1 Welcome Nursing Facilities Department of Human Services June 2009.
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Transcript of 1 Welcome Nursing Facilities Department of Human Services June 2009.
1
Welcome Nursing Facilities
Department of Human Services
June 2009
2
Goal
To provide you with the tools and resources that are necessary to access and perform many of the
features and functions that you need to submit your claims for payment processing.
3
Objectives
After completing today’s session, you will: • Have a basic understanding of the replacement MMIS
and how it impacts Nursing Facility providers.
• Be able to submit Institutional (UB-04) claims on paper, through the provider Web portal, or by submitting through Electronic Data Interchange (EDI).
• Be able to perform basic Web portal functions.
• Be able to perform claim searches and adjustments by using the Web portal.
4
DHS at a glance
DHS structureDHS Director Bruce Goldberg, MD
Addictions and
Mental Health (AMH)
Administrative Services Division
(ASD)
Children, Adult and
Families Division (CAF)
Division of Medical Assistance
Programs (DMAP)
Public Health Division
(PHD)
Seniors and People with
Disabilities (SPD)
6
Department of Human Services
• The Department of Human Services (DHS) mission:– To make it possible for people to lead lives that are independent,
healthy and safe.
• DHS provides:– Services to more than 1 million Oregonians every year.– More than 300 programs and different services through 170 field
offices located throughout the state.– Approximately 85% of our biennial budget flows directly to
clients and communities as payments to:• Foster parents• Nursing homes• Healthcare providers and clinics• Local governments, and• Other service providers
7
Seniors and People with Disabilities
• SPD provides services to seniors and people with disabilities, including physical and developmental disabilities.
• Services are determined by an individual’s financial circumstances and/or personal daily needs.
• SPD determines eligibility for state and federal programs.
8
Division of Medical Assistance Programs
• Administers state programs that provide medical coverage to low-income Oregonians.
• Processes health care claims according to the policies of the State of Oregon’s Medicaid programs.
• Issues payment to enrolled Medicaid providers.
9
DMAP programs
• DHS Programs administered by DMAP:
– Medicaid (OHP)
– Children’s Health Insurance Program (CHIP)
– Breast and Cervical Cancer Program (BCCP)
– Senior Prescription Drug Assistance Program (SPDA)
– Disease Case Management Program (DCM)
10
Medicaid Management Information System (MMIS)
11
Medicaid Management Information System
• Previous MMIS:– Implemented in 1980.– Designed to handle paper claims and track eligibility.– It was decided that a replacement MMIS was needed due to
outdated technology.– It was unable to meet the demands of federal, state and local
legislation.
• Replacement MMIS:– Implemented in 2008/2009.– Provides real-time client eligibility.– Allows for faster claims processing.– Self-service access via the Internet.
12
MMIS
• The replacement MMIS, has a secure Web portal feature that will allow DHS authorized providers access to perform various internet-based self-service functions, such as:
– Verify and view current client eligibility.
– Submit, track and view claims online.
– Submit, track and view prior authorization requests.
– Perform Health Services Commission (HSC) prioritized list inquiries.
13
Provider Web portal
• The Provider Web portal is free of charge and designed to be accessible 24 hours a day, 7 days a week.
• Access to the Web portal requires:
– An Internet connection.
– Microsoft Internet Explorer 6 or 7, or Firefox 2.0.
– Authorization from DHS to access Web portal services.
– Your Provider ID and the Personal Identification Number (PIN) issued by DHS.
14
ID and PIN
• To access the Provider Web portal for the first time, providers must login using their DHS provider ID and a Personal Identification Number (PIN) sent by DHS.
• After the account has been set up, providers will login using their own usernames and passwords; you will no longer need the PIN letter.
• If you have not received your PIN or you need to have your PIN reset, contact:
DMAP Provider Services800-336-6016DMAP.providerservices@[email protected] - Friday, 8:00 a.m. to 5:00 p.m.
15
Eligibility verification
16
Verification of eligibility
Providers are responsible to verify eligibility prior to providing services in order to ensure reimbursement of services.
Providers are responsible to verify that a person is enrolled in a benefit package that covers the services rendered.
Providers assume full financial responsibility in serving a person whose eligibility was not confirmed on the date(s) of service.
17
Resources
Two options are available to verify medical eligibility:
1. Automated Voice Response (AVR):
Provides free, phone-based eligibility verification.
2. MMIS Provider Web portal:
Provides free, real-time eligibility verification over the Web.
18
Automated Voice Response (AVR)
19
What is AVR?
• The AVR is a computer system that gives:– Client eligibility. – Status of a claim.– Status of a prior authorization. – Recent payment or suspended claim information.– Benefit limits for eye exams and optical services.
• Allows providers to complete automated inquiries using a touch-tone telephone.
• AVR is available 24 hours a day, 7 days a week.
