West Virginia Medicaid Provider Update Bulletin. Qtr. 1, 2007

Transcription

1 West Virginia Medicaid Provider Update Bulletin. Qtr. 1, 2007 Volume 1 Helpful Hints from WVMI. Utilizing WVMI website a Obtain instructions on how to request Smart Sheets from McKesson for Interqual criteria for imaging, outpatient surgical procedures and durable medical equipment (DME). Also obtain copies of review forms for all areas of medical review a Elective inpatient surgeries should be submitted or called into WVMI in a timely manner. It is not a good practice to call for elective surgery precertification the day before or the day of the surgery. a Acute care (Inpatient admissions) including inpatient surgery are reviewed using McKesson s Interqual criteria. a It is very important for inpatient admissions to include vital signs on the prior authorization and retrospective authorization forms. The vital signs help WVMI to quickly apply Interqual Criteria and decrease turnaround time. The following should be utilized for contacting WVMI. WVMI-Outpatient Phone or Fax or WVMI-Inpatient Phone Fax WVMI-All other Phone or Fax APS TO REGISTER MR/ DD WAIVER SERVICES WITH UNISYS. APS Healthcare is scheduled to begin authorizing and registering MR/DD Waiver services with Unisys. Previously, the Bureau for Behavioral Health and Health Facilities authorized global PA s for Waiver members. BHHF PA s will remain in place until APS PA s are issued. The system of transition from old global PA s to new individual PA s from APS is designed with safeguards, graduated transition, and a quality improvement period. Providers are scheduled to receive specified training and technical assistance from APS prior to the implementation of the new system. For assistance, you may contact: APS Healthcare Randy Hill, Director of MR/DD Waiver Services Web site: Susan Hall, BHHF, MR/DD Waiver Program Manager Website: susanhall@evdhhr.org APS BEHAVIORAL HEALTH PRIOR AUTHORIZATIONS APS is continuing to authorize services for behavioral health clinic, rehabilitation, psychiatrists, and psychologists. For assistance, you may contact: APS Healthcare Web site: As an ongoing effort to continuously improve quality, APS, Unisys, and BMS implemented a quality improvement effort around the interface process of authorization to claims. As the result, system improvements were implemented and a helpful hints was published on the BMS website. For further information, contact: BMS website (Helpful Hints) Web site: Inside This Issue: Hints from WVMI... 1 APS Updates and Information... 1 Unisys Web Portal... 2 Registration... 2 Features... 2 Acknowledgements/Responses... 2 Billing Updates & Tips... 3 Tips from the Mail Room... 3 Billing for immunizations for VFC prog... 3 Bureau for Medical Services Website... 4 Critical Access Hospitals... 4 Pharmacy and Drug Update(s)... 4 Provider Enrollment... 5 General Updates... 5 Enrollment Tips... 5 NPI Information... 5 Update on J,Q codes and Medications... 5 Remittance Advices... 6 Provider Communication... 6 Readmissions within 7 days of discharge for Acute Care Hospitals... 6 Timely Filing Policy... 7 Quick Tips for Dental... 7 Contact Information

2 Get a Web Account at To register for a web portal account, download and complete a Trading Partner Agreement (TPA) located in the Forms section of the Health PAS Online web site at Once Unisys receives this TPA, the EDI Helpdesk will return an EDI form for you to complete. The EDI form may be returned via at edihelpdesk@. com or faxed to After returning the EDI form, insert www. wvmmis.com into your browser s address bar and select Health PAS Online Registration. The online registration process will allow you to choose your logon name. When your account is approved, you will be ed a link that will allow you to set your account password. If you have any problems downloading and completing these forms or with the online registration process, please contact the EDI Helpdesk. Assistance and Contact Information: The EDI Helpdesk is staffed Monday thru Friday from 8 am until 5 pm for assistance with the web portal and electronic billing. You may call , prompt 6 or edihelpdesk@.com. Health PAS Online. The Health PAS Online web portal offers the WV Medicaid provider community access to a variety of convenient services through an Internet based system, available through any computer with an Internet connection. The website address is Web Portal Features: a Access 24 hours a day, 7 days a week from any Internet enabled computer. a Claim submission via direct-dataentry and X12 file upload. a Billing module stores provider and Medicaid member information to pre-populate claim forms. a Near-instant feedback for front end claim rejections based on HIPAA regulations and WV Medicaid billing rules, allowing providers to immediately correct and resubmit claims. a Claim status check. a Member eligibility check. a Remittance advices and related reports. a Forms and publications