Kentucky Medicaid. Spring 2009 Billing Workshop UB04

Transcription

1 Kentucky Medicaid Spring 2009 Billing Workshop UB04

2 Agenda Representative List Reference List UB Claim Form Detailed Billing Instructions NDC (Hospitals and Renal Dialysis) Forms Timely Filing FAQ S Did You Know? Top Denials Questions Evaluation 2

3 Representative List 3

4 Representative List 4

5 Reference List Helpful Phone Numbers Web Addresses EDI Helpdesk Provider Billing Inquiry EDS Website KyHealthnet KY Medicaid 5

6 Top Half of UB Claim 6

7 Form Locators and Descriptions Required Information 1 Provider Name, Address and Telephone Enter the complete name, address, and telephone number (including area code) of the facility. 3 Patient Control Number Enter the patient control number. The first 14 digits (alpha/numeric) will appear on the remittance advice as the invoice number. 4 Type of Bill Enter the appropriate code to indicate the type of bill. Please refer to billing instructions for the appropriate type of bill. 1st Digit Enter zero. 2nd Digit (Type of Facility) 3rd Digit (Bill Classification) 4th Digit (Frequency) 0 = Non-payment TOB 0111 for inpatient hospital claims except for Critical Access, Rehab and Psychiatric Hospitals. TOB 0110 is for newborn claims while mom and newborn are in the same facility (Inpatient Hospital only) DPU s are inpatient claims only 7

8 Form Locators and Descriptions Required Information 6 Statement Covers Period FROM: Enter the beginning date of the billing period. THROUGH: Enter the ending date of the billing period. 10 Date of Birth Enter the member s date of birth. 12 Admission Date Enter the date on which the Member was admitted to the facility in numeric format (MMDDYY). 13 Admission Hour Enter the code for the time of admission to the facility. Admission hour is required for both inpatient and outpatient services. (Inpatient Hospital, Mental Hospital, PRTF, DPU, Nursing Facility ONLY) 14 Admission Type Enter the appropriate type of admission (Hospital Only) 8

9 Form Locators and Descriptions Required Information 16 Discharge Hour Enter the hour the member was discharged. (This is now a requirement and will result in claim denials for Provider Types Inpatient Hospitals, Mental Hospital, and DPU s.) 17 Patient Status Code Enter the appropriate two digit patient status code indicating the disposition of the patient as of the through date in Form Locator Condition Codes Peer Review Organization (PRO) Indicator Enter the appropriate indicator, describing SHPS determination of Medical Necessity for the stay. For Home Health Providers enter a Y1 whenever a MAP 34 has been completed and is available in the member s records Occurrence Codes and Dates Enter the appropriate code (s) and date (s) defining a significant event relating to this bill. Reference the UB-04 Training Manual for additional codes. Discharge Code and Date Enter 42 and the actual discharge date when the THROUGH date in Form Locator 6 is not the actual discharge date and Form Locator 4 indicates Final Bill. (Inpatient Hospital s Only) 9

10 Form Locators and Description Required Information Occurrence Span Code and Dates Enter occurrence span code MO and the first and last days approved by the PRO/UR when condition code C3 (partial approval) has been entered in Form Locators Medicare EOB Date (cross-overs only) Enter Medicare EOMB date when Medicare allow the service. (leave blank if Medicare Denies) Value Codes 80 = Covered Days - Enter the total number of covered days from Form Locator 6 82 = Coinsurance Days - Enter the number of coinsurance days billed to KY Medicaid during this billing period. 83 = Life Time Reserve Days -Enter the Lifetime Reserve days the patient has elected to use for this billing period. A1 = Deductible Payer A-Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due. A2 = Coinsurance Payer A - Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due. B1 = Deductible Payer B - Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due. B2 = Coinsurance Payer B - Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due. 10

11 Form Locators and Description Required Information 42 Revenue Codes Enter the three digit revenue code identifying specific accommodation and ancillary services. NOTE: Total charge Revenue code 0001 must be the final entry in column 42, line 23. Total charge amount must be shown in column 47, line Description Enter the standard abbreviation assigned to each revenue code. Effective July 1, 2009 for Outpatient Hospital and Renal Dialysis, the NDC is required when billing outpatient services for revenue codes and The N4 qualifier proceeds the NDC. Do not use dashes or spaces. When billing a revenue code which requires more than one NDC, the NDC detail attachment form must be used. 44 CPT/RATES Enter the CPT if required. 11

12 Required Information Form Locators and Description 45 Service Date Enter the date the service was provided. Field 45, line 23 is to be used to indicate invoice date. 46 Unit Enter the quantitative measure of services provided per revenue code. 47 Total Charges Enter the total charges relating to each revenue code for the billing period. The detailed revenue code amounts must equal the entry total charges. Claim total must be shown in field 47, line Non-Covered Charges Enter the charges from Form Locator 47 that are non-payable by KY Medicaid. 12