20
What does AVR provide?
• The AVR can tell you the following information:– The client’s Medicaid identification number. – The client’s date of birth. – If a client is eligible on a specific date of service.– Which benefit plan the client is eligible for. – The client’s copayment requirement.– If the service is covered in the client’s benefit plan.– If the client is enrolled in a managed care plan.– If the client has other insurance coverage.– The date of the client’s last vision exam and glasses.
21
Personal Identification Number
• To access AVR, providers must use the personal identification number (PIN) sent by DHS.
• If you have not received your PIN from DHS or you need to have your PIN reset, contact:
DMAP Provider Services
800-336-6016DMAP.providerservices@[email protected] - Friday, 8:00 a.m. to 5:00 p.m.
22
23
Web portal eligibility verification
24
Getting started
• In the address field of your Internet browser, type https://www.or-medicaid.gov.
• The session “times out” after 20 minutes of inactivity. – Any work or changes that have not been submitted will be lost. – If your session expires, you will receive a message.
Accessing the Web portal
Click here to access the Web portal.
Web Portal login
1. Select “Account”.
2. Select “Secure Site”.
3. Enter your “User Name” and “Password”.
4. Select “Login”.
Home pageSelect “Eligibility”
This is the DHS provider that corresponds with the user name entered on the previous screen.
Provider ID: ###### MCD Taxonomy: ########## Zip Code: ##### - ####
Eligibility verification request
• To search for client eligibility use one of three combinations:1. Client ID and dates of service;2. Client SSN, birth date and dates of service; 3. Client name, birth date and dates of service.
• The Procedure Code field is used to identify service limitations for a specific procedure.
Eligibility verification request
• Enter one of the 3 combinations as indicated on the previous page and click search.
• You can view 13 months of historical eligibility up to today’s date.
– The Provider Web portal will not give future eligibility information. All end dates listed in your search results are either the date the client’s coverage ended or the “To DOS” you listed in your request.
XX#####X 12/01/2008
12/31/2008
Eligibility search results; displays 6 sections
1. Client information.2. Benefit Plan (formerly
benefit package).3. TPL (third party liability).4. Managed Care.5. Lockin.6. Service Limitations.
XX#####X#########
Doe Jane
Client information section
• The client information section displays basic information about the client.– ID– SSN– Last dental visit– Branch ID and phone number– Name of client– Medicare Parts A, B or D effective dates
XX#####X #########
Doe Jane
Benefit plan section
• The client benefit plan section gives information about the client’s benefit plan (formerly benefit package).
• The following codes indicate DHS benefit plans. Disregard all other codes; they are for internal use only.
NFC - Nursing Home NFG - Nursing Facility
Developmental Disability Specialized Services
NFS - Nursing Home Short Term
BMH - OHP Plus KIT - OHP Standard MED - Qualified Medicare Beneficiary BMM - QMB + OHP with Limited Drug CWM - Citizen/Alien-Waived
Emergency Medical (CAWEM) CWX - CAWEM Plus
SMHS – Title 19 State Plan Mental Health Services
Should have all 3 plans
Third party liability (TPL) section
• Displays specific information about the client’s third-party resources (other insurance).
Carrier Name Policy Number Policy Holder Coverage Type Effective Date End Date
Blue Cross # # # # # # # # Doe, John Major Medical 08/01/2000 11/30/2008 Prime Dental Health # # # # # # Doe, John Dental 08/01/2000 11/30/2008
Managed Care section
• The Managed Care section displays information about which managed care plan or primary care manager the client is enrolled in.
• Plan types are:FCHP - Fully Capitated Health PlanDCO - Dental Care OrganizationMHO - Mental Health OrganizationPCO - Physician Care OrganizationPCM - Primary Care ManagerCDO - Chemical Dependency Organization
Lockin section
• If the client is required to use a specific pharmacy through the Pharmacy Management Program (PMP), that information will be listed in this section.
Lockin Plan Effective Date End Date Provider Provider Name Provider Phone
Pharmacy 08/01/2000 10/31/2007 # # # # # # # # # # NPI My Pharmacy (503) # # # - # # # # #
Service limitation section
• This section shows the next available date for a specific service that has limitations according to Oregon Administrative Rules.
• This would not apply to Nursing Facilities.
Service Limitation has been found for Procedure Code 92002, next possible date of service is 12/01/2008
Open card example1. This example shows a
“From/To DOS” date range.
2. Indicates that the client has Medicare Parts A and B coverage.
3. Indicates the client is in the BMM (Qualified Medicare Beneficiary and OHP with Limited Drug) and NFC (Nursing Home) benefit plans. Ignore SMHS.
4. “No rows found” indicates the client is not enrolled in a managed care plan during the “From/To DOS” listed in this request.
XX#####X
XX#####X Doe Jane
Managed care example1. This example shows a
“From/To DOS” date range.