including billing instructions and manuals. a Provider directory. Web Site Requirements: a All files downloaded from the website are in compressed format and require WinZip to decompress. WinZip is available for download at winzip.com. a Internet Explorer version 6 or greater, or Mozilla FireFox version 1.5 or greater are recommended. Upgrade instructions are posted under Site Requirements at Transaction Submission: Claims entry, member eligibility verification, and claims status requests are accomplished via a direct data-entry process. Providers who own software capable of generating HIPAA-compliant (X12) transaction files may use the X12 file exchange feature to bypass direct data entry submission. Responses to these transactions are posted in the Download area. Transaction Responses: A variety of responses provide feedback to transaction submissions. It is imperative to check claim responses. Claims rejected on the TA1, 997, or 824 responses will not appear on your remittance advices because they were not accepted for processing. Access these responses by selecting Download File under File Exchange. Responses are generally available within 5 10 minutes after submission. TA1 Interchange Acknowledgement Response. a The TA1 acknowledges that the inbound 837 (claim file) was received. a The TA1 will indicate if the file was accepted or rejected. a This feature is for uploaded claims only. a If you need a TA1 rejection list please contact the EDI Help Desk. 997 Functional Acknowledgement Response. a The 997 acknowledges that the 837 is syntactically correct. The entire file of claims can be rejected depending upon the error. Contact your software vendor or the EDI Helpdesk for more information. a Two versions of this file are available: a PDF document and a X12 transaction. Open the X12 file with your X12 compliant software and the PDF Human Readable version with Adobe Reader. a You may immediately correct and rebill claims rejected on the Application Advice Response. a The 824 rejects claims based on business rules, i.e., invalid diagnosis codes, invalid procedure codes, invalid provider numbers, etc. a Unlike the TA1 and 997, the 824 will only display claim rejections. a Two versions are available: the Human Readable report in plain text format and the X12 file format. Use a text editor such as NotePad, UltraEdit, or MS Word to open these files. a You may immediately correct and rebill claims rejected on the Eligibility Request Response. a Eligibility requests return HMO, PAAS, and TPL enrollment information. Up to twenty requests may be entered per transaction. Two eligibility request responses are available: the 271 Eligibility Inquiry Report in PDF format and the Eligibility Inquiry Response in X12 format. 277 Claim Status Response. a Providers may enter up to twenty claim status requests per transaction. Two claim status request responses are available: the 277 Claim Status Report in PDF format and the 277 Claim status Responses in X12 format. Electronic Remittance Advices: 835 Claim Payment Advice Response. a The 835 is a HIPAA-compliant X12 transaction set listing finalized claims and payment information. The production of this transaction is dependent upon the availability of payment information from the State Auditor s office. Due to this fact, 835s are produced approximately one week after standard RAs. a 835s require a software program to be translated. The 835 is generally used to electronically post payments to your practice management or accounting software package. Contact your software vendor for support verification. a For your convenience, we also post a PDF document containing a summary of the 835 transaction set. (Unisys also produces a PDF version of the RA for registered users who elect this option) 2

3 Billing Updates & Tips. Coordination of Benefits Tips. Did you know that Secondary Claims can be submitted electronically? Also, did you know that secondary claims have special rules as it relates to PA requirements and payment methodology? Secondary claims can be submitted electronically through the Web Portal. Also, certain software applications are approved to upload secondary claims. When submitting electronically, you are not required to submit an EOB or EOMB. However, TPL explanations of benefits (EOB) are requested as a courtesy by BMS. These should be mailed to PO Box 3767 where they will be used to update member information. The receipt of the EOB will not hold up the processing of an electronic secondary claim. When sending these EOB s, attach a cover letter or note indicating that the claims have been filed electronically. Paper Secondary Claims when filing Medicare or TPL claims, do not enter payment information on the face of the claim. Information will be taken from the attached EOB. Prior Authorization if a service requires PA and the member has a primary COB who pays, allows or approves on the service, you are not required to obtain an