West Virginia Medicaid Provider Update Bulletin. Qtr. 1, 2008 Volume 1. EMERGENCY AMBULANCE TRANSPORTS HOSPITAL to HOSPITAL (HH)

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1 West Virginia Medicaid Provider Update Bulletin. EMERGENCY AMBULANCE TRANSPORTS HOSPITAL to HOSPITAL (HH) To ensure timely and accurate processing of claims follow these important tips: Claims must be accompanied with documentation for review of medical necessity including a copy of the run sheet and or any other appropriate information. The diagnosis, signs and symptoms of the patient must be documented. Additionally the services the patient will be receiving at the servicing Hospital must also be documented. Avoid broad terms in your documentation such as: To receive further care. Be specific in service definition by documenting with terms such as Neurosurgery, Intensive Care, Trauma, etc. Failure to document why transport is necessary will result in a delay or denial of claim. Initialing information on run sheets prevents Unisys from being able to identify information and/or institutions involved. Information must be completed with complete spelling. Information must be legible. Use caution with the large EMS sticker in the middle of the documentation which can conceal information being reviewed. Claim Adjustment Reason Code 117 on the Remittance Advice advises the provider that the information submitted did not sufficiently document the need to move patient elsewhere. Providers often confuse this edit as referring to mileage (closest facility). LONG TERM CARE BILLING TIPS Long Term Care Billing Tips: Qtr. 1, 2008 Volume 1 Inside This Issue: Emergency Ambulance Transports HH... 1 Long Term Care Billing Tips... 1 Waiver Billing Tips... 1 Timely Filing Policy... 2 Clinical Auditing Advice... 3 Dental Billing Review... 3 Documentation for Unlisted Codes... 4 Remittance Message Reminders... 4 Change of Ownership Policy... 4 Medicare HMO Plans... 4 Finance Tips... 5 Lab Services Bill Type 14X... 5 NDC Requirement for Physician and Outpatient Administered Drugs... 6 NPI Paper FAQ S... 7 Sterilization & Hysterectomy Consent Review... 8 Claim Billing Tips... 8 Payment Error Rate Measurement (PERM) & Medicaid Providers... 9 Unisys AVRS Prompt Tree Payer Workshops Please be advised that the 2008 Payer Workshops will not be held in June. When submitting the MDS Confirmation Report to Unisys for review there are a few tips that could help process your claims in a more timely manner. Read the warning messages and correct the errors that are not related to the prior authorization Indicate the member and date of service Verify the member s social security number is correct The target and effective dates are NOT blank Make sure the MDS was sent before the extraction date WAIVER BILLING TIPS Waiver (HAB) services must be billed on separate claims using the assigned prior authorization number The new weekly deadline for submitting waiver claims is no later than 5pm Tuesday to assure payment on the weeks cycle. 1

2 TIMELY FILING POLICY To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service o The year is counted from the date of receipt to the from date on a CMS-1500, Dental or UB-04. 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: o Valid provider number o Valid member number o Valid date of service o Valid claim form/format Claims that are over one year old must be submitted to Provider Relations with a copy of the remittance advice showing the claim was received prior to turning a year old Services with dates of service over two years old are NOT eligible for reimbursement This policy is applicable to reversal/replacement claims o If a reversal/replacement claim is submitted 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 o You are NOT allowed to add additional services to the replacement claim o 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 Timely Filing o The normal WV Medicaid timely filing requirement for Medicare primary claims is one year from the EOMB date Claims Processing o The web portal is available to direct data enter Medicare and TPL primary claims TPL Primary Claims Timely Filing o 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/letter of eligibility (LOE) to the Provider. Providers have one year from the date the eligibility was backdated to bill the claim. The claim must be sent on paper with a copy of the card/loe to Provider Relations address at P O Box 2002, Charleston, WV in order for us to verify the card was actually backdated. Once verified, timely filing will be waived and the claim will be submitted for processing. Special Exceptions for HMO Unisys will accept HMO Medicaid remits as proof of timely filing. The HMO must be one of the HMOs acting on behalf of Medicaid, not an HMO that has a private insurance policy for the member. The claim could be denied for timely filing from the HMO as they sometimes have a 3 month billing period, but if the date of denial is not over a year from the date of service it can be used as proof of timely filing. *Please note: 824 reports are no longer accepted as proof of timely filing. 2

