Medicaid pays Lower of Pricing (LOP) Example:

Charge = $500 Program allowable = $400 TPL payment = $300 Program allowable – TPL payment = LOP

Colorado Medicaid pays Lower of Pricing (LOP) Example:

Charge = $500 Program allowable = $400 TPL payment = $300 Program allowable – TPL payment = LOP


28

Commercial Insurance

Commercial InsuranceCommercial Insurance

Colorado Medicaid always payor of last resort Indicate insurance on claim Provider cannot:

Bill member difference or commercial co‐payments Place lien against members right to recover Bill at‐fault party’s insurance

Colorado Medicaid always payor of last resort Indicate insurance on claim Provider cannot:

Bill member difference or commercial co‐payments Place lien against members right to recover Bill at‐fault party’s insurance


29

Co‐Payment Exempt Members

Image courtesy of FreeDigitalPhotos.net & David Castillo Dominici

Nursing Facility Residents

Children Pregnant Women


30

Co‐Payment Facts

Auto‐deducted during claims processing Do not deduct from charges billed on claim

Collect from member at time of service Services that do not require co‐pay:

Dental Home Health HCBS Transportation Emergency Services Family Planning Services


Specialty Co‐payments

31

.50 per unit of service, 1 unit = 15 minutes.50 per unit of service, 1 unit = 15 minutes

Psych ServicesPsych Services

$1.00 per date of service$1.00 per date of service

$2.00$2.00

DME / SupplyDME / Supply

PractitionerOptometristSpeech TherapyRHC / FQHC

PractitionerOptometristSpeech TherapyRHC / FQHC

OutpatientOutpatient $3.00$3.00

InpatientInpatient$10.00 per covered day or 50% of the average allowable daily rate‐whichever is less

$10.00 per covered day or 50% of the average allowable daily rate‐whichever is less


32

Record Retention Claim submission Prior Authorization Requests (PARs) Timely filing Extensions for timely filing

Billing Overview


33

Record Retention

Providers must: Maintain records for at least 6 years Longer if required by:

Regulation Specific contract between provider & Colorado Medical Assistance Program

Furnish information upon request about payments claimed for Colorado Medical Assistance Program services


34

Record Retention

Medical records must: Substantiate submitted claim information Be signed & dated by person ordering & providing the service

Computerized signatures & dates may be used if electronic record keeping system meets Colorado Medical Assistance Program security requirements


35

Submitting Claims

Methods to submit: Electronically through Web Portal Electronically using Batch Vendor, Clearinghouse,or Billing Agent

Paper only when Pre‐approved (consistently submits less than 5 per month) Claims require attachments


36

ICD‐10 Implementation Delay

ICD‐10 Implementation delayed until 10/1/2015 ICD‐9 codes: Claims with Dates of Service (DOS) on or before 9/30/15

ICD‐10 codes: Claims with DOS 10/1/2015 or after Claims submitted with both ICD‐9 and ICD‐10 codes will be rejected


Providers Not Enrolled with EDI

37

Colorado Medical Assistance Program PO Box 1100

Denver, Colorado 80201‐1100 1‐800‐237‐0757 or 1‐800‐237‐0044

colorado.gov/hcpf

Providers must be enrolled with EDI to use the Web Portal to submit HIPAA compliant claims, make inquiries and retrieve reports electronically• Select Provider Application for EDI Enrollment Colorado.gov/hcpf→ Providers →EDI Support

Providers must be enrolled with EDI to use the Web Portal to submit HIPAA compliant claims, make inquiries and retrieve reports electronically• Select Provider Application for EDI Enrollment Colorado.gov/hcpf→ Providers →EDI Support


38

Crossover Claims

Automatic Medicare Crossover Process:

Crossovers May Not Happen If: NPI not linked Member is a retired railroad employee Member has incorrect Medicare number on file

Medicare Fiscal Agent Provider Claim Report (PCR)


39

Crossover Claims

Provider Submitted Crossover Process:

Additional Information: Submit claim yourself if Medicare crossover claim not on PCR within 30 days

Crossovers may be submitted on paper or electronically Providers must submit copy of SPR with paper claims Provider must retain SPR for audit purposes

Provider Fiscal Agent Provider Claim Report (PCR)


Weekly claim submission cutoffWeekly claim

submission cutoff

Paper remittance statements & checks

dropped in outgoing mail

Paper remittance statements & checks

dropped in outgoing mail

Accounting processes Electronic Funds Transfers

(EFT) & checks

Accounting processes Electronic Funds Transfers

(EFT) & checks

Payment information is transmitted to the State’s

financial system

Payment information is transmitted to the State’s

financial system

EFT payments deposited to

provider accounts

EFT payments deposited to

provider accounts

Fiscal Agent processes submitted claims &

creates PCR

Fiscal Agent processes submitted claims &

creates PCR

40

Payment Processing Schedule

Mon.Mon. Tue.Tue. Fri.Fri. Sat.Sat.Wed.Wed. Thur.Thur.


