Commonwealth of Kentucky KyHealth Choices Provider Billing Instructions For Qualified Medicare Beneficiary Provider Types 82, 87, 88, 89, 91, and 95

Transcription

1 Commonwealth of Kentucky KyHealth Choices Provider Billing Instructions For Qualified Medicare Beneficiary Provider Types 82, 87, 88, 89, 91, and 95 Version 1.8 September 22, 2006

2 Revision History Document Version Date Name Comments /14/2005 EDS Initial creation of DRAFT Home Health Services Provider Type /19/2006 EDS Updated Provider Rep list /16/2006 Carolyn Stearman Updated with revisions requested by Commonwealth /28/2006 Lize Deane Updated with revisions requested by Commonwealth /01/2006 Tammy Delk Updated with revisions requested by Commonwealth /18/2006 Ron Chandler Updated with revisions sent by Stayce Towles /28/2006 Ann Murray Updated with revisions submitted by Vicky Hicks /18/2006 Ann Murray Replaced Provider Representative table.

3 TABLE OF CONTENTS NUMBER DESCRIPTION PAGE 1 General Member Eligibility Plastic Swipe KyHealth Card Member Eligibility Categories Lock-In KenPAC QMB and SLMB Managed Care Partnerships KCHIP Presumptive Eligibility Breast & Cervical Cancer Program Verification of Member Eligibility Obtaining Eligibility and Benefit Information General Billing Instructions General Instructions Imaging Optical Character Recognition Electronic Data Interchange (EDI) Means Of Electronic Submission How To Get Started Format and Testing ECS Help Additional Information and Forms Claims with Service Dates Over One Year Old Retroactive Eligibility (Back-Dated) Card Unacceptable Documentation Third Party Coverage Information (Excluding Medicare) Documentation That May Prevent A Claim From Denying For Accident And Work Related Claims Provider Inquiry Form Prior Authorization Information Adjustments And Claim Credit Request Cash Refund Documentation Form Return To Provider Letter Provider Representative List Phone Numbers and Assigned Counties HIPAA Information for Billing Completion of UB-92 Billing Form Detailed UB-92 Billing Instructions Completion of CMS-1500 (12/90) Paper Claim Form Completion of Invoice CMS-1500 (12/90) Crossover (Medicare/Medicaid) Completed CMS-1500 (12/90) Claim Form Completion of CMS-1500 (12/90) Paper Claim Form Detailed Instructions New Completed CMS-1500 (08/05) Claim Form Completion of New CMS-1500 (08/05) Paper Claim Form Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page i

4 7.5.1 Detailed Instructions Appendix A Internal Control Number (ICN) Appendix B Remittance Advice Examples Of Remittance Advice Pages Title Banner Page Paid Claims Page Denied Claims Page Claims in Process Page Returned Claim Adjusted Claims Page Accounts Receivable Summary Page Summary of Benefits Page Appendix C Remittance Advice Location Codes (LOC CD) Appendix D Remittance Advice Reason Code (ADJ RSN CD or RSN CD) Appendix E Remittance Advice Status Code (ST CD) Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page ii

5 1 General 1 General 1.1 Member Eligibility KY Members must apply for Medicaid eligibility through their Department for Community Based Services (DCBS) local office. If you have any questions or concerns, you must contact the KY Administrative Agent (KMAA), which is First Health Services Corporation, at , 8:00 a.m. 6:00 p.m. Eastern Time, Monday through Friday, except Holidays and select the prompt for Member Eligibility. The primary identification for Medicaid eligible members is the KyHealth Card. It is a permanent plastic card issued when the Member becomes eligible for Medicaid coverage. The name of the member and the Member Identification number is the only data displayed on the card. The provider has the responsibility to check identification and eligibility of each member before providing services. NOTE: Payment cannot be made for services provided to ineligible members, and/or, Possession of a Member Identification card does not guarantee payment for all medical services. The following is an example of the KyHealth Card: Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 1

6 1 General 1.2 Plastic Swipe KyHealth Card Member Name First, Middle Initial (if available), Last Ten DIGIT Member Identification Number Magnetic Strip Through a vendor of your choice, the magnetic strip can be swiped to obtain eligibility information. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 2