3 CLINICAL AUDITING ADVICE WV Medicaid implemented a clinical auditing solution in July The solution audits claims for unbundling, mutually exclusive, incidental, and pre-operative and post operative edits. Currently the clinical auditing solution is applied to CMS-1500 claim forms only. To ensure timely and accurate processing of claims follow these important tips: Check procedure code/modifier combinations against the indicators on RBRVS. (Example: is not indicated for bilateral procedure on the RBRVS file; therefore, with modifier 50 (bilateral procedures) is an invalid procedure code/modifier combination) Transportation providers often use modifiers to indicate the patient was taken to the scene of an accident. Modifiers that indicate travel was provided to the scene of an accident are invalid modifiers. (Example: Modifier PS indicates the patient was taken from the physician office to the scene of an accident. This is an invalid modifier.) Evaluation & Management Services on the same day as an ECG interpretation and report (93010) is reimburseable without use of modifier 25. Modifier 59 (distinct procedural service) should not be added to physician administered drugs. When submitting claims for laboratory services, check RBRVS to ensure that modifier 26 (professional component) is appropriate with the service provided. If the laboratory service is not listed in RBRVS with modifier 26, then modifier 26 would not be appropriate for those services. Modifier 91 (repeat clinical diagnostic laboratory test) will not override bundling logic in the system. The claim must indicate that a distinct procedural service was performed. Evaluation & Management modifiers 21 (prolonged E&M), 24 (unrelated E&M during post operative period), and 25 (significant, separately identifiable E&M) should not be submitted with surgical CPT/HCPCS codes. Modifiers LT (left side) and RT (right side) should be used on claims to indicate the side of the body on which the service was provided; however, these modifiers will not override system edits. If a service was distinct, then a modifier indicating distinct procedural service should be added to the appropriate code. It is not recommended that modifier 51 be added to practitioner s claims when multiple surgeries are being submitted for reimbursement. The clinical auditing solution will add modifier 51 to the least comprehensive procedure on CMS 1500 claim forms as necessary. This does not apply to hospital claims because only major surgical procedures should be reported when billing those services. See OUTPATIENT BILLING SURGERY, RECOVERY, OBSERVATION, AND EMERGENCY DEPARTMENT in Appendix 1 of the Hospital Services Manual located on the BMS web page under Manuals and Instructions. Coding guidance may be obtained from the following sources: American Medical Association guidelines (CPT4) CMS guidelines (HCPCS) Medicare CCI standards DENTAL BILLING REVIEW To ensure timely, accurate processing of claims follow these important tips: When submitting paper claims with added or deleted lines, please remember to update total charges as well. Bill with tooth numbers and/or alpha characters when required. Secondary Claims that have both paid and denied lines on the Insurance EOB must be submitted on paper. Submit one claim with denied lines, one claim with paid lines and attach a copy of the EOB to each claim. Contact Provider Relations for training on this process. Prior Authorizations must be requested on the individual Physician number-- not on the group number. If the physician on the PA is not in the office on the date of service, a call should be placed to WVMI to have the PA changed to the Physician providing the service or the member should be rescheduled. Do NOT bill more than one unit on any service line when billing electronically or paper. When submitting paper claims, do not submit multiple units in the description field. 3