Electronic Funds Transfer (EFT)

Several Advantages: Free! No postal service delays Automatic deposits every Thursday Safest, fastest & easiest way to receive payments Located in Provider Services Forms section on Department website

41


PARs Reviewed by ColoradoPAR

With the exception of Waiver and Nursing Facilities: ColoradoPAR processes all PARs including revisions Visit coloradopar.com for more information

42

Mail:Prior Authorization Request55 N Robinson Ave., Suite 600Oklahoma City, OK 73102

Mail:Prior Authorization Request55 N Robinson Ave., Suite 600Oklahoma City, OK 73102

Phone:1.888.454.7686FAX:1.866.492.3176Web:ColoradoPAR.com

Phone:1.888.454.7686FAX:1.866.492.3176Web:ColoradoPAR.com


43

Electronic PAR Information

PARs/revisions processed by the ColoradoPAR Program must be submitted via CareWebQI (CWQI) The ColoradoPAR Program will process PARs submitted by phone for: emergent out‐of‐state out‐of area inpatient stays e.g. where the patient is not in their home community and is seeking care with a specialist, and requires an authorization due to location constraints


44

PAR Letters/Inquiries

Continue utilizing Web Portal for PAR letter retrieval/PAR status inquiries PAR number on PAR letter is only number accepted when submitting claims If a PAR Inquiry is performed and you cannot retrieve the information: contact the ColoradoPAR Program ensure you have the right PAR type e.g. Medical PAR may have been requested but processed as a Supply PAR


PARs Reviewed by the Department Continue utilizing Web Portal for PAR letter retrieval/PAR status inquiries PAR number on PAR letter is the ONLY number accepted when submitting claims Long Term Care Nursing Facility PARs only

45


Waiver PARs

46

Community Center BoardAdult & Children DHS

Waivers

Supported Living Services (SLS)

Developmentally Disabled (DD)

Children’s Extensive Support (CES)

Day Habilitation Services and Support (DHSS)

Community Center BoardChildren DHS Waivers

Children’s Habilitation Residential Program (CHRP)


Waiver PARs

47

Case Management AgencyAdult & Children HCPF Waivers

Elderly Blind and Disabled (EBD)

Community Mental Health Services (CMHS)

Brain Injury (BI)

Spinal Cord Injury (SCI)

Children's Home Community Based Services (CHCBS)

Children With Autism (CWA)

Children with Life Limiting Illness (CLLI)


48

Transaction Control Number

0 14 129 00 150 0 00037

Receipt Method0 = Paper2 = Medicare Crossover3 = Electronic4 = System Generated

Receipt Method0 = Paper2 = Medicare Crossover3 = Electronic4 = System Generated

Julian Date of Receipt

Julian Date of Receipt

Batch NumberBatch

Number

Adjustment Indicator1 = Recovery2 = Repayment

Adjustment Indicator1 = Recovery2 = Repayment

Document NumberDocument Number

Year of ReceiptYear of Receipt


49

Timely Filing

120 days from Date of Service (DOS) Determined by date of receipt, not postmark PARs are not proof of timely filing Certified mail is not proof of timely filing Example – DOS January 1, 20XX:

Julian Date: 1 Add: 120 Julian Date = 121 Timely Filing = Day 121 (May 1st)


50

Timely Filing

From “through” DOSFrom “through” DOS

Nursing FacilityHome HealthWaiver In‐ & OutpatientUB‐04 Services

Nursing FacilityHome HealthWaiver In‐ & OutpatientUB‐04 Services

Obstetrical ServicesProfessional FeesGlobal Procedure Codes: Service Date = Delivery Date

Obstetrical ServicesProfessional FeesGlobal Procedure Codes: Service Date = Delivery Date

From delivery dateFrom delivery date

FQHC Separately Billed and additional Services

FQHC Separately Billed and additional Services

From DOSFrom DOS


51

Documentation for Timely Filing

60 days from date on: Provider Claim Report (PCR) Denial Rejected or Returned Claim Use delay reason codes on 837P transaction Keep supporting documentation