7 1 General 1.3 Member Eligibility Categories Lock-In KY Medicaid monitors utilization patterns of Medicaid members to ensure that benefits received are at an appropriate frequency and are medically necessary given the condition presented by the member. Referrals regarding suspected over-utilization are investigated by the Department. In those cases where improper utilization can be documented, the member is "locked-in" or assigned to one physician to serve as case manager and/or one pharmacy for supply of prescription drugs. The lock-in member is thereafter limited to use the services of these providers except in cases of emergency or appropriate referrals by the physician case manager. Providers who are not designated as lock-in case managers or pharmacies do not receive payment for services provided unless a medical emergency is documented or an appropriate referral has been made KenPAC Kentucky Patient Access Care (KenPAC) is a patient care system which provides Medicaid members with a primary care provider. The primary care provider is responsible for providing or arranging for the member s primary care and for referral of other medical services. Similar to "lock-in" members, a service provided to a KenPAC member by a medical provider other than the assigned primary care provider is not covered unless an appropriate referral has been made by the KenPAC PCP. Some categories of medical service are exempt from the KenPAC referral requirement. A complete list of these is listed in 907 KAR 1:320. Some of the physician-provided services which do not require a KenPAC referral include a mental health service (if provided by a psychiatrist), a vision service, a maternity care service, an EPSDT service, a family planning service, or a newborn care service QMB and SLMB Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs) are Medicare eligible members who also qualify for limited Medicaid assistance. The QMB eligible individual is issued a medical card with a designation indicating the individual is eligible for either QMB and Medicaid benefits or QMB benefits only. QMB benefits entitle the individual to Medicaid coverage of Part A & Part B Medicare premiums, co-pays, and deductibles. An individual who qualifies for SLMB benefits is not eligible for Medicaid benefits other than coverage of their monthly Medicare premium Managed Care Partnerships Passport is a Medicaid health care plan serving Medicaid members living in the following counties: Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble, and Washington. Although medical benefits for individuals whose care is managed by Passport mimic those of KY Medicaid, some billing procedures may differ. A physician having questions regarding Passport coverage should contact Passport Provider Services at KCHIP The KY Children's Health Insurance Program (KCHIP) is for children through the age of 18 years who have no other type of insurance and whose family meets specified income criteria. Based upon household income, these children are issued a regular Medicaid card. Children Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 3

8 1 General having KCHIP III category eligibility are covered for all Medicaid covered services except nonemergency transportation and EPSDT special services Presumptive Eligibility Presumptive Eligibility (PE) is a program offering pregnant women temporary medical coverage for prenatal care. A treating physician may issue an Identification Notice to a woman once pregnancy is confirmed. Presumptive eligibility expires 90 days from the date the Identification Notice is issued This short-term program is only intended to allow a woman to have access to prenatal care while she is completing the application process for full Medicaid benefits Presumptive Eligibility Definitions Presumptive Eligibility (PE) is designed to provide coverage for ambulatory prenatal services when these services are provided by approved health care providers. A. SERVICES COVERED UNDER PE Office visits to a Primary Care Provider (see list below) and/or Health Department, Anesthesia Services; Surgical Services; Termination of Pregnancy; Laboratory Services; Diagnostic radiology services (including ultrasound); General dental services; Emergency room services; Transportation services(emergency and non-emergency); and, Prescription drugs (including prenatal vitamins). B. DEFINITION OF PRIMARY CARE PROVIDER Any health care provider who is enrolled as a KY Medicaid provider, in one of the following programs: Physician/osteopaths practicing in the following medical specialties: --Family Practice --Obstetrics/Gynecology --General Practice --Pediatrics --Internal Medicine; Physician Assistants; Nurse Practitioners/ARNP s; Nurse Midwives; Rural Health Clinics; Primary Care Centers; and, Public Health Departments. SERVICES NOT COVERED UNDER PE Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 4

9 1 General Office visits or other procedures performed by a specialist physician (those practicing in a specialty other than those listed in Section B above), even if that visit/procedure is determined by a qualified PE primary care provider to be medically necessary; Inpatient hospital services, including labor, delivery and newborn nursery services; Mental health/substance abuse services; Any other service not specifically listed in Section A as being covered under PE; and, Any services provided by a health care provider who is not recognized by the Department for Medicaid Services (DMS) as a participating provider Breast & Cervical Cancer Program Breast and Cervical Cancer Program (BCCP) offers Medicaid coverage to individuals who have a confirmed cancerous or pre-cancerous condition of the breast or cervix. In order to qualify for Medicaid eligibility under this program, an individual must be under age 65 and have no other insurance coverage. Eligible individuals receive an Identification Notice. The length of coverage extends through the required treatment period for the breast of cervical cancer condition. Those members receiving Medicaid through the Breast and Cervical Cancer Program are entitled to full Medicaid services. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 5