authorization from WV Medicaid. If the primary COB denies the claim, you will need to follow the regular Medicaid guidelines and obtain a prior authorization prior to submitting to WV Medicaid. Payment methodology on TPL and Medicare claims is explained in Chapter 600 of WV Medicaid Provider Manuals. Billing Denied Secondary Claims Denied secondary claims should not be submitted electronically. These claims should be submitted on paper with EOB attached. If the EOB does not clearly summarize the Top 5 Reasons for Return to Provider Letters, (RTP) a Provider Number Make sure that the provider number is valid, in the correct field, and that the signature is either on file or in the appropriate field. a Timely Filing Make sure that if the claim is over 1 year old there is appropriate proof showing that the claim was in here on time. (i.e. Remittance Advice or an 824 Report) a Member Number Make sure that the Member s ID number is a valid 11 digit number and that it is in the appropriate field. a EOMB s (Explanation of Medical Benefits) Make sure that when submitting secondary and third party claims that the Explanation of Benefits is attached. a Reversal/Replacement Specific Information Make sure when you are submitting a reversal/replacement that you are specifying what needs to be changed in the Replacement Explanation box. Claims can only change what is specified in writing even if it is common sense. a Please Note: Effective , claims that are billed on a HCFA 1500 without a place of service will be sent back with a Return to Provider (RTP) Letter. explanation of the denial code, the provider must also attach a summary or key that clearly explains the reason for denial. These codes are not uniform and vary from one payer to another. Medicaid is not able to consider payment 3 of a claim unless they can confirm why the primary payer denied the claim. (NOTE: Denied Medicare claims require only the EOMB as an attachment.) Quick Tips for Coding Familiarizing yourself with coding and documentation requirements can reduce the number of denied and PEND claims. Types of Documentation Needed on Unlisted Codes: Unlisted surgical codes require an operative report and a brief description of why an unlisted code was used. Unlisted drugs/ vaccines require a description of the service and a cost invoice Unlisted laboratory services require the name of the test performed Unlisted lesion removal require documentation including a description of the size of all lesions removed Any other physician service not listed should include the physician s notes and a brief description of why an unlisted code was used. A surgical history and physical does not provide adequate information for unlisted surgical services. All documentation needs to be legible. When required, all documentation needs to be the submitting physician s documentation. (Example: With a team surgery Dr. Smith should submit his report and Dr. Jones should submit his report). Assistant and co-surgeries can use the primary physician s operative report; however, the need for an assistant or co-surgeon and his/her participation should be documented in the report. When a provider receives a remit message of A1 (Claim Denied Charges) and no other remit message, the provider should call Provider Relations. Quick Tips for Claims Processing a Signature is required on the claim. However, the original signature is not required. A computer generated or stamp signature is acceptable. a Billing a continuing (multiple page claim) the claim total field on the first page must read continued and the total line on the final page should have the total of all the charges. In addition to this, you must also write the following on the claim: Page 1 of 2, Page 2 of 2, etc. a Medicare crossover claims Group number must be in the 1D Qualifier when billed electronically on the 837 format. a Multiple lines/dates on a HCFA 1500 or 837P the earliest date on the claim becomes the header date. If this date is over one year, the entire claim will deny for timely filing. a Span Date if the date on the claim is a span date, the earliest date on the claim becomes the header date. If this date is ver one year, the claim will deny for timely filing. Example: 01/01/ /31/2006 will deny for timely filing after 01/01/2007. a TIMELY FILING Allow MAIL time AND PROCESSING TIME. (At least 10 days) Billing for immunizations under the Vaccines for Children (VFC) Program: If the provider does not participate in the VFC Program, they cannot bill for the immunizations. VFC immunization stock should be provided only to Medicaid eligible members. Please contact VFC Program on rules to using VFC stock for Insurance Primary/ Medicaid Secondary recipients. Below is a listing of all approved VFC codes Please be advised that you may not bill & with an oral vaccine. WV Medicaid does not reimburse for the administration of an oral vaccine. West Virginia Medicaid considers this part of the E & M services.