Paper Claims CMS 1500‐ Note the Late Bill Override Date (LBOD) & the date of the last adverse action in Field 19 (Additional Claim Information)


52

Timely Filing – Medicare/Medicaid Enrollees

Medicare pays claimMedicare pays claim

•120 days from Medicare payment date

•120 days from Medicare payment date

Medicare denies claimMedicare denies claim

•60 days from Medicare denial date

•60 days from Medicare denial date


53

Timely Filing Extensions

Extensions may be allowed when: Commercial insurance has yet to pay/deny Delayed member eligibility notification

Delayed Eligibility Notification Form

Backdated eligibility Load letter from county


54

Extensions – Commercial Insurance

365 days from DOS 60 days from payment/denial dateWhen nearing the 365 day cut‐off:

File claim with Colorado Medicaid Receive denial or rejection

Continue re‐filing every 60 days until insurance information is available


55

Extensions – Delayed Notification

60 days from eligibility notification date Certification & Request for Timely Filing Extension –Delayed Eligibility Notification Form Located in Forms section Complete & retain for record of LBOD

Bill electronically If paper claim required, submit with copy of Delayed Eligibility Notification Form

Steps you can take: Review past records Request billing information from member


56

Extensions – Backdated Eligibility

120 days from date county enters eligibility into system Report by obtaining State‐authorized letter identifying:

County technician Member name Delayed or backdated Date eligibility was updated


CMS 1500

57

Who completes the CMS 1500?Who completes the CMS 1500?


CMS 1500

58


59

CMS 1500 Field Number 1Field Title Medicare, Medicaid, TRICARE, CHAMPVA, Group

Health Plan, FECA, Black Lung, Other

Requirement Required

Instructions Indicate the type of health insurance coverage applicable to this claim by placing an “X” in the appropriate box. Only one box can be marked.


60

CMS 1500 Field Number 1aField Title Insured’s ID Number


Instructions Enter the insured’s ID number as shown on insured’s ID card for the payer to which the claim is being submitted.


61

CMS 1500 Field Number 2Field Title Patient’s Name


Instructions Enter the patient’s full last name, first name, and middle initial. If the patient uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.


62

CMS 1500 Field Number 3Field Title Patient’s Birth Date, Sex


Instructions Enter the patient’s eight‐digit birth date MM/DD/YY). Place an “X” in the correct box to indicate the sex (gender) of the patient.


63

CMS 1500 Field Number 4Field Title Insured’s Name

Requirement Conditional

Instructions Complete if the member is covered by a Medicare health insurance policy.


64

CMS 1500 Field Number 5Field Title Patient’s Address

Requirement Not Required

Instructions


65

CMS 1500 Field Number 6Field Title Patient’s Relationship to Insured


Instructions Complete if the member is covered by a commercial health insurance policy. Place an “X” in the box that identifies the member's relationship to the policyholder.


66

CMS 1500 Field Number 7Field Title Insured’s Address


Instructions


67

CMS 1500 Field Number 8Field Title Reserved for NUCC Use

Requirement

Instructions


68

CMS 1500 Field Number 9Field Title Other Insured’s Name


Instructions If field 11d is marked “yes”, enter the insured’s last name, first name and middle initial.


69

CMS 1500 Field Number 9aField Title Other Insured’s Policy or Group Number


Instructions If field 11d is marked “yes”, enter the policy or group number.


70

CMS 1500 Field Number 9bField Title Reserved for NUCC Use


Instructions


71

CMS 1500 Field Number 9cField Title Reserved for NUCC Use


Instructions


72

CMS 1500 Field Number 9dField Title Insurance Plan Name or Program Name


Instructions If field 11d is marked “yes” enter the insurance plan or program name.


73

CMS 1500 Field Number 10a‐cField Title Is Patient’s Condition Related To:


Instructions When appropriate, place an “X” in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.


74

CMS 1500 Field Number 10dField Title Reserved for Local Use


Instructions


75

CMS 1500 Field Number 11Field Title Insured’s Policy, Group, or FECA Number


Instructions Complete if the member is covered by a Medicare health insurance policy.


76

CMS 1500 Field Number 11aField Title Insured’s Date of Birth, Sex


Instructions Complete if the member is covered by a Medicare health insurance policy.Place an “X” in the appropriate box to indicate the sex of the insured.