4 DOCUMENTATION REQUIRED FOR UNLISTED CODES To ensure timely, accurate processing of claims follow these important tips: Unlisted surgical code claims should include an operative report and an explanation of the service. for which the unlisted code was used and why it was necessary to use an unlisted code. Unlisted drug/vaccination claims should include a description of the drug/vaccine and a cost invoice. Unlisted laboratory service claims should include the name of the test performed. Unlisted quantitation of drug claims should include the name of drug, the method by which the level was determined, and the name of reference laboratory. Unlisted lesion removal claims should include the size of all lesions removed. Unlisted radiology service claims should include the name of the radiology service and a copy of the report. Claims for any other service not listed should include the physician s notes and an explanation of the service for which the unlisted code was used and why it was necessary to use an unlisted code. A surgical history and physical alone does not provide adequate information for unlisted surgical services. All documentation needs to be legible. All documentation needs to have the submitting physician s documentation. (Example: Dr. Smith, Team Surgeon, should submit his report and Dr. Jones, Surgeon, should submit his report). Assistant and co-surgeons 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. REMITTANCE (EOB) MESSAGE REMINDERS When a remit message of A1 (Claim Denied Charges) is received without any other remit message, the provider should contact provider relations for additional information. The definition and other information on Claim Adjustment Reason Codes and Remittance Advice Remark Codes can be obtained at Unisys also has a Claim Denial Checklist document located on the Unisys website at under the FAQ section, listed in the REMARK CODES topic. CHANGE OF OWNERSHIP POLICY EFFECTIVE JUNE 1, 2008 A change of ownership requires that all parties involved shall collaborate to ensure that services are billed and paid to the correct owner using the correct provider number. The new provider must obtain an enrollment number to participate in the West Virginia Medicaid Program. The effective date of the new owner s enrollment is determined when the enrollment application is approved by Unisys. Providers are required to submit a complete and accurate enrollment packet 10 days prior to the change of ownership date and inform Unisys of the exact date of change of ownership to ensure a seamless transition. Services rendered prior to the effective date will not be payable through Medicaid to the new owner. Federally qualified health centers (FQHC), rural health centers (RHC), home health providers, hospice, independent diagnostic testing facilities (IDTF), renal centers, ambulatory surgical centers, and critical access hospitals (CAH) are the only exceptions to this policy. These provider types will have their enrollment date correspond with their Medicare approval letter. MEDICARE HMO PLANS Due to the advent of numerous Medicare Advantage plans or Medicare HMOs, BMS and Unisys are working to develop additional programming that will allow claims billed to the Medicare Advantage plans as primary to process through Unisys as secondary without denying for other insurance because Medicaid cannot always identify which insurances are commercial and which are Medicare Advantage plans, errors will still occur. If you bill your secondary claim on paper, you can help minimize the errors by writing on the EOMB that it is a Medicare Advantage or Medicare HMO plan. 4

5 FINANCE TIPS Important Facts about 1099s Did you receive a 1099 and should not have? There are some things you can do throughout the year to prevent this. You or your group should monitor payments received during the year. If you receive a payment made out to you directly or reported on your Tax ID instead of the group Tax ID, you could potentially receive a 1099 at the end of the year. Should a payment like this occur you should have the claim corrected by submitting a Reversal/Replacement Request Form with the appropriate documentation. Contact Provider Relations if instructions are needed. If you are no longer billing for services for any organization or entity, contact Provider Enrollment to have those affiliations termed to avoid payments when billing errors occur. Please make sure that you have a W-9 on file with Unisys in the name that your Tax ID is registered with the IRS. Failure to do so could result in your receiving a 1099 in the incorrect name. Please remember that all 1099 s are printed and mailed to the provider no later than January 31 st each year. You will have until March 31 st of each year to make name corrections to your As of March 31 st all 1099s are submitted to the IRS. Change or set up an EFT (Electronic Funds Transfer) You should complete an EFT authorization form which can be obtained online at wvdhhr.org/bms/ under Provider Information and by selecting EFT Form. You may also call Provider (888) to request a form. Please include a copy of a voided check for account verification purposes and Fax it to (304) Attention: Finance. Requesting reversals and returning checks Overpayments or erroneous payments may occur with billing or processing errors. We ask that you not submit checks to resolve overpayments without first discussing the preferred methods of correction with Provider Relations. Also, it is not accepted accounting practice to write checks between two providers to correct billing errors. The preferred method of correction on these issues is to correct utilizing the Reversal/Replacement Form. Contact Provider Relations for assistance on making these corrections. If a reversal only of funds is required to resolve the issue, and you are no longer actively billing on that provider number, the reversal could create a credit balance. In this case, you may need to submit a check to negate the credit balance. Instructions on this process may be obtained from Provider Relations or Finance. If it is necessary to submit a check to resolve payment issues, checks would be submitted payable to BMS along with claim and payment (Remittance) information to: 350 Capital Street, Room 251, Charleston, WV LAB SERVICES BILL TYPE 14X (Hospital Non-Patient Services) April 1, 2008 For hospitals billing with 14x bill type, services provided for non-patient in outpatient hospital, only lab codes will be processed for payment for dates of service (DOS) beginning April 1, Billing with 13x and 85x bill types remains the same; all outpatient services including lab will process for payment. Lab services can stand alone on both a 13x and 14x bill type; however, for 14x the only valid services are lab. 5

6 NDC REQUIRMENT FOR PHYSICIAN/OUTPATIENT ADMINISTERED DRUGS BILLING POINTERS To assist practitioners with questions regarding the National Drug Code (NDC) requirement for physician/outpatient administered drugs, a list of useful documents is available on the BMS website, These documents have been gathered under the Drug Code/NDC Drug Information link under the Information Bar on the homepage and include a Provider Notice, Frequently Asked Questions, a drug code list, HCPCS J3490 codes, and paper and electronic billing instructions. The Drug code list includes an indicator for codes that require an NDC and what unit of measurement to be used for the drug. The paper billing instructions include changes regarding billing field 43 of the UB-04 and field 24 of the CMS Please note that for products and services that fall within the bounds of this policy, only the following NDC unit of measurement codes will be allowed: UN, GR, ML, and F2. The following general advice may help in determining which NDC unit of measurement code is applicable for a given claim: NDC UNIT OF MEASURE DESCRIPTION ML= (Milliliters): Any liquid form of anything (syrups, IV solutions, injectable in liquid form etc) UN= (Units): Any single unit (for single dosage units like capsules, tablets, kits, vials with powder that has to be reconstituted, etc.). GR= (Grams): Powders, ointments, creams, etc. F2= (International Units): International units pertaining to a product s strength and not volume DOSAGE ADMINISTERED TO PATIENT NDC DOSAGE ON VIAL/BOX NDC BILLING UNIT HCPCS CODE DOSAGE 4 mg 2 mg/ml 2 ml 1 mg 4 5 gm 500 mg 10 un 250 mg 20 3 gm 1 gm 3 gm 500 mg IU 516 U/VL 12 IU Per IU 6192 HCPCS CODE BILLING UNIT Please note that all claims with an NDC requires one of the above named NDC units of measurement codes or the claim line will deny and Claim Adjustment Reason Code 125 (Payment adjusted due to a submission/billing error(s) and Remittance Advice Remark Code M53 (Missing/incomplete/invalid days or units of service) will appear on the paper remittance advice or the 835 transaction. 6

7 NPI Paper FAQ s May 23 rd 2008 has passed. Providers MUST now bill with NPI. If you are still having concerns about the switch, please contact Unisys Provider Enrollment at Below are some Frequently Asked Questions: How long do we have to obtain an NPI? You should have obtained your NPI and communicate it to Unisys. You may fax or mail to: Unisys, PO Box 625, Charleston, WV Fax: Do I have to obtain NPIs for each of my Medicaid IDs? Individuals will only be issued one NPI. Organizations or groups have the option of obtaining a single NPI or obtaining multiple NPIs (called sub-part enumeration). It is the provider s option. Obtaining NPIs for an organization s sub-parts does have benefits like separated remittance advice and easier billing because of the direct link from NPI to Medicaid ID.(One-to-One match) Do I need to bill utilizing taxonomy codes? A taxonomy code is needed when an NPI is shared by more than one Medicaid provider number. Providers who chose to get only one NPI for two or more Medicaid provider numbers (One-to-Many) will have to bill with taxonomy codes in addition to NPI for Unisys to determine which Medicaid # the claim is to be processed on. You may refer to the Billing Instruction or Companion Guide to obtain the correct fields for Billing Taxonomy. Where does the NPI go on the new paper forms? West Virginia Medicaid will be following the NUCC claim billing guidelines with the exception of field 19 (PAAS authorization number). CMS-1500 Field 24J Field 33a Field 33b UB-04 Field 56 Field 57 Dental Field 49 Field 54 Rendering Provider NPI (In the white space) Billing, Pay-to, or Individual Practice providers NPI Taxonomy code if applicable Billing/Pay-to NPI Taxonomy code if applicable Billing/Pay-to NPI Individual Dentist NPI How can I get a copy of the new billing instructions? The billing instructions and/or companion guides have been posted to the web portal. Go to and then click Manuals. 7

8 STERILIZATION & HYSTERECTOMY CONSENT REVIEW STERILIZATION CONSENT REVIEW To ensure timely, accurate processing of claims follow these important tips: Medicaid Consent Form required (not the form from the hospital or physicians office). All areas must be completed and legible (dates, names, procedures). Non legible M.D. signatures are common and may cause delays when the consent is not accompanied by transmittal letter or claim form. It is helpful if the physician s name is printed by the signature. The consent form must be signed by the operating physician who is a Medicaid provider. The patient signature and date must be the same as the person obtaining consent. All signatures must be original. The patient must be considered mentally competent by the physician and able to sign the consent. The physician must sign the consent form after the date of service. They can sign the same day but this requires they note surgery and signature time to meet requirement that MD signs after surgery. There are exceptions to the time restrictions of Sterilizations being done prior to the 30 day waiting period from patient signature. This section is on consent form just above MD signature area (section 2). If applicable this section must be completed with reason marked and circumstances explaining reason for being done less than 30 days. Must have expected delivery date (EDD) written in if applicable. HYSTERECTOMY ACKNOWLEDGEMENT REVIEW Only Medicaid Acknowledgement forms are acceptable (not hospital or physician consent forms). All lines must be completed (missing Medicaid number is a common problem). Consents should be received with transmittal letter or claim form. Without one of these it is impossible to know the date of surgery or the name of surgeon. CLAIM BILLING TIPS To ensure timely, accurate processing of claims follow these important tips: When billing services that require Prior Authorization please make sure the correct Prior Authorization number is being billed. Do not bill a Prior Authorization number when billing for services that do not require an authorization. When submitting a request for a Prior Authorization to WVMI for DME services that require a cost invoice, please make sure to submit the cost invoice and not a quote invoice with the claim. The Prior Authorization submitted on the claim must match the authorization that was given by APS and\or WVMI. When submitting Reversal/ Replacement Forms, be clear in requesting the changes you want made. Contact Provider Relations for training on this process. If claims are hand written, please write legibly to avoid data entry errors. Please bill with the correct taxonomy number on your claim if applicable. When submitting secondary paper claims, we recommend that you do not enter prior payments in field #29 on the CMS Doing so may result in deducting the amount of payment twice. The claims processor can obtain the payment information from the EOB accompanying the paper claim form when the claim is processed. 8

9 PAYMENT ERROR RATE MEASUREMENT (PERM) & MEDICAID PROVIDERS The Centers for Medicare and Medicaid Services (CMS) implemented the Payment Error Rate Measurement (PERM) program to meet the requirements of the Improper Payments Information Act of Federal agencies are required to annually review and estimate the amount of improper payments identified for Medicaid and SCHIP programs. Under PERM, CMS will conduct reviews in three areas of Medicaid and SCHIP programs: Fee-For-Service (FFS), Managed Care, and Program Eligibility. The results of these reviews will be used to produce both national and State specific error rates. States are measured once every three years, and West Virginia Medicaid and SCHIP have been selected for review for Fiscal Year CMS has awarded contracts to a statistical contractor (who will calculate error rates), a documentation/database contractor (who will collect State specific policies and medical records directly from Medicaid providers), and a review contractor (who will perform the medical and data processing review to determine if each claim was medically necessary and paid properly). Livanta is the assigned data documentation contractor who has the responsibility of requesting and collecting provider s medical records to be used in the review process. Providers can expect to receive Livanta s documentation request letters beginning in February All Medicaid providers should be aware that they may be included in the records request process. If a provider receives a request of documentation for Medicaid billings, please be advised that it is imperative that you send in all supporting documentation within the timeframe stated by Livanta. Any requested documentation from providers which is not received by Livanta for review will be counted as an error against WV Medicaid. This will result in a money payback for WV Medicaid. If a provider does not provide all documentation to support their billings within the timeframe stipulated by Livanta, that provider will have all outstanding Medicaid payments withheld until they have fully cooperated with Livanta s documentation request. Therefore, all Medicaid providers full cooperation with the PERM process is requested by BMS. If any WV Medicaid provider has questions or concerns about the PERM process or their responsibility regarding the Livanta documentation requests, please contact Scott Winterfeld at Unisys AVRS Prompt Tree ( ) Contact Information. HMO Contacts Carelink Advocate-Dennis May Please make sure that you are utilizing the appropriate prompts when making your selection(s) on the AVRS system to ensure that you will be connected to the appropriate department for your inquiry. Once you have entered in your provider number, the following prompts will be announced; 1. Accounts Payable Information 2. Eligibility Information 3. Claim Status Information 4. Provider Enrollment Department 5. Hysterectomy Sterilization Review 6. EDI Help Desk/Electronic Submission Inquiries 7. LTC Department 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 ( ) 9 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 #

10 West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Provider Update Bulletin. Q.1, 2008 UNISYS Imagine It. Done. UNISYS PO Box 625 Charleston WV