2. Indicates that the client does not have Medicare coverage.
3. Indicates the client is in the BMH (OHP Plus)
and NFC (Nursing Home) benefit plans. Ignore SMHS.
4. Indicates the client is enrolled with FCHP, MHO and DCO managed care plans.
XX#####X
XX#####X Doe Jane
Client not eligible example
• This example shows a specific “from/to DOS” date range.
• Indicates that the client is not eligible for the requested date range.
40
Plan of Care
Plan of Care
• The POC search screen allows you to look up an approved and active Plan of Care.
• There are four ways to search for a Plan of Care.– Enter the From/To date of service and Client ID.– Enter the Client ID only.– Enter the From/To dates of services.– Leave all fields blank.
Select “POC”
XX#####X
POC results
• The POC search results returns all active POCs based on the criteria that was entered at the Search screen.
• To review the details of the POC, click on the line and the detail information will appear.
Detail information
• POC information includes:– Service code– Effective dates– Client liability– Used units
#########
Nursing Facility
XX#####X
Jane Doe
Revenue Code 100
All inclusive/room and board
01/01/2008 04/15/2008
SPD Resident Stay
System price
106
$0.00
0
$0.00
44
Claims processing
45
MMIS
• The federal government requires DHS to process Medicaid claims through the automated claim processing system which is MMIS.
• This system is a combination of people and computers working together to process claims.
• This system performs daily edits for presence and validity of data.
• DHS staff only reviews claims that MMIS cannot make a payment decision based on the information submitted on the claim and other system related data (i.e.; eligibility).
46
Claims submission
• No matter how the claim was submitted (paper, electronically, or through the Web portal), providers will have the capability of viewing the claim.
– If billing through the Web portal, the claim will process real-time so you will know the status of the claim as soon as you submit it.
– If billing EDI, it is near to real time, in that within 20 minutes or so of MMIS receiving the claims transaction, the status of the claim is available.
– Providers can:• View submitted claims for status and accuracy.• Submit new claims.• Correct and resubmit denied claims.• Adjust, void or copy paid claims.
47
Claim processing times
• 80% of the department’s claim volume is electronic.
• Electronic claims process in real-time and usually adjudicate the week in which they are submitted.
• Paper claims may take up to three weeks for processing.
• DMAP pays providers on a weekly Friday cycle.
• Electronic fund transfers are processed on Wednesdays in the week following the Friday claims cycle.
• Less than two percent of claims suspend. Once they suspend, DMAP works them within 14 days.
48
Claims Processing
• Paper claims submitted by mail go to the DHS Office of Document Management (ODM) Imaging Unit.
• ODM processes hardcopy claims using Optical Character Recognition (OCR) scanning.
• Make sure your claim form meets OCR specifications.
• Effective August 1, 2009, only red forms will be acceptable.
• A Remittance Advice (RA) listing all claims adjudicated is mailed to the provider (with payment if appropriate).
49
Prior to submitting a paper claim
• Verify eligibility to assure the client is eligible on the date of service for the services provided.
• Bill third-party resources first.
• Check the provider number to verify the claim will be submitted for the correct provider.
50
A few tips!
• When submitting handwritten claim forms, you must use blue or black ink, never use red ink.
• Make sure your hand writing is legible and clearly indicates zero’s (0) versus O’s, five’s (5) versus S’s, and eight’s (8) versus B’s.
• If possible, submit no more than twenty-two lines of services per claim form.
• Do not use liquid whiteout.
• Check your printer alignment.
51
Form suppliers
• The UB-04 form is not supplied by DHS.
• Forms are available by contacting one of the following:
– Local business forms suppliers
– Standard Register Company, Forms Division (800-755-6405)
52
Introducing the UB-04
The UB-04 claim form
• Not sure if you are using the correct form?
The bottom left corner will say the following:
Top section
Red = Required Yellow = Optional
Required for SNF claims
Required for SNF and PHEC claims
Box 1 - optional
Nursing Facility PO Box ### Anytown, OR 97###
Billing Provider Information
• Enter the name and address of the Nursing Facility that is requesting to be paid for the services rendered.
Box 3a - optional
X123400
Patient Account Number
• Enter your resident’s account number here.
• This box allows up to twelve characters.
• This number will appear on your Remittance Advice (RA).
Box 4 - required
651
Type of Bill Enter the three-digit numeric code to identify the type of facility, type of care provided, and frequency of services you are billing for.
ICF SNF Swing Description
651 211 181 Admit through discharge.
652 212 182 First claim.
653 213 183 Continuing claim.
654 214 184 Last claim.
Box 6 - required
120108 123108
Statement Covers Period
• Enter the beginning and ending dates of services covered by this claim.
• “From” date is the date services began.
• “Through” date is the last paid date for the service period.