4 Bureau for Medical Services Website. A convenient tool for providers to use is the BMS website org/bms. This website can be utilized for any number of problems that a provider may have. Here is a preview of such services: a Are you having difficulty processing a claim? Does your head hurt every time you get a remittance? The claims doctor can help. The claims doctor can give you a list of the most common problems that have occurred. If you have a specific question you could the Dr. at medclaimdoc@wvdhhr.org. You can also access the Billing Instructions, Check Payments and Provider Information. a Information about HIPAA regulations can be found on the web site. This includes a message to providers, HIPAA basics, provider steps to getting paid, HIPAA security, CMS Enforcement, 837 for Professional claims and 837 for Institutional claims. a Provider information can be retrieved including provider payment info, Electronic Funds Transfer forms, workshop information, provider newsletters, PAAS facts and procedure codes. You can also perform enrolled provider inquires. a Pharmacy information includes a Preferred Drug List, an OTC Drug List and Unisys Pharmacy Information. a Manuals and Instructions can be retrieved online; these include RBRVS spreadsheets, provider manuals, program instructions and RBRVS information. Periodically BMS finds it necessary to amend the policies and procedures in the provider manuals. Providers are notified of these changes through Programs Instructions mailed to providers and posted on the internet. For a list of all current and past revisions log onto or call Provider Relations for a printed copy. This is just a sampling of the information that can be found on the Bureau for Medical Services provider website. Log onto www. wvdhhr.org/bms for more information. Critical Access Hospitals. The Bureau for Medical Services issued a policy change for Critical Access Hospitals (CAHs), effective on each hospital s cost reporting period that begins with 7/1/2006, 10/1/06, and 1/1/07. The change requires that each CAH modify current billing practices with their respective cost reporting period as follows: a The T1015 will no longer be valid for billing services for those providers who chose the encounter rate billing methodology. Payment will be based on a percent of the outpatient billed charges and not the encounter rate. a Providers billing fee-for-service under type of bill (TOB) 13X will be required to begin utilizing TOB 85X, effective with their new cost reporting period. a CPT/HCPCS codes are required to be used on each outpatient service billed using TOB 85X (outpatient services) and TOB 14X (hospital-lab services provided to non-patients). An exception to this policy is revenue codes 25X (pharmacy), 27X (medical supplies), 37X (anesthesia), 636 (drug/detail), 637 (self-administered drugs), 710 (recovery), 760 and 762 (observation). a Revenue codes 51X (clinic), 52X (free standing clinic), 761 (observation treatment) will not be valid for payment. a Outpatient surgical procedures must be billed with the appropriate CPT/HCPCS code and revenue codes. a Charges for the procedure(s) must be rolled to the primary, most complex procedure and billed on one line. If reporting multiple procedures, bill all additional lines with zero charges. Modifier 50 is not allowed. a All outpatient services, including emergency room visits, which results in an admission are to be rolled into the inpatient bill. a When more than one (1) Emergency Department visit occurs on the same day, to the same facility, for the same diagnosis the charges must be rolled to the highest level appropriate to the visits. a If two unrelated medical visits occur on the same day, to the same facility, supportive documentation must accompany the paper claim and mailed directly to the claims processor Provider Relations Department - Attention: Unisys Medical Review Nurse. Pharmacy/Drug News. Preferred Drug List The WV Medicaid Preferred Drug List was updated on 10/02/2006. All Non-Preferred Drugs require a prior authorization. Prior authorization requests are reviewed by the clinical staff at Rational Drug Therapy Program. The New Preferred Drug List is available on the BMS website. bms_pdl_preferreddruglist pdf Narcotic Analgesics WV Medicaid Pharmacy has recently implemented stringent rules on Narcotic Analgesics. Submission of a claim for narcotic analgesics within an overlapping time period may result in a denied claim. Pharmacy providers will receive an Early Refill (ER), Ingredient Duplication (ID), or Therapeutic Duplication (TD) edit message when appropriate. Providers may contact the Rational Drug Therapy Program (RDTP) at , Option 2, or by fax at for clinical review and consideration of these claims. Medicare Part D Please be aware that some West Virginia Medicaid members may be Dual Eligible Medicare Part D members who have not yet been enrolled in a Medicare Part D plan. The pharmacy provider may facilitate the enrollment by calling the Wellpoint