10 1 General 1.4 Verification of Member Eligibility This section discusses: 1. Methods for verifying eligibility; 2. How to verify eligibility through an automated 800 number function; 3. How to use other proofs to determine eligibility; and, 4. What to do when a proof of eligibility is not available Obtaining Eligibility and Benefit Information Eligibility and benefit information is available to providers via the following: 5. Voice Response Eligibility Verification (VREV) available 24 hours/7 days a week at ; 6. Access KyHealth-Net at and, Contacting the First Health Services Corporation, the fiscal agent for KMAA, Call Center Customer Representative at Monday through Friday 8:00 a.m. 6:00 p.m., except Holidays Voice Response Eligibility Verification (VREV) EDS maintains a Voice Response Eligibility Verification (VREV) system that provides member eligibility verification, third party liability (TPL) information, KenPAC, Lock-in, Managed Care, PRO review, Card Issuance, Co-pay, provider check write, and claim status information. The VREV system generally processes calls in the following sequence: 1. Greet the caller and prompt for mandatory provider ID. 2. Prompt the caller to select the type of inquiry desired (eligibility, check amount, claim status, or etc.). 3. Prompt the caller for the dates of service (enter four digit year, for example, MMDDCCYY). 4. Respond by providing the appropriate information for the requested inquiry. 5. Prompt for another inquiry. 6. Conclude the call. This system provides a fast-path mode that permits a provider to take a short path to information. By simply keying the appropriate responses to prompts such as provider ID or Member Identification number as soon as each prompt begins. This greatly increases the speed of the inquiry. The number of inquiries is limited to 5 per call. The VREV spells the member name and announces the dates of service to ensure accuracy of responses. The check amount data is accessed through the VREV voice menu. The provider file is accessed to obtain up to the last three (3) processing check dates and check amounts. The telephone number (for use by touch-tone phones only) for the VREV is If you have a rotary telephone, the VREV is not available. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 6

11 1 General VREV Conversion Chart If you have the Member name and Date of Birth, dial , then choose from the following prompts: 1# to access VREV Enter the eight digit Medicaid provider ID number followed by the # 1# for Eligibility Verification 5# for Standard Eligibility Verification 2# to access using the Member s First Name and Last Name Enter first 5 digits of LAST NAME: *22*72*63*91*62# (*B*R*O*W*N#) 1# to Confirm the LAST NAME 2# to Change the LAST NAME Enter first 4 digits of FIRST NAME: *51*21*62*32# (J*A*N*E#) 1# to Confirm the LAST NAME 2# to Change the LAST NAME Using the following conversion chart for the letters of the alphabet, with a * before each letter and a # after the last character of the name: A 21 H 42 O 63 V 83 B 22 I 43 P 71 W 91 C 23 J 51 Q 11 X 92 D 31 K 52 R 72 Y 93 E 32 L 53 S 73 Z 12 F 33 M 61 T 81 SP * G 41 N 62 U 82 END # 1# to verify eligibility by the member s social security number (SSN) 2# to verify eligibility by the member s DATE OF BIRTH Enter the Member s DATE OF BIRTH: MMDDCCYY# Enter 1# = Male or 2# = Female, Enter the FROM DATE OF SERVICE# Enter the TO DATE OF SERVICE# Or Enter # for today s date The system gives the entire name and member Medicaid identification number as well as stating if the member is eligible or ineligible for the DATE OF SERVICE requested. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 7

12 1 General KyHealth-Net Online Member Verification KYHEALTH-NET ONLINE ACCESS CAN BE OBTAINED AT: Click on KYHEALTH-NET This web-based system is designed to allow Medicaid Providers instant access to pertinent member information. A User Manual is available for downloading and is designed to assist you in navigating through the system. If at any time you have suggestions, comments, or questions, please contact us through the assistance address located at the bottom of each primary web page (KyHealthNet@EDS.com). Please keep in mind information contained on the KyHealth-Net is highly confidential and access should be strictly limited to those with valid reasons. It is the responsibility of the provider and the system administrator to ensure all persons with access understand the appropriate use of this data. We highly recommend the creation and implementation of guidelines within your office outlining appropriate and inappropriate uses of this data. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 8