60
Statement covers period - notes
• If billing for an entire month and there is no break in service or change in level of care, the through date will be the last day of the month.
• When a resident is discharged, the through date must be one day prior to the day of discharge.
– Example: Admitted 12/01/08 Discharged 12/15/08 Through date will be 12/14/08 (it will read 12/01/08 thru 12/14/08).
• Submit a new UB-04 each time there is a break in service.
Box 7-required for SNF claims only
Crossover Indicator
• Enter “XOVR” to indicate the claim is a Medicare or a Medicare Managed Care crossover claim.
• Leave this blank for ICF claims.
XOVR
Box 8b - required
Resident, Your
Patient Name
• Enter the resident’s name exactly as it is printed on the Medical Care Identification.
• Use the client’s last name first.
• Do not use nicknames.
Box 12 - required
120108
Admission Date
• Enter the actual date of admission.
Box 13 - required
Admission Hour
• Enter the hour of admission in military time.
• Example: 01 1:00 a.m. 10 10:00 a.m. 14 2:00 p.m. 23 11:00 p.m.
10
Box 16 - optional
Discharge Hour
• Required if the resident discharged on the last day of the “Statement Covers Period”.
• Enter the discharge hour in military time.
• Example: 01 1:00 a.m. 10 10:00 a.m.
15
Box 17 - required
30
Discharge Status
• Enter resident discharge status.
• Enter 30 on nursing facility claims.
• NOTE: The last day in the statement covers period will not be paid if using any other code.
Box 31 - optional
Occurrence
• Enter the two-digit code to indicate the type of occurrence and the date of the occurrence: 01 Auto accident 04 Employment related accident
• Pursue all prior resources first.
• DHS is the payer of last resort.
Box 35 - required for SNF claims only
• Occurrence Span:– Enter 70 occurrence code.– Enter the date the resident was admitted to the hospital– Enter the date the resident discharged from the hospital.– To receive coinsurance payment, or the 20-day post hospital
extended care (PHEC) benefit, this box must be completed.
70
Box 39 & 40 - required for SNF claims only
A1 695 00
Value Codes
• Box 39:
– Enter value code “A1” to identify Medicare Part A or Part B deductible, and the amount.
• Box 40:
– Enter value code “A2” to identify Medicare Part A or Part B coinsurance, and the amount.
A2 95 00
Middle section
Red = Required
Box 42 - required
Revenue Center Codes
• Enter a three-digit revenue center code which most accurately describes the service provided.
• Enter 001 in line 23 to indicate claim total charges.
100
001
Revenue center codes
Type of care Revenue code Level of care Description
ICF/LTC 100 01 Basic
ICF/LTC 100 02 Pediatric
ICF/LTC 100 03 Complex medical add-on
ICF/LTC 100 04 Enhanced care
ICF/LTC 100 05 Outlier
ICF/LTC 100 06 Out-of-state NF
Swing bed 101 N/A Hospital swing bed (short stay)
20 day PHEC 101 N/A Post hospital extended care
SNF 022 N/A Medicare (no coinsurance days)
SNF 022 N/A Medicare (with coinsurance days
Box 44 - do not use
• Leave this box blank.
• If anything is entered here, the claim will deny, suspend, or pay at an incorrect amount.
Box 46 - required
31Service Units
• Enter the number of days for each revenue center code listed.
• One day equals one unit of service.
• The total number of units must match the total number of days in the statement covers period listed in box 6.
Box 47 - required
4,200 00
Total Charges
• Enter the total usual and customary charge for each related revenue center code listed.
• Do not list credits.
• Do not use dashes.
Total - required
Total Charges
• Enter the total amount billed.
• Add the charges as indicated from column 47.
• Do not list credits.
• Do not use dashes.
• Each claim form is a separate document, and is to be totaled as such.
4,200 00
Bottom section
Red = Required Yellow = Optional
Box 50 - optional
Primary payer Secondary payer Tertiary payer
Payer Name
• Enter the names of up to three payer organizations in order.
Example: If Medicare is primary, enter on line A. If another Third Party payer is secondary, enter on line B. If Medicaid is tertiary payer, enter on line C.
Box 54 - optional
Prior Payments
• Enter the total amount paid by other third party resource’s.
• Do not list write-off’s.
• Do not include how much DHS previously paid.
• Do not include copayments.
• Use this box if a resident has long-term care insurance.
Box 56 - required
# # # # # # # # # #
National Provider Identifier (NPI)
• Enter your ten-digit NPI.
Box 57 - required
# # # # # #
Provider Number
• Enter your six or nine-digit (DHS issued) provider number.
• Do not list other payer provider numbers.
• Correspond the placement number as outlined in box 50 instructions.
Box 60 - required
X X # # # X # X
Insured’s Unique ID
• Enter the resident’s eight-character prime identification number (clearly enter letters versus numbers).