Pharmacy help desk at DRA 2005 The Deficit Reduction Act of 2005 (DRA) requires that State Medicaid Programs invoice pharmaceutical manufacturers for rebates due to the state for physician administered drugs. In order for WV Medicaid to comply with the DRA requirements, all providers billing for drugs using HCPCS or CPT codes on the CMS-1500 form or the UB forms must also supply the National Drug Code (NDC). The NDC code is required for proper rebate invoicing. The NDC is located on the drug container and consists of eleven (11) digits XXXXX-XXXX-XX. Drug Administration Billing. Medicaid has become aware that providers are sometimes billing the drug code (J-code or CPT code) when only the administration of the drug is being provided. This is an incorrect billing practice. The appropriate administration code should be billed, i.e., for IM injection, for IV infusion, etc. Please note that if a drug is administered during an office visit, the administration fee is included in the office visit reimbursement and an additional administration code will not be reimbursed. 4

5 Provider Enrollment. Quick Tips for Provider Enrollment a Licensure updates should be kept current to avoid payments being placed on hold. FAX to Provider Enrollment as soon as received. a Providers will be placed on pay hold if updated license is not received by expiration date. Provider will be terminated from WV Medicaid if updated license is not received within 30 days of expiration date. a Change of address must be MAILED - can result in important communication break down i.e. notification of licensure, receiving RA s, receiving updates on provider information. a CLIA Certifications must be kept current. FAX any updates or changes to provider Enrollment. a If enrolling more than two providers on the same TAX ID, you must request a Group Medicaid number. Enrollment Representatives will walk you through the process and assist you in the completion of all necessary forms. a Update MEDICARE numbers (linked to Medicaid Provider numbers). Failure to do so will result in crossover payments paying incorrectly. (i.e. they could pay to the wrong pay to provider or group provider, or may not find correct provider to pay when it crosses over). a Notify Provider Enrollment when you receive you National Practitioner Identifier (NPI). Provider Enrollment Address PO Box 625 Charleston, WV Fax # Ways to Speed up the Enrollment Process a Complete the full application. List N/A if something does not apply to you. Sign on the correct signature line for Practitioner or Facilities Non-Practitioner. List contact information on page 6 of Individual application/ page 5 of Group application so we may contact you if additional information is needed. a Make sure all criteria requirements are current and up to date. Providers located 30 miles or greater from the WV border must attach a claim to be considered for enrollment. Read all attached Program Instructions to make sure all criteria is met. a Complete the Electronic Funds Transfer authorization form. EFT is mandatory per West Virginia Code a. Refer to the Medicaid Program Instruction MA for further information. Instead of having Section 2 completed by your Financial Institution, you may attach a voided check to verify the account information. a If you have more than one Provider billing under the same Tax ID or if you are an Individual Provider billing more than one Physical Location, you must establish a group. The Individual Providers cannot be enrolled until the Group is enrolled. You must complete an EFT form for the Group even if you are a current Individual Provider already set up for EFT. a Do not submit application until you have all criteria. We cannot issue you a provider number until we have all of the required material. NPI: Get It. Share It. Use It. NEW!! NPI Training Package CMS has developed a Training package on the NPI that will assist providers with self-education, as well as education of staff. This package is also useful to national and local medical societies for group presentations and training. The entire package will consist of five modules: General Information, Electronic File Interchange (EFI), Subparts, Data Dissemination and Medicare Implementation. Each Module consists of a PowerPoint presentation (with speaker s notes) and is designed to stand alone or can be combined with other modules for a training session tailored to the particular audience. Modules will be posted to the CMS NPI web page as completed. Modules currently available include: Module 1: General Information Module 2: Electronic File Interchange (EFI) Module 3: Subparts To view these Modules, visit Stand/04_education.asp#TopOfPage on the CMS NPI web page and find the NPI Training Package under the Downloads. Medicare providers who bill a Fiscal Intermediary should send questions to: CMSNPIQuestionsfromFIB illers@cms.hhs.gov Medicare providers who bill a Carrier should send questions to: CMSNPIQuestionsfromCarri erbillers@cms.hhs.gov Medicare providers who bill a Durable Medical Equipment Regional Carrier (DMERC) should send questions to: CMSNPIQuestionsfromDME RCBillers@cms.hhs.gov As always, more information and education on the NPI can be found at the CMS NPI page gov/nationalprovidentstand on the CMS website. Providers can apply for an NPI online at or can call the NPI enumerator to request a paper application at Getting an NPI is free - not having one can be costly Update J, Q and Medications Approved to Bill HCPCS J3490 Lists. The J codes, Q codes and Medications Approved to Bill HCPCS J3490 code lists have been updated effective September 2006 and are available on the BMS website at 5