77

CMS 1500 Field Number 11bField Title Other Claim ID


Instructions


78

CMS 1500 Field Number 11cField Title Insurance Plan Name or Program Name


Instructions

79

S 1500 Field Number 11dd Title Is there another Health Benefit Plan?

uirement Conditional

ructions When appropriate, place an “X” in the correct box. If marked YES, complete 9, 9a and 9d.

80

S 1500 Field Number 12d Title Patient’s or Authorized Person’s Signature

uirement Required

ructions Enter “Signature on File”, “SOF”, or legalsignature. If there is no signature on file, leave blank or enter “No Signature on File”.Enter the date the claim form was signed.

81

S 1500 Field Number 13d Title Insured’s or Authorized Person’s Signature

uirement Not Required

ructions

82

S 1500 Field Number 14d Title Date of Current Illness, Injury, or Pregnancy


ructions Complete if information is known. Enter the date of illness, injury or pregnancy.

83

S 1500 Field Number 15d Title Other Date


ructions

84

S 1500 Field Number 16d Title Dates Patient Unable to Work in Current

Occupation


ructions

85

S 1500 Field Number 17d Title Name of referring Provider or Other Source


ructions

86

S 1500 Field Number 17a d Title Other ID#


ructions

87

S 1500 Field Number 17bd Title NPI #


ructions

88

S 1500 Field Number 18d Title Hospitalization Dates Related to Current

Services


ructions Complete for services provided in an inpatient hospital setting.If the member is still hospitalized, the discharge date may be omitted.

89

S 1500 Field Number 19d Title Additional Claim Information


ructions Use to document the Late Bill Override Date for timely filing.When applicable, enter the word “TRANSPORT CERT” to certify that you have a transportation certificate on file for this service.

90

S 1500 Field Number 20d Title Outside Lab? $ Charges


ructions Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services.Enter the charge amount for this service.

91

S 1500 Field Number 21d Title Diagnosis or Nature of Illness or Injury

uirement Required

ructions Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.Enter the applicable ICD indicator to identify which version of ICD codes is being reported.

92

S 1500 Field Number 22d Title Resubmission and/or Original Reference

Number


ructions List the Original reference number for theresubmitted claim.This field is not intended for use for original claim submissions.

93

S 1500 Field Number 23d Title Prior Authorization Number


ructions Enter any of the following: prior authorization number, referral number, mammography pre‐certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

94

S 1500 Field Number 24Ad Title Date(s) of Service

uirement Required

ructions Enter date(s) of service, both the “From” and “To” dates. If there is only one date of service, enter the date under “From”. Leave “To” blank or re‐enter “From” date. This field allows for data to be entered in the MM/DD/YY format.

95

S 1500 Field Number 24Bd Title Place of Service

uirement Required

ructions Enter the appropriate two‐digit code from the Place of Service Code list for each item used or service performed.


96

CMS 1500 Field Number 24CField Title EMG


Instructions If the service is an emergency, place an “Y” for YES in the bottom, unshaded area of the field.


97

CMS 1500 Field Number 24DField Title Procedures, Services, or Supplies


Instructions Inter the CPT or HCPCS code(s) and modifier(s)from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two‐digit modifiers.


98

CMS 1500 Field Number 24EField Title Diagnosis Pointer


Instructions Enter the diagnosis code reference letter as shown in Field 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first.


99

CMS 1500 Field Number 24FField Title $ Charges


Instructions Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.


100

CMS 1500 Field Number 24GField Title Days or Units


Instructions Enter the number of services provided for each procedure code.Enter whole numbers only‐ do not enter fractions or decimals.

101

S 1500 Field Number 24Hd Title EPSDT/Family Plan


ructions EPSDT‐ enter the qualifier response in the shaded portion of the field.Family Planning‐ if the service if for Family Planning, enter “Y” for YES or “N” for NO in the bottom, unshaded portion of the field.

102

S 1500 Field Number 24Id Title ID Qualifier


ructions

103

S 1500 Field Number 24Jd Title Rendering Provider ID #

uirement Required

ructions In the unshaded portion of the field, enter the eight‐digit Colorado Medical Assistance Program provider number assigned to the individual who actually performed or rendered the billed service.

104

S 1500 Field Number 25d Title Federal Tax ID Number


ructions


105

CMS 1500 Field Number 26Field Title Patient’s Account Number

Requirement Optional

Instructions Enter the information that identifies the patient or claim in the provider’s billing system.


106

CMS 1500 Field Number 27Field Title Accept Assignment?