• Enter the number exactly as it appears on the Medical Care Identification.
• Correspond the placement as outlined in box 50 instructions.
Box 66 - required
2989
Diagnosis Code
• Enter the primary diagnosis code of the resident by using a valid ICD-9-CM code carried out to its highest degree of specificity.
• The diagnosis code must be the reason chiefly responsible for the service being provided.
• You may enter up to five codes if necessary listing them in boxes 67 - 67D.
• Do not use the decimal point.
Box 69 - required
2989
Admit DX
• Enter the admitting diagnosis of the resident by using a valid ICD-9-CM code carried out to its highest degree of specificity.
• Do not use the decimal point.
Box 78 - optional
Other Physician ID
• This box is only required when the resident has a Primary Care Manager (PCM).
• Enter the ten-digit NPI of the PCM.
• Enter the six or nine-digit (DHS issued) provider number of the PCM.
########## ######
Box 80 - optional
NC
Third Party Resource
• If the resident has other medical coverage, enter the appropriate two-digit third party resource (TPR)
explanation code.
• A code must be listed when the other insurance did not make a payment, and always when the recipient has more than one other insurance carrier.
UD Service under deductible
NC Service not covered by insurance policy
PN Patient not covered by insurance policy
IC Insurance coverage canceled/terminated
IL Insurance lapsed or not in effect on date of service
IP Insurance payment went to policyholder
PP Insurance payment went to patient
NA Service not authorized or prior authorized by insurance
NE Service not considered emergency by insurance
NP Service not provided by primary care provider/facility
Single carrier TPR codes continued on next slide
Single carrier TPR codes
MB Maximum benefits used for diagnosis/condition
RI Requested information not received by insurance from patient
RP Requested information not received by insurance from policyholder
MV Motor Vehicle Accident Fund (MVAF) maximum benefits exhausted
AP Insurance mandated under administrative/court order through an absent parent and not paid within 30 days
OT Other (if above codes do not apply, include detailed explanation of why there was no payment from insurance)
Single carrier TPR codes
MP Primary insurance paid – secondary paid
SU Primary insurance paid – secondary under deductible
MU Primary and secondary under deductible
PU Primary insurance under deductible – secondary paid
SS Primary insurance paid – secondary service not covered
SC Primary insurance paid – secondary patient not covered
ST Primary insurance paid – secondary canceled/terminated
SL Primary insurance paid – secondary lapsed or not in effect
SP Primary insurance paid – secondary payment went to patient
Multiple carrier TPR codes continued on next two slides
Multiple carrier TPR codes
SH Primary insurance paid – secondary payment went to policyholder
SA Primary insurance paid – secondary denied – service not authorized
SE Primary insurance paid – secondary denied – service not considered emergency
SF Primary insurance paid – secondary denied – service not provided by primary care provider/facility
SM Primary insurance paid – secondary denied – maximum benefits used for diagnosis/condition
SI Primary insurance paid – secondary denied – requested information not received from policyholder
Multiple carrier TPR codes continued on next slide
Multiple carrier TPR codes
SR Primary insurance paid – secondary denied – requested information not received from patient
MC Service not covered by primary or secondary insurance
MO Other (if above codes do not apply, include detailed explanation of why there was no payment from insurances)
Multiple carrier TPR codes
C
O
M
P
L
E
T
E
D
E
X
A
M
P
L
E
Nursing Facility PO Box ### Anytown, OR 97###
120108 10 15 30
651
120108 120108
Resident, Your
X123400
100 31 4,200 00
0001 4,200 00
Medicaid ######
XX###X#X
2989
NC
##########
2989
93
Billing Cycles
• Monthly– Bill on a monthly basis for resident’s that are identified as still a patient
(Patient status code 30, as identified in box 17).– Claims must be submitted on or after the 1st day of the month following
the month in which services have been provided.• Partial
– Bill for a partial month if the resident is discharged or if the resident expires before the end of the month.
• Paid– Can adjust if necessary.
• Denied– Rebill at any time.
• Suspended– Wait for DHS to complete the review.
94
Break in service
• Any time a resident is out of the facility past midnight and is expected to return, it is considered a break in service.
• Each time there is a break in service, you must submit a separate UB-04 claim form.
– 12/01/08 resident is admitted to a basic level of care (separate UB-04).
– 12/05/08 resident goes to hospital and is expected to return.– 12/06/08 resident returns from hospital at the basic level of care
and remains at the facility through the end of the month (separate UB-04).
• Notify the local SPD office so the resident’s Plan of Care can be updated.
95
Things to remember
• Do not enter resident’s liability on the UB-04.– Liability is automatically deducted from your total billed amount.
• Do not include the resident’s level of care on the UB-04.– SPD enters the maximum daily amounts in MMIS.– Contact your local SPD office for questions concerning level of
care.