13 Bottom Half of Claim form 13

14 Required Information Form Locators and Descriptions 50 Payer Identification Enter the names of payer organizations from which the provider receives payment. All other liable payers, including Medicare, must be billed first. * KY Medicaid is payer of last resort. 54 Prior Payments Enter the amount the facility has received toward payment of the claim. Third party payor or Medicare payment. 55 Est. Amount Due Enter Medicare s allowed amount only when Medicare allows the charges. (Medicaid uses this field for crossover claims only. Leave blank for all other circumstances) 56 NPI Enter the Pay To NPI number. 57 Taxonomy Enter the Pay To Taxonomy number. 57B Other Enter the facilities zip code. 14

15 Form Locators and Descriptions Required Information 58 Insured s Name Enter the Member s name in Form Locators 58 A, B, and C that relates to the payer in Form Locators 50 A, B, and C. 60 Identification Number Enter the Member Identification number in Form Locators 60 A, B, and C that relates to the Member s name in Form Locators 58 A, B, and C. 63 Prior Authorization Number Enter the prior authorization number assigned by the SHPS. 67 Principal Diagnosis Code Enter the ICD-9-CM Vol. 1 and 2 code describing the principal diagnosis. 67A-Q Other Diagnosis Code Enter the ICD-9-CM Vol. 1 and 2 codes that co-exist at the time the service is provided. 69 Admitting Diagnosis (Inpatient Only) Enter the ICD-9-CM diagnosis code describing the admitting diagnosis. 15

16 Form Locators and Descriptions Required Information 74 Principal Procedure Code and Date Enter the ICD-9-CM (Vol.3) procedure code that identifies the principal obstetrical or surgical procedure performed during the billing period. Enter the date the procedure was performed in numeric format (MMDDYY). (Hospital Inpatient only) 74A Procedure Code (s) and Date (s) Enter the ICD-9-CM (Vol.3) procedure codes identifying the procedures, other than the principal obstetrical surgical procedure, performed during the billing period. Enter the date the procedures were performed in numeric format (MMDDYY). (Hospital Inpatient only) 76 Attending Physician ID Enter the Attending Physician NPI number. 77 Operating Enter the Operating Physician NPI number. 78 Other Enter the NPI number of the Nursing Facility. (For Hospice Providers Only) 79 Other (NPI) Enter the KenPAC NPI number. (When billing revenue code 450, KenPAC approval is not required, Outpatient Hospital only) 16

17 NDC (National Drug Code) Effective DOS July 1, 2009, Outpatient Hospitals and Freestanding Renal Dialysis Clinics will be required to bill NDC codes with Physician administered drugs. May start billing 4/1/09. The required revenue codes are and You may obtain a copy of the NDC Detail Attachment form at or by calling Provider Inquiry at The NDC FAQ s are on the website at The NDC is required with all claims when billing Medicaid. Which includes, Medicare crossovers and TPL as primary. For Medicare claims to crossover, you will need to bill the NDC s on the Medicare claims. 17

18 NDC The NDC is required when billing Outpatient services and Freestanding Renal Dialysis Clinics for revenue codes and The N4 qualifier precedes the NDC on UB04 paper claims and 837I. Do not use dashes or spaces. Example N4XXXXXXXXXXX When billing a revenue code which requires more than one NDC, the NDC detail attachment form must be used when billing paper claims. If the revenue code does not have an NDC billed along with it, the entire claim will deny. The NDC billing is Date of Service specific. Example: DOS 7/1/09 bill claim with NDC; for DOS 6/30/09 do not bill claim with NDC. 18

19 NDC Detail Attachment EXAMPLE 19

20 NDC Detail Instructions Fill out the top part of the NDC detail attachment form such as provider name, provider ID, member name, member ID and DOS. Column 1 ~ Claim Line This is the claim line number on the UB-04 claim form for which you are billing the NDC. The claim line number must be in sequential order. Column 2 ~ NDC Enter the appropriate NDC code that corresponds to the HCPCS code. Columns 3-6 not applicable **Return to provider reasons. There are two reasons why an NDC Detail Attachment form may be returned. The form must have a corresponding line number to the UB-04 claim form. The line number must be in sequential order. 20

21 Completed NDC Example Revenue code 250 has 4 NDC s associated with it. (1 on the claim and other 3 on NDC sheet) Revenue code 636 has 3 NDC s associated with it. (1 on claim and other 2 on NDC sheet) 21

22 Billing NDC on KyHealth Net

23 Summary Page of KyHealth Net

24 Forms Third Party Liability Adjustment and Claim Credit Cash Refund 24

25 TPL Lead Form 25

26 TPL Helpful Hints When to use the TPL Lead Form: When there is no response within 120 days from the insurance carrier. When the other health insurance has not responded to a provider s billing within 120 days from the date of filing a claim, a provider may complete a TPL Lead Form. Mark no response in 120 days on the TPL Lead Form. Attach it to the back of claim and submit it to EDS. EDS overrides the other health insurance edits and forwards a copy of the TPL Lead form to the TPL Unit. The TPL staff contact the insurance carrier to see why they have not paid their portion of liability. Used for Commercial Insurance Only Not to be used for Medicare Other section is obsolete Contact name and phone number is person and phone number at Commercial Insurance 26