Instructions The accept assignment indicates that the provider agrees accept assignment under the terms of the payer’s program.


107

CMS 1500 Field Number 28Field Title Total Charge


Instructions Enter the sum of all charges listed in field 24F.


108

CMS 1500 Field Number 29Field Title Amount Paid


Instructions Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.


109

CMS 1500 Field Number 30Field Title Rsvd for NUCC Use


Instructions


110

CMS 1500 Field Number 31Field Title Signature of Physician or Supplier Including

Degrees or Credentials


Instructions Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.Enter the date the claim form was signed.

111

S 1500 Field Number 32d Title Service Facility Location Information


ructions Complete for services provided in a hospital or nursing facility.32a‐ enter the NPI of the billing provider32b‐ enter the eight‐digit Colorado Medical Assistance Program provider number of the individual or organization.

112

S 1500 Field Number 33d Title Billing Provider Info & Ph #

uirement Required

ructions Enter the name of the individual or organization that will receive payment for the billed services.33a‐ enter the NPI of the billing provider33b‐ enter the eight‐digit Colorado Medical Assistance Program provider number of the individual or organization.

113

Common Denial Reasons

Medicaid is always the “Payor of Last Resort”. Provider should bill all other appropriate carriers first

Medicaid is always the “Payor of Last Resort”. Provider should bill all other appropriate carriers first

l Medicare or her Insurancel Medicare or her Insurance

No approved authorization on file for services that are being submittedNo approved authorization on file for services that are being submittedAR not on fileAR not on file

tal Charges validtal Charges valid

Line item charges do not match the claim totalLine item charges do not match the claim total

mely Filingmely FilingClaim was submitted more than 120 days without a LBODClaim was submitted more than 120 days without a LBOD

A subsequent claim was submitted after a claim for the same service has already been paid.

A subsequent claim was submitted after a claim for the same service has already been paid.

uplicate Claimuplicate Claim

Claim accepted by claims processing system

Claim processed & denied by claims processing system

Claim has primary data edits – notaccepted by claims processing system

Claim processed & paid by claims processing system

114

Claims Process ‐ Common Terms

ject

Accept

Denied

Paid

Correcting under/overpayments, claims paid at zero & claims history info

“Cancelling” a “paid” claim(wait 48 hours to rebill)

Re‐bill previously denied claim

Claim must be manually reviewed before adjudication

115

Claims Process ‐ Common Terms

justment Rebill

spend Void

116

Adjusting Claims

hat is an adjustment? Adjustments create a replacement claim Two step process: Credit & Repayment

Adjust a claim when:Adjust a claim when:

Provider billed incorrect services or charges Claim paid incorrectly

Provider billed incorrect services or charges Claim paid incorrectly

Do not adjust when:Do not adjust when:

Claim was denied Claim is in process Claim is suspended

Claim was denied Claim is in process Claim is suspended

Adjustment Methods

Paper Use Medicaid Resubmission Reason Code 7 to

replace a prior claim or Reason Code 8 to void/cancel a claim. The TCN that needs to be replaced or voided is the original reference number. Providers will continue to see Reason Code 406 for replacement claims and Reason Code 412 for voided claims on the Provider Claim Reports. 117

Web PortalPreferred methodEasier to submit & track

118

Provider Claim Reports (PCRs)

ontains the following claims information: Paid Denied Adjusted Voided In process

oviders required to retrieve PCR through File & Report rvice (FRS) Via Web Portal

119


vailable through FRS for 60 dayswo options to obtain duplicate PCRs:Fiscal agent will send encrypted email with copy of PCR attached $2.00/ page

Fiscal agent will mail copy of PCR via FedEx Flat rate‐ $2.61/ page for business address $2.86/ page for residential address

harge is assessed regardless of whether request made thin 1 month of PCR issue date or not

120


PaidPaid

DeniedDenied

VoidsVoids

AdjustmentsAdjustments

121


Net ImpactNet Impact

RepaymentRepayment

RecoveryRecovery

Xerox1‐800‐237‐0757

Claims/Billing/ Payment

Forms/Website

EDI

Enrolling New Providers

Updating existing provider profile

CGI1‐888‐538‐4275

Email [email protected]

CMAP Web Portal technical support

CMAP Web Portal Password resets

CMAP Web Portal End User training

Provider Services

122

123

Thank You!

beginning billing workshop cms 1500 - colorado.gov · xerox state healthcare medicaid ... 12...

Documents