96
SNF crossovers (XOVR)
• Before billing DHS for coinsurance, you must bill the primary payer responsible for Medicare Part A benefit.
• DHS will pay coinsurance for days 21 through 100.
• Don’t forget required boxes on the UB-04:– Box 7 enter XOVR.– Box 35 enter occurrence span of the date the resident was
admitted to the hospital, and the date the resident discharged from the hospital.
– Box 39 enter the appropriate value code and amount of coinsurance.
– Box 54 enter the amount Medicare paid.
97
Web portal institutional claims
98
Institutional claims
• From the main menu select Claims.
• Select Institutional from the drop-down menu.
• There are six sections that will display.
1. Institutional Claim
2. TPL
3. Medicare Information
4. Detail
5. Hard Copy Attachments
6. Claim Status Information
• There are six additional sections that do not display.
Additional sections located here.
100
Institutional claim - section 1
• Enter SPD’s required information and as much information as possible to process your claim.
• The left side includes billing information. • The right side includes service information.
Required fields are:
1. Client ID
2. Claim type
3. Type of bill
4. From date
5. To date
101
Additional sections
102
Additional sections• A navigation menu allows access to additional
sections that do not appear on the main page.
• Additional sections are:– Diagnosis – Condition– Payer– Procedure– Occurrence/Span– Value
• Click on the item to navigate a section.
103
Diagnosis - additional section
• Allows entry of up to ten diagnoses.
• Click “add” to activate the diagnosis section for each diagnosis to be entered.
• Enter the Diagnosis (to find a diagnosis code, use the Search feature).
• Enter the Sequence (diagnosis code pointer) number.
104
Condition - additional section
• Allows entry of one or multiple conditions (i.e., disabled beneficiary, private room medically necessary).
• Click “add” to activate the condition section for each condition to be entered.
105
Payer - additional section
• This section allows entry of the names of the payer organizations being billed (A. Medicare, B. Other, C. Medicaid).
• Payers are to be entered in order of primary, secondary, and tertiary.
• Click “add” to activate the Payer panel for each payer to be entered.
106
Procedure - additional section
• Allows entry of the 4-digit principal procedure code.
• The procedure code is used to describe the procedure performed for definitive treatment rather than for diagnostic or exploratory purposes.
• Click “add” to activate the procedure section for each procedure to be entered.
107
Occurrence/Span - additional section1. Sequence
2. Occurrence code
3. From date
• Allows entry of the occurrence code (auto accident, employment related accident, qualifying hospital stay) relating to the billing period.
• Click “add” to activate the Occurrence/Span section.• Required fields are:
– Sequence– Occurrence code– From date
108
Value - additional section
• Allows entry of the value code and related dollar or unit amounts to identify data of a monetary nature (most common semi-private rate).
• Click “add” to activate the Value section.
• Enter the Value (to find a value code, use the Search feature).
109
TPL - section 2
• If a third party payer was billed, enter that information in this section.
• Click “add” to activate.• Enter as much information as necessary.• If a third-party did not make a payment or made a
partial payment, the appropriate HIPAA Adjustment Reason Codes (ARC) must be entered.
110
Medicare information - section 3
• This section is completed when the client has Medicare.
111
Detail - section 4 Required fields are:
1. From and To Dates of Service
2. Units
3. Charges
4. Revenue code
5. Medicare fields (if applicable)
• Allows entry of up to 999 detail lines.
• Click “add” to activate the section for each service you are billing.
• Enter all required information.
112
Hard-copy attachments - section 5
• If you need to submit attachments with your claim, click “add” and complete as much information as possible.
• Examples include, sterilization or hysterectomy consent forms, op reports, medical records, etc.
113
Claim status information - section 6
• Claim status information displays at the bottom of all claims.
• No data displays before the claim has been submitted.
• Click “submit”.
Completed institutional claim example.
The buttons at the bottom provides further action if necessary.
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Claim status information - section 7
• Once the claim is submitted, this section indicates whether a claim is paid, suspended or denied.
• If applicable, click on “coversheet for supporting documentation.”
– Examples include, sterilization or hysterectomy consent forms, op reports, medical records, etc.
Complete the following:
• Requestor Information• Provider ID• Recipient ID Write the ICN on all supporting documentation.
Coversheet is required to fax or to mail supporting documentation.
Fax: 503-378-30862 2 0 9 1 3 0 0 0 4 5 6 0
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HIPAA Adjustment Reasons
• The HIPAA Adjustment Reasons section appears once the claim is submitted, and provides explanation of benefit (EOB) information.
• This section populates with explanations/reasons specific to the claim.
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Web portal claim search
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Claims search section
1. Select “Claims” from the main menu. 2. Select “search.”3. Enter any of the fields necessary (ICN, client ID, date of
services, claim type, status, or date paid) to conduct your search.