27 Adjustment Claim Credit 27

28 Adjustment, Claim Credit/Void Hints An adjustment/void is a change to be made to a PAID claim. Please keep the following points in mind when filing an adjustment request: Attach a copy of the corrected claim and the paid remittance advice page to your adjustment form. Do not send refunds on claims for which an adjustment or void has been filed. Be specific. Explain exactly what is to be changed on the claim. Claims showing paid zero dollar amounts are considered paid claims by Medicaid. If the paid amount of zero is incorrect, the claim requires an adjustment. Do not do a adjustment/void on KyHealth Net and paper. Do one or the other. A claim credit is on paper, a void is on the KyHealth Net. They are the same. Only a void/claim credit will re-set a Prior Authorization 28

29 Cash Refund 29

30 Cash Refund Hints The Cash Refund Documentation Form is used when refunding money to KY Medicaid. Please keep the following points in mind when refunding: Attach to the Cash Refund Documentation Form a check for the refund amount made payable to the KY State Treasurer. Attach applicable documentation, such as a copy of the remittance advice showing the claim for which a refund is being issued. Do not send a refund and an adjustment/void on the same claim. A refund will NOT reset a Prior Authorization 30

31 Timely Filing Aged claims (those older than 12 months from date of service or 6 months from the Medicare payment or denial date) may be considered for payment only when documentation is submitted behind the claim to support timely filing. The ONLY Acceptable documentation will include a copy of one or more of the following: Remittance advices to verify timely filing within each 12 months from date of service. A Screen Print from KYHealth-Net to verify issue date of the eligibility. (this is the card issuance screen) A Screen Print from KYHealth-Net Summary Page, to verify timely filing within each 12 months from date of service. Medicare explanation of benefits (EOMB). Commercial Insurance EOB 31

32 Timely Filing Examples 1 Year From Issue Date 32

33 Timely Filing Examples KyHealth Net Search Criteria Screen Not Acceptable for timely filing 33

34 Timely Filing Examples KyHealth Net Header Screen Not Acceptable for timely filing 34

35 Timely Filing Examples KyHealth Net Summary Screen Acceptable for timely Filing 35

36 FAQ s If you bill Medicare, remember to list your Medicare information on the UB claim form when Medicare allows, this would also include the Medicare Replacement Policy s. When billing Medicare electronically, you may bill with NPI and taxonomy and the claim will cross via 837. Medicare s website about taxonomy is: When submitting a paper claim with attachments, the claim must always be on top of any attachments. Except, when submitting paper adjustments, the form is to be on top of the claim. 36

37 FAQ s Cont. Member Program Codes to watch for Z-QMB Only-Medicaid only allows after Medicare, so if Medicare denies, Medicaid will deny. ZJ, ZK, ZL, ZQ Buy-In Member-Medicaid is only paying the Medicare Premiums. No Medicaid coverage. For Inpatient Hospitals, Medicaid does not want the DRG billed on the UB claim form. Beginning July 1, 2009, for Inpatient Hospital, Mental Hospital, and DPU claims only, Medicaid will edit claims for the discharge hour. 37

38 FAQ S Cont. Internal Control Number (ICN) All claims, adjustment and Voids are given a unique number. First two digits are the Region, Second 2 digits is the Year the claim was received and the 3 rd three digits are the Julian Date of receipt. *Example Claim received as an electronic claim, March 2, If the ICN begins with: 10-Paper claim with no attachments 11-Paper claim with attachments 20-Electronic claim 22-KyHealth billed claim 50-Adjustment 56-Claim Void 38

39 Did You Know? * Coming Soon--Paper checks are going to be mailed from the KY State Treasurer. Remittance Advices will continue to be mailed by EDS. * GO GREEN--Did you know that you can opt not to receive paper RA's. You can download the RA from the KyHealth Net and keep an electronic copy. 39

40 Top Denials EOB 0482-Exact duplicate Resolution: The claim has already paid, a duplicate will not hit against a previously denied claim. EOB 2003-Member not eligible for Medicaid Resolution: Always check member eligibility. EOB 0102-Timely filing Resolution: You have 1 year from the date of service, attach documentation to the back of the paper claim to show proof of timely filing. 40

41 KY MMIS Project Provider Evaluation Provider Workshop Date: Thank you for attending this session. We d appreciate your feedback, as well as suggestions on how we can improve future sessions. Please answer the following questions, rating them on a scale of 1-5, with 1 being strongly disagree and 5 being strongly agree. Strongly Disagree Somewhat Agree Strongly Agree Question Material was appropriate for the audience. Comments: 2. Presentation was well-organized and easy to follow. Comments: 3. Session leader was easy to hear/understand. Comments: 4. The Session leader was well-versed in their subject area and presented information in a clear, understandable manner. Comments: 5. I was given appropriate material/handouts. Comments: 6. Questions were answered to my satisfaction. Comments: 7. I was able to see/hear the audiovisual portion with no trouble. Comments: If you would like to receive information via , please provide address below. Comments: Optional: if you would like a member of the KY MMIS team to contact you, please provide your contact information below. Name: Department/Branch: Phone Number: