Remittance Advices. a Only edits with deny status are now shown on the RA. All warn and okay edits have been removed.

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1 West Virginia Medicaid Provider Update Bulletin. March 2005 Volume 2 Number 1 Provider Communication. Maintaining an open line of communication between Unisys and WV Medicaid providers is critical. The quarterly 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 for receiving updates is via the Unisys web portal, www. wvmmis.com. On the homepage, notices of website content additions such as new remittance advices are posted under Updates. Website configuration changes including maintenance notices and changes to website functions are posted under Site Status. Unisys also added an alert window that appears when you log-in. This function is used to alert website users to important, time-sensitive information. The FAQ (Frequently Asked Questions) content area, accessible on the left side of the web page, is a convenient method to gain quick answers to common questions. Unisys has also added a provider survey accessible on the website homepage. If you have not yet done so, please take a few minutes of your time to complete this survey. Your input is a critical factor in our assessment of our products and services. We thank you for your participation in the Medicaid Program and your assistance with this survey. Unisys also conducts many conference calls for different provider types. Below is the schedule for these conference calls. If you are one of the provider types listed and would like to join the calls, please contact Provider Services for additional information. a RHC/FQHC Last Monday of each month a Nursing Homes, Every Tuesday a Hospitals, Every Wednesday The most efficient way to receive updates is... wvmmis. com. a Behavioral Health, Every Friday Remittance Advices. Unisys is in the process of making your remittance advice more user friendly. We have already implemented a few changes beginning with the February 25 RA. a Claims are now listed alphabetically under the headings of denied, reversed, and paid. Hospitals will continue to have inpatient and outpatient claims listed separately. a Only edits with deny status are now shown on the RA. warn and okay edits have been removed. Some RA changes that have been approved and will be implemented in the future are: a Claims denied as duplicates will list the conflicting claim number and paid date. a The current edits will be crosswalked and changed to the standard HIPAA remark codes. a Reversal and associated replacement claims will appear on the same RA. Electronic Remittance Advices and Related Reports: a Electronic Remittance Advices are posted on the Web Portal in PDF format, and require Adobe Reader to open, view, and print. The ERA shows claims that are paid, denied, or reversed. This report is an image of the RA normally received in the mail. RAs remain available for 60 days. a Claims-in-Process reports list claims that have been accepted for processing by Unisys, but are not yet paid, denied or reversed. This report is only available to providers who receive their remits electronically; it is not available to providers who receive paper remits. The report 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. 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. For providers who have chosen to receive a paper version of the remittance advice, these are mailed each Tuesday. Return to Provider (RTP) Letters. Many Medicare primary claims were returned inappropriately to providers during the month of February. These RTP letters were attached to Medicare primary claims. The rejection reason was the claim adjustment reason code 01 09, 28, or 93 was not found in the external code table adjustment reason codes These claims will be reprocessed for you; there is no reason to resubmit these claims. Please note that these are crossover claims and will not be processed immediately. Inside This Issue: Provider Communication... 1 Remittance Advices... 1 Return to Provider Letters... 1 Get a Web Account... 2 Health PAS Online... 2 Provider Training Request... 2 Billing Updates... 3 Children s Specialty Care vs Medicaid... 3 PAAS Provider Information... 3 Tips from the Unisys Mail Room... 3 Secondary Medicare & Insurance Claims 3 Timely Filing... 3 UB-92 & 837I Information... 3 Claim Reprocessing Schedule... 4 Provider Enrollment... 5 FQHC/RHC Medical Group Numbers.. 5 EPSDT Provider Numbers... 5 Updated Licenses Required... 5 WV Medicaid Provider Manuals... 5 Budget Relief... 5 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 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 Mozilla FireFox version 1 or greater are recommend. 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 file receipt or rejection. 997 Functional Acknowledgement Response. a The 997 acknowledges that the 837 is syntactically correct. The entire file or specific 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: RA Remittance Advices & Related Reports. These reports described on the cover page. 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. 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. Angela Richards (Gray counties and Kanawha) angela.richards@.com Virginia Leffingwell (Red counties and Kanawha) virginia.leffingwell@.com 2

3 Billing Updates. Occurrence Code 57. It has recently come to our attention that many providers are billing occurrence code 57 on their UB-92 claims in blocks According to the UB-92 Editor dated September 2004, occurrence codes are reserved for national assignment. Therefore, this is not a valid occurrence code to submit to WV Medicaid. Please reference the UB-92 Editor or call Provider Services for valid occurrence codes. Rolling Month Limit Update. There have been problems with the rolling month limit, so Unisys is in the process of reconfiguring this service limit. The December 2004 bulletin defined the limit as a thirty day period of time. The count of days began when the member received the initial service and a claim was processed. The services that have a rolling month limit will continue to be limited per month; however, this reconfiguration will allow services to be given each month. For example: If services are provided January 31, they may be provided again on February 28; if a member was given services March 31, they can be provided again on April 30. Dental Update. Procedure code D4341 requires a prior authorization from WVMI. This was omitted from the information provided at the January 2005 dental workshop. The dental manual is being corrected and will be reposted on the BMS website at www. wvdhhr.org/bms. You will receive notice when all corrections are made. Children s Specialty Care vs. Medicaid. The Children with Special Health Care Needs (CSHCN) Program is undergoing several changes. Services for dual eligible children (children with coverage by both Medicaid and the CSHCN program) must now first be billed with the child s Medicaid ID. Prior authorization for services that exceed the Medicaid service limit or that require prior approval for coverage must be requested from WVMI under the child s Medicaid ID number. Tips from the Unisys Mail Room a Providers billing on HCFA (CMS) 1500 claims, please ensure your address and provider number are in block 33. a Do not place stickers on claims especially covering staples. This causes the claim to be torn when trying to remove the staples. a Tape small receipts and any other small papers to an 8½ " x 11" piece of paper. a Attach a complete copy of the EOMB. Claims will be returned if the necessary information is not shown, i.e., paid date and amount. a When submitting copies of claims, ensure they are legible and the entire claim has been copied. Requests for approvals that WVMI denies may be faxed to CSHCN at with the child s CSHCN ID number. Claims for these services should be mailed to OMCFH/ Fiscal Dept., Attention: Karen Pauley, Room 427, Charleston, WV Questions may be directed to PAAS Provider Information. claims that have been denied for edits 153 and 171 since June 28, 2004, will be reprocessed (see reprocessing schedule, page 4). This reprocessing will occur in three phases: a Claims for members who are enrolled in PAAS (completed March 5). a Claims for members who are enrolled in an HMO. a Claims that paid but line items denied for edits 153 or 171 Below are the correct fields to place PAAS information: a PAAS provider number placement on UB-92 is field 83 a PAAS provider number placement on HCFA (CMS) 1500 is field 19 a PAAS provider number placement in 837I is 2310C REF02 using a 1D qualifier in the REF01 a PAAS provider number placement in 837P is 2310A REF02 Secondary Medicare and Insurance Claims. Unisys began processing Medicare secondary claims on January 29, These claims continue to be released on a weekly basis. claims sent to a Medicare Intermediary (Palmetto, Administar [DMERC], and UGS inpatient hospital claims) from July 2004, to present are being held for processing. After these Medicare claims are processed, the Third Party Liability (TPL) secondary claims will be released for processing. Timely filing for Medicare or TPL secondary claims will be extended. Timely filing will be overridden if the date on the EOB is 07/01/2003 or after. Claims that have been inadvertently processed will be reprocessed (see reprocessing schedule on page 4). Timely Filing. To meet timely filing requirements for WV Medicaid primary services, claims must be received within one year of the date of service. Claims that are over one year old, but not yet two years old must have been originally billed and received within the one-year filing limit, and with the following valid information: a Correct provider number a Correct member number a Correct date of service a Correct type of bill Claims over one year old must be submitted on paper to Provider Relations with a copy of the original remittance advice attached to prove timely filing. If submitting a reversal/replacement claim over one year old, the replacement claim must be billed on paper with a copy of the original RA to provider services for verification of the above criteria. You are not allowed to add additional services to the claim. If a replacement claim has additional services added that are not replacing services on the original claim, these lines will be denied for timely filing. Timely filing limits for Medicare primary claims are normally one year from the paid date on the Medicare EOB. Timely filing limits for TPL primary claims are normally one year from the date of service. These limits have been extended due to the claim processing issues. Timely filing will be overridden if the date on the EOB is 07/01/2003 or after for Medicare and TPL primary at this time. UB-92 & 837I Claim Information. When billing outpatient services, all services using any revenue code must be billed on one claim form. If you receive a duplicate denial and the original claim is billed using the same date of service, same member number, and same revenue code, you must submit a reversal/replacement claim. If a second claim is submitted separately it will deny as a duplicate. For example, an original claim is billed using revenue code 300 with procedure code 81000, and a separate claim is submitted with same date of service and member number using revenue code 300 with procedure code 36415, the second claim will deny. The original claim would need to be reversed and replaced with the additional service added. 3

4 Claim Reprocessing Schedule. In an effort to correct claims that were processed incorrectly, Unisys has placed the reprocessing schedule below on the web portal. Note that the Scheduled Reprocessing Dates are the dates that Unisys will begin to reprocess the claims described in the Reprocessing Reason column. Reprocessing Reason, Error Description School-Based Services, Claims that processed without a servicing provider identification number. Claims denied with W procedure codes and 6/30/04 DOS (Denied for Edit 158). RHC & FQHC claims that paid zero dollars due to missing procedure codes. Claims denied for Prior Authorization number not found (Denied for Edit 606). Claims that paid when they were exact duplicates of previously paid claims. Claims with procedure code A0120 that paid zero dollars or reduced units. Scheduled Reprocessing Date Claim Status Processed Dates Dates of Service 2/11/2005 Complete Paid June 2004 current 2/11/2005 Complete Denied June 2004 current 6/30/2004 2/11/2005 Complete Paid June 2004 current 2/11/2005 Complete Denied June 2004 current 2/18/2005 Partially Complete. Unisys continuing to analyze claims for possible additional reprocessing. Claims denied for Edits 153 and /25/2005 Begin Reprocessing 3/25/2005 Complete Reprocessing Anesthesia claims paid at 100% of the allowable with modifiers 95 and QX that should have paid 40% of the allowable, and modifiers 95, AD, QK, and QY that should have paid at 60% of the allowable. Children s Specialty Care (or CSHCN) claims denied in error because of incorrect numbers in the system. Claims with Prior Authorizations from WVMI or Children s Specialty Care (or CSHCN) for unpriced codes that paid full in error. Medicare crossover claims denied for edit 311, Claim Submission Window Exceeded, although the EOMB dates are within one year of claims submission dates. Medicare COB claims paid at 100% of Medicare allowed amount without deducting the COB payment. A/D Waiver claims for G9002 that were denied in error for Benefit visit limit exceeded (Edit 206). Claims with procedure code TH that paid at the regular conversion factor instead of the maternity conversion factor Claims billed with procedure code H0004 without modifiers. System chose the term with modifiers and paid incorrectly. Issue corrected 1/21/2005. Paid June 2004 current 2/25/2005 Complete Paid June 2004 December /25/2005 Rescheduled 3/4/2005 Revised Date 3/4/2005 Complete Denied June 2004 current Paid June 2004 current 3/11/2005 Denied 6/28/ /12/2004 3/11/2005 Paid June 2004 current 3/18/2005 Denied June 2004 current 3/18/2005 Paid June 2004 current 3/25/2005 Denied June 2004 January 21, /25/2005 Paid June 2004 November 30, /8/2005 Paid June 2004 January 21,

5 Provider Enrollment. FQHC/RHC Medical Group Provider Numbers. RHC/FQHC medical group provider numbers (these are the number previously used as the pay-to on a HCFA-1500) will be closed. After the group number has been closed, all claims for services that are carved out of your encounter rate must be billed to Unisys using the individual provider s Medicaid number and your RHC/FQHC facility number in block 33 of the HCFA The servicing provider s individual number should be placed directly to the right of PIN. The facility number, now serving as your pay-to, should be placed directly to the right of GRP. Those services that are included in your encounter rate should continue to be billed on a UB-92 with your RHC/FQHC facility provider number listed in block 51. You are also required to place the attending practitioner s individual Medicaid provider number in block 82. A letter will be mailed to all RHC/FQHC providers to inform them of this closure and give more specific billing information. EPSDT Provider Numbers. As part of the transition from the previous fiscal agent to Unisys, we are diligently reviewing areas where we can improve services and claims payment to providers. As a result of this review, we have found that it is not necessary for some offices to bill for EPSDT services utilizing an EPSDT provider number separate from the provider number used for billing general claims. If your office will be affected by this provider number closure, you will be receiving a detailed letter with specific information regarding this change. Once the EPSDT number is closed, you must bill under the practitioner s provider number used for billing general claims. If you have any questions regarding this information, please contact Provider Enrollment. Updated Licenses Required. Unisys will be mailing letters to all providers with terminated licenses. This letter will request your updated license. If an updated license is not received by the date given in the letter, your provider number will be terminated on that date. To ensure that this does not occur, please fax a copy of your current license to Provider Enrollment at If you have any questions regarding the status of your license, please contact Provider Enrollment at or WV Medicaid Provider Manuals. The following WV Medicaid manuals are listed on both the BMS website at www. wvdhhr.org/bms and the Unisys Health PAS Online web portal at a Aged & Disabled Waiver a Behavioral Health Clinic a Behavioral Health Rehabilitation a Dental Services a Ambulatory Surgical Center & Birthing Centers a Home Health a Hospice Services a Hospital Services a ICF/MR Services a Laboratory & Radiology a MR/DD Waiver Services a Nursing Facility Services a Occupational/Physical Therapy a Orthotics & Prosthetics a Personal Care a Pharmacy Services a Podiatry Services a Psychological Services a RHC/FQHC Services Contact Information. Provider Services Monday-Friday, 8:00 am until 5:00 pm wvmmis@.com ( ) EDI Helpdesk , prompt Monday-Friday, 8:00 am until 5:00 pm edihelpdesk@.com ( ) Member Services Monday-Friday, 8:00 am until 5:00 pm Fax AVRS. Access AVRS using the same phone numbers, 24 hours a day, 7 days a week. a Targeted Case Management a Transportation a Vision Services a Common Chapters Although there are a few provider manuals that have not been updated, all providers are responsible for the common chapters ( ) and their appendices. Most information on the Health PAS Online website, including Program Instructions, Billing Instructions, Provider Manuals and User Guides, is secured. You must have a valid logon ID and password to access the secured portion of the website. See the article Get a Web Account on page 2 of this newsletter for more information. Budget Relief. The State Medicaid payments of July 2004, through December 2004, were not indicative of the way Medicaid normally pays providers. Beginning with the December 3 payment run, the State did not release all claims to be paid. This is the normal course of payment for the State. Please note that Medicaid pays the oldest claims in the claims processing system first. It is recommended that providers bill as frequently as possible; therefore, there will always be claims in the system that are aging. Claims are normally paid 20 to 30 days after receipt. 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 HCFA-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 Provider Enrollment & EDI Help Desk. PO Box 625 Charleston WV

6 West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Provider Update Bulletin. March 2005 UNISYS Imagine It. Done. UNISYS PO Box 625 Charleston WV