4. Click on “search.”
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Claims search results
• To view the entire claim, click on the line item.
• The claim will appear identical to the completed claim example shown previously.
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Claim actions
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• The adjust button allows modification of information within the claim, and then resubmits the claim to DHS.
• Modify and update data as necessary.
• Click on “adjust.”
Paid claim - adjust
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Paid claim - void
• The void button cancels an entire claim that was previously submitted and paid.
• Click on “void”.
• Any amount previously paid by DHS will be recouped.
• Be extremely cautious when using the “void” button. You will not receive a warning.
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Paid claim - copy claim
• The copy claim button makes an exact duplicate of the existing claim.
• Once copied, claims data can be updated, and the claim can be submitted as a new claim.
• Click “copy claim.”
• Update information as needed.
• Click “submit.”
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Denied claim - re-submit
• The re-submit button allows modification of information within the claim, and then resubmits the claim to DHS.
• Enter new data in appropriate fields.
• Click “re-submit.”
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Questions?
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Remittance Advice (RA)
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About the RA
• DHS mails the paper Remittance Advice (RA) to the provider.
• The RA tells about payment or other claims actions made by DHS.
• You will continue to receive the paper RA until you specifically request DHS to stop sending the paper RA to you.
• You can also obtain claim status and payment information through Automated Voice Response, the Provider Web Portal, or the 835 transaction (Electronic Remittance Advice) typically because the electronic version of the RA is requested.
Claim received
Claim processes through the Medicaid Management Information System (MMIS)
Meets payment criteria
A Remittance Advice is generated
Claim Paid Claim Partial Paid Claim Denied
Do not resubmit claim. If needed, complete a DMAP Individual Adjustment Request
form (DMAP 1036) or adjust the claim via the Web portal.
If needed, correct claim and resubmit, on paper, the Web
portal or EDI.
How it works for claim submissions
Does not meet payment criteria
Claim in Process
No action needed. Wait
for DHS resolution.
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RA information
• Claim information is broken out by:– Internal Control Number (ICN) – Type of claim – Claim status
• The RA now includes additional information:– Banner message – Third Party Liability (TPL) information (if applicable)– Financial Transactions– Remittance Advice Summary– Explanation of Benefit (EOB) Descriptions
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Order of RA information
• Information will appear on the RA (as applicable) in this order:
– Banner messages – Messages from DHS.– Claims – By type of bill and ICN - Paid, denied, in process,
adjustments.– TPL information – For each client, in order of ICN.– Financial transactions – Non-claim-specific payouts to or
refunds from providers; accounts receivable information.– Summary – Of all activity reported on the RA.– EOB Code Descriptions – For all the Explanation of Benefit
(EOB) codes listed in the RA.
• Check the page headings to find the information you’re looking for!
RA page headings
• Every page of the RA contains the following header information:
1. The report number.2. RA number.3. The title of the RA section – Check this section!4. Date of the RA.5. Provider name and address.6. DHS provider number (Payee ID), National Provider
Identifier (NPI), Check or Electronic Fund Transfer (EFT) number, and the date the RA was generated.
Page 1 - Banner message
Messages from DHS appear on this page, separated by asterisks (*).
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Claim information
• After the banner message page, claim information is divided in sections by the type of bill that is submitted:
– Institutional claims: Medicare Crossover Part A, Long Term Care (LTC).
• Claim information will be in order of Internal Control Number (ICN).
• Each type of bill section is further divided by claim status (paid, denied, in process, and/or adjustments).
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Internal Control Number (ICN)
• The first two digits of a claim’s ICN is the region code, which tells how the claim originated.
• This also tells you the order you will see the claims appear on your RA.
Because claim information is sorted by ICN, the claim information on your RA will be sorted by the claim origin within each type of bill, in this order:1. Paper claims 2. EDI claims 3. Web claims
Region Code Region Code Description
10 Paper Claims With No Attachments
11 Paper Claims With Attachments
20 Electronic Claims With No Attachments
21 Electronic Claims With Attachments
22 Internet Claims With No Attachments
23 Internet Claims With Attachments
LTC - claims paid
LTC - claims denied
LTC - claims in process
LTC - claim adjustment
The top ICN is the original claim; the bottom ICN is the adjustment (adjustments have an ICN beginning with “5”).
Long Term Care - financial transactions
1. Transitional payments will display in the Non-Claim Specific Payouts section.
2. Provider payments (e.g., refunds) will display in this section.
3. The Accounts Receivable (A/R) section shows recoupment information. (You will receive RAs with A/R information until there is a total balance of zero in this section).
Summary information
This page is a summary of all actions described in the RA.
1. Current weeks totals.
2. Year-to-Date totals.
Explanation of benefit
The last section of the RA is a list of the EOBs used throughout the RA (in EOB order).
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Common EOB code descriptions
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EOB code descriptions
• The EOB message explains the outcome of the claim that was submitted for payment processing.