6 Remittance Advices. Electronic Remittance Advices and Related Reports: a Electronic Remittance Advices are posted on the Web Portal in HIPAA- X and PDF formats. The PDF version is an image of the RA normally received in the mail. RAs remain available for 60 days. Additional 835 information is on page 2. a Claims-in-Process reports list claims that have been accepted for processing by Unisys, but are not yet paid, denied or reversed. The claims status is listed as pay, wait deny and in-process. This report is only available to providers who receive the PDF remit version; it is not available to providers who receive mailed paper remits. The report is replaced every week with current information. a Check or EFT Payment reports list the date and either the check number or EFT transaction code of your payments. This report is only available to web portal users and remains available for 60 days. a You may elect to receive these electronic reports by contacting the EDI Helpdesk at x 6, or by at edihelpdesk@. com. Selecting the electronic PDF RA s will stop the paper version. a Electronic remittance advices and related reports are posted on the web portal by close of business each Monday. a If a State holiday falls on a Monday, the electronic remittance advices will be posted on the web portal by close of business each Tuesday. Paper RAs are mailed out each Tuesday or Wednesday on Holiday weeks. Charging for Duplicate RA Requests. Effective July 1, 2006, Unisys will charge $10.00 Per remit for duplicate remit requests for both paper and electronic copies. Paper Remits that are less than 25 pages will be mailed. Paper Remits that are over 25 pages will be placed on a CD Rom and mailed to the provider. Providers will not be charged for the first 90 days after the original remit has been mailed or posted. Provider Communication. Maintaining an open line of communication between Unisys and WV Medicaid providers is critical. The provider bulletins and the weekly banner page messages on remittance advices are two methods by which Unisys communicates updated information to providers. The most efficient method of receiving updates is via the Unisys web portal, Provider Training Request: Provider representatives are available for on-site training or assistance with issues related to the web portal, and the submission of electronic and paper claims. Providers who would like to request on-site training should contact the provider representatives listed below. a Angie Richards , angela.richards@.com a Counties: Berkeley, Boone, Fayette, Grant, Greenbrier, Hampshire, Harrison, Jefferson, Kanawha, Lewis, Logan, McDowell, Mercer, Mineral, Mingo, Monroe, Morgan, Nicholas, Pendeleton, Pocahontas, Preston, Raleigh, Randolph, Summers, Taylor, Tucker, Upshur, Webster, Wyoming. Out-of-State: Maryland, Virginia. Or a Virginia Leffingwell , virginia.leffingwell@.com a Counties: Braxton, Brooke, Cabell, Calhoun, Clay, Doddridge, Gilmer, Hancock, Hardy, Jackson, Lincoln, Marion, Marshall, Mason, Monongalia, Ohio, Pleasants, Putnam, Ritchie, Roane, Tyler, Wayne, Wetzel, Wirt, Wood. Out-of-State: Kentucky, Ohio. Readmissions Within 7 Days of Discharge for Acute Care Hospitals WV Medicaid policy states that readmissions within 7 days of a hospital discharge will be reviewed to determine if they are unrelated and therefore separately payable. If the subsequent admission is determined to be related, the amount payable by Medicaid for both admissions is calculated over the combined length of stay. Currently, readmissions occurring within 7 days are reviewed on a post-payment basis. To avoid future recoupments for related admissions the Bureau suggests the following for claims submission: a Combine all services on one claim form a Enter the admit date of the first admission as the from date in block # 6, Statement covers period a Enter the date of discharge of the second stay as the through date in block # 6 a Bill the days the patient was inpatient as covered days with appropriate room and board revenue code (can be billed on one line with total days from both stays or on separate lines with number of days from each stay) a Bill days not inpatient in the facility with 18x revenue code as non-covered days (If patient is in observation between the two stays those charges are deemed to be part of the second admission and not separately billable.) a An authorization from WVMI for the second stay will not be required if the two stays are related and billed as one claim If one or both claims are paid in error, the provider must reverse and replace claim(s) to combine both services into one claim. 6

7 Timely Filing Policy. To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. a The year is counted from the date of receipt to the from date on a CMS1500, Dental or UB92. a Claims that are over one year old must have been billed and received within the one year filing limit. The original claim must have had the following valid information listed on it: a Valid provider number a Valid member number a Valid date of service a Valid type of bill Claims that are over one year old must be submitted to Provider Relations with a copy of the remittance advice or 824 rejection notice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement. This policy is applicable to reversal/replacement claims: a If you submit a reversal/replacement claim with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice a You are NOT allowed to add additional services to the replacement claim a If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing Medicare Primary Claims. a The normal WV Medicaid timely filing requirement for Medicare primary claims is one year from the Medicare paid date a The backlog of all paper Medicare primary claims has been processed a Beginning 07/08/2005, the web portal is available to direct data enter Medicare and TPL primary claims TPL Primary Claims. a The normal WV Medicaid timely filing requirement for TPL primary claims is one year from the date of service Backdated Medicaid Cards. When a Member has a backdated Medicaid card, the Member must provide a copy of the card or letter of eligibility (LOE) to the Provider. Providers have one year from the date the eligibility was backdated in order to submit the claim. The claim must be sent on paper with a copy of the card or LOE to the Provider Relations Department at PO Box 2002, Charleston, WV in order for Unisys to verify the card was truly backdated. Once verified, we will waive timely filing and submit the claim for processing. Special Exceptions for HMO. Unisys accepts HMO remits as proof of timely filing. The remit must be from one of the Medicaid HMOs acting on behalf of Medicaid; not a commercial insurance HMO. However, If the HMO was billed within one year of the date of service, Unisys will consider the charges. 824 s as Proof of Timely. Unisys will accept a Unisys 824 rejection as proof of timely filing. The 824/record must contain valid values for the following: Provider Name and Number, Member Name or Number (either or), Date of Service; Claim Type, and the Date it was rejected. The general timely filing rules apply as specified above and special cases will be reviewed by BMS. Please contact Unisys Provider Relations at , Monday through Friday, between 8:00 a.m. and 5:00 p.m. with questions concerning claims that have denied or did not cross over from Contact Information. Unisys Provider Relations wvmmis@.com ( ) EDI Helpdesk , prompt Provider Enrollment , prompt Unisys PR Pharmacy Help Desk Member Services Monday-Friday, 8:00 am until 5:00 pm Provider Services Fax. a BMS Main Number medclaimdoc@wvdhhr.org ( ) 7 Medicare properly. A provider service representative will be happy to assist you. Quick Tips for Dental Providers. We recommend that dental providers not bill more than one unit per service line. When billing paper claims or Direct Data Entry claims on the Web Portal, this is not an issue as neither option will accommodate more than one unit per service line. However, if you are uploading claims through the Web Portal, VAN, Clearing House, etc., it is possible to submit more than one unit per line. This could affect the payment of claims and Provider Relations Representatives cannot view multiple units in the system when you inquire on claims. When billing secondary claims and only partial lines that are partially approved/paid by primary insurance, you need to split bill the claim. All lines that were paid or approved by the primary insurance must be billed on one claim and all lines denied on a separate claim. EOB s must be attached to both with applicable lines indicated. HMO Contacts Carelink Advocate-Dennis May The Health Plan Advocate-Jennifer Johnson same Unicare Advocate-Mitch Collins Claim Form Mailing Addresses. Please mail your claims to the appropriate Post Office Box as indicated below. Unisys PO Box 3765 NCPDP UCF Pharmacy PO Box 3766 UB-92 PO Box 3767 CMS-1500 PO Box 3768 ADA-2002 Charleston WV PO Box 2254 Hysterectomy, Sterilization and Pregnancy Termination Forms Charleston WV Unisys Mailing Addresses. Provider Relations & Member Services. PO Box 2002 Charleston WV Fax # Provider Enrollment & EDI Help Desk. PO Box 625 Charleston WV Fax #

8 West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Provider Update Bulletin. Q.1, 2007 UNISYS Imagine It. Done. UNISYS PO Box 625 Charleston WV