• The EOB itemizes the reason for reducing or rejecting payment on your claim.
• By reading the explanation and following the instructions listed in the EOB, you will be able to correct the error in a timely manner.
• The following pages lists common billing “Header” errors, and common billing “Detail” errors, in EOB numeric order, and “Helpful Tips” to assist you in identifying and correcting common errors that most providers make.
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Common errors
EOB 0015 Service is a duplicate of a previously processed/paid service.
– The services billed match a claim in history. – This appears when the date range, revenue center code, and
diagnosis code are an exact match of a previously processed/paid claim.
– Look for previous RAs to determine if the service has been previously processed and/or paid.
– If applicable, correct any incorrect data and resubmit the claim.
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Common errors
EOB 0028 Recipients name and number disagree and DMAP cannot resolve.
– The client name and ID number that was entered on your claim mismatch.
– If you have determined that both the name and number entered is correct, contact DMAP Provider Services, or the Senior and Peoples with Disabilities branch for assistance.
– Correct the name or ID number and resubmit the claim.
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Common errors
EOB 0032Recipient number missing.
– The client ID number is missing on your claim. – Correct and resubmit the claim.
EOB 0044Claim form inconsistent with provider type.
– The services were billed on the incorrect claim form. Submit the claim on the UB-04 claim form or Institutional billing format on the provider Web portal.
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Common errors
EOB 00541st diagnosis code is missing or invalid.
– The 1st diagnosis code entered on your claim is missing or invalid.
– Check the diagnosis field on your claim to verify that a diagnosis code is listed.
– If a diagnosis code is listed, check the diagnosis to determine if it is a valid diagnosis.
– Correct and resubmit the claim.
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Common errors
EOB 0065Over 31 days billed. Bill no more than one calendar month on a claim.
– A claim was billed for more than one calendar month.– Only bill for one calendar month. – If necessary, correct and resubmit the claim.
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Common errors
EOB 0091
Non-covered service.
– The revenue center code billed is not covered for the benefit plan or provider program on the date of service.
– If applicable, correct the revenue center code and resubmit. – If the revenue center code is correct, contact DMAP Provider
Services for clarification.
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Common errors
EOB 0145
The recipient number listed is not in our records.
– The client ID number is invalid. – Verify the client ID number that was entered on your claim. – If the number entered is correct, contact DMAP Provider
Services, or the Senior and Peoples with Disabilities branch for assistance.
– If the ID number can be corrected, resubmit the claim.
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Common errors
EOB 0161
The sum of days billed does not equal reported period covered.
– The date range you are submitting does not match the sum of days as reported with the revenue center code.
– Correct the date range, or the units that correspond with the
revenue center code and resubmit the claim.
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Common errors
EOB 0244
Number of visits or units of service is missing or invalid.
– The number of units that correspond with the revenue center code is zero or blank.
– Correct as appropriate and resubmit the claim.
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Common errors
EOB 1116:
No pricing segment is on file.
– The dates of service on the claim span multiple benefit plan segment dates for this client.
– The client’s benefit plan changed sometime during the month. – The claim cannot be submitted with two different date ranges
under two different benefit plans. – If applicable, submit two separate claims, one with one benefit
plan date range, and the second claim with the other benefit plan date range.
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Common errors
EOB 3138
Missing/invalid type of bill.
– The type of bill on the claim is missing or invalid. – Add or correct the type of bill and resubmit the claim.
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Informational only
Some EOBs are informational or have suspended for DHS review only. No action is needed from the provider.
– 0038: Our records do not show client certified for billed level of care.
– 0052: Provider ineligible to perform this procedure or type of service.
– 0067: Total amount billed exceeds amount authorized.– 0193: Revenue center code restriction.– 1043: Claim indicates recipient expired.– 1114: Taxonomy code invalid.– 1124: Cannot prioritize clients programs.– 9013: Provider and submitter mismatched.
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Resources
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Reminders for successful billing
• Make sure you have the most current information that is in effect for the date of service being billed.
• Verify client eligibility on the date the service is provided.
• Bill electronically, it saves you time, you get paid faster, less chance the claims will suspend.
• If billing on paper, use commercially available “red forms”.
• Read the explanation of benefit codes on your remittance advice, they will tell you what the error is.
• Sign up for Electronic Funds Transfer (EFT) and receive your payments via direct deposit.
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Need help?
• For assistance reading RA’s or to request a re-print, contact:
– DMAP Provider Services– 800-336-6016 – [email protected] – [email protected]
• For questions specific to Long Term Care Facilities, contact: Vivien VanHatten at 503-945-6528, or Rose Laurente at 503-945-5779, or
David Allm at 503-945-6407 (program and policy)
• To view claim status on the Web:Provider Web Portal https://www.or-medicaid.gov
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Thank You!