13 2 General Billing Instructions 2 General Billing Instructions 2.1 General Instructions The Department for Medicaid Services is mandated by the Centers for Medicare and Medicaid Services (CMS) to use the UB92 form for the reimbursement of services. You may bill on paper or electronically. 2.2 Imaging All paper claims are imaged. Imaging is taking a picture of the claim and using that picture during claims processing. The major objectives of the imaging technology are: increased accuracy in claims processing; improved customer and provider service; and, reduced storage requirements. This state of the art technology streamlines Medicaid claims processing and provide efficient tools for claim resolution, inquiries, and attendant claim related matters. Considerable gains in productivity and data accuracy are achieved with the EDS Imaging Solution implemented. Listed are a few guidelines for original claims, as well as claims that are being resubmitted, to ensure accurate readability: USE BLACK INK ONLY; Do not use glue; Do not use more than one staple per claim; Press hard to guarantee strong print density if claim is not typed or computer generated; Do not use white-out or shiny correction tape; and, Do not send attachments smaller than the accompanying claim form. 2.3 Optical Character Recognition Optical Character Recognition (OCR) eliminates human intervention by sending the information on the claim directly to the processing system, bypassing data entry. OCR is used for computer generated or typed claims only. Information obtained mechanically during the imaging stage does not have to be manually typed, thus reducing claim processing time. Information on the claim must be contained within the fields in order for the text to be properly read by the scanner. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 9

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15 3 Electronic Data Interchange (EDI) 3 Electronic Data Interchange (EDI) Healthcare organizations have traditionally conducted business by trading information on preprinted paper forms. The variety and volume of paper-based exchanges has grown. This has forced healthcare organizations to seek more efficient ways of communicating. Electronic Data Interchange (EDI) is structured business-to-business communications using electronic media rather than paper. 3.1 Means Of Electronic Submission EDS processes electronic transactions on either soft or hard media as defined below. Soft Media Asynchronous Modem transmission Mainframe Communications (contact the EDS EDI Technical Support Help Desk for constraints) Hard Media CD 3 1/2 inch diskette 3.2 How To Get Started All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner contact the EDS Electronic Data Interchange Technical Support Help Desk at: EDS P.O. Box 2016 Frankfort, KY Help Desk hours are between 7:00 a.m. and 6:00 p.m. Monday through Friday except holidays. 3.3 Format and Testing All EDI Trading Partners must test successfully with EDS and have Department for Medicaid Services (DMS) approved agreements to bill electronically before submitting production transactions. Contact the EDI Technical Support Help Desk at the phone number listed above for specific testing instructions and requirements. 3.4 ECS Help If you are already billing electronically, or have questions of a technical communications nature contact the EDI Technical Support Help Desk at Help Desk hours are 7:00 a.m. to 6:00 p.m. Monday through Friday except holidays. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 11

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17 4 Additional Information and Forms 4 Additional Information and Forms 4.1 Claims with Service Dates Over One Year Old In accordance with federal regulations, claims must be received by Medicaid within 12 months from the date of service or six months from the Medicare payment date, whichever is later. Received is defined in 42 CFR (d) (5) as, The date the agency received the claim as indicated by its date stamp on the claim. For KY, the date received is included in the Internal Control Number (ICN). The ICN is a unique number assigned to each incoming claim and the claim s related documents during the data preparation process. To consider claims 12 months past the date of service for processing, the provider must attach documentation showing timely receipt by DMS or EDS and documentation showing subsequent billing efforts, if any. To process claims beyond the 12 month limit, you must attach to each claim form involved, a copy of a Claims in Process, Paid Claims, or Denied Claims section from your Remittance Statement no more than 12 months old, which verifies that the original claim was received within 12 months of the service date. Additional documentation that may be attached to your claims for processing for possible payment is: A Screen Print from KyHealth-Net verifying eligibility issuance date and eligibility dates must be attached behind the claim. A Screen Print from KyHealth-Net to verify timely filing within each 12 months from date of service, such as the appropriate section of the Remittance Advice or from the Main Menu s Claims Inquiry selection; and, A copy of the Medicare Explanation of Medicare Benefits received twelve months after service date, but less than six months after the Medicare adjudication date. 4.2 Retroactive Eligibility (Back-Dated) Card Aged claims for Members whose eligibility for medical assistance or a specific service is determined retroactively may be considered for payment if filed within one year from the issuance date noted on the Member Identification card. A copy of the Member s Identification card covering the services dates must be attached behind the claim. Claim submission must be within 12 months of the issuance date. Paper Cards are obsolete as of July 1, Providers who are billing for services prior to this may use a copy of the paper card. After July 1, 2005 a copy of the KyHealth-Net card issuance screen is also acceptable documentation. 4.3 Unacceptable Documentation Copies of previously submitted claim forms, providers in-house records of claims submitted, or letters detailing filing dates are not acceptable documentation of timely billing. Attachments must prove the claim was received timely by EDS. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 13

18 4 Additional Information and Forms 4.4 Third Party Coverage Information (Excluding Medicare) When a claim is received for a Member whose eligibility file indicates other health insurance is active and applicable for the dates of services and no payment from other sources is entered on the Medicaid claim form, the claim is automatically denied unless documentation is attached Documentation That May Prevent A Claim From Denying For Other Insurance The following forms of documentation prevent your claim from denying for other health insurance when attached to the claim. 1. Remittance statement from the insurance carrier that includes: a. Member name; b. Date(s) of service; c. Billed information that matches the billed information on the claim submitted to Medicaid; and, d. An indication of denial or the billed amount was applied to the deductible. NOTE: Rejections from insurance carriers stating additional information necessary to process claim is not acceptable. 2. Letter from the insurance carrier that includes: a. Member name; b. Date(s) of service(s); c. Termination or effective date of coverage (if applicable); d. Statement of benefits available (if applicable); and, e. Signature of insurance representative or the letter must be on the insurance company s letterhead. 3. Letter from a provider that states they have contacted the insurance company via telephone. The letter must include the following information: a. Member name; b. Date(s) of service; c. Name of insurance carrier; d. Name of insurance representative spoken to and the phone number of the insurance carrier or notation indicating a voice automated response system was reached; e. Termination or effective date of coverage; and, f. Statement of benefits available (if applicable). 4. A copy of a prior remittance statement from an insurance company may be considered an acceptable form of documentation if it is: a. For the same Member; b. For the same or related service being billed on the claim; and, c. The date of service specified on the remittance advice is no more than six months prior to the claim s date of service. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 14

19 4 Additional Information and Forms NOTE: If the remittance statement does not provide a date of service, the denial may only be acceptable by EDS if the date of the remittance statement is no more than six months from the claim s date of service. 5. Letter from an employer that includes: a. Member name; b. Date of insurance or employee termination or effective date (if applicable); and, c. Employer letterhead or signature of company representative. 6. No response within 120 days from the insurance carrier a. 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. Write no response in 120 days on either the TPL Lead Form or the claim form, attach it to the claim and submit it to EDS. EDS overrides the other health insurance edits and forward 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 For Accident And Work Related Claims For claims related to an accident or work related incident, the provider should pursue information relating to the event. If an employer, individual, or an insurance carrier is a liable party, but the liability has not been determined, you may submit your claim to EDS with an attached letter containing any relevant information, that is, names of attorneys, other involved parties and/or the Member s employer to: EDS P.O. Box 2107 ATTN: TPL Unit Frankfort, KY Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 15

20 4 Additional Information and Forms EDS EDS Corporation Attention: TPL Unit P.O. Box 2107 Frankfort, KY THIRD PARTY LIABILITY LEAD FORM Provider Name: Member Name: Address: From Date of Service: Date of Admission: Provider #: Member #: Date of Birth: To Date of Service: Date of Discharge: Insurance Carrier Name: Address: Policy Number: Start Date: End Date: Date Claim was Filed with Insurance Carrier: Please check the one that applies: No Response in Over 120 Days Policy Termination Date: Other: Please explain in the space provided below Contact Name: Contact Telephone #: Signature: Date: Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 16

21 4 Additional Information and Forms 4.5 Provider Inquiry Form Provider Inquiry Forms may be used for any unique questions concerning claim status, paid or denied claims, and billing concerns. The mailing address for the Provider Inquiry form is: EDS Corporation P.O. Box 2100 Provider Services Frankfort, KY Please keep the following points in mind when using this form: Send the two-part completed form to EDS. The yellow copy is returned to you with a response; When resubmitting a corrected claim, do not attach a Provider Inquiry Form; A toll free EDS number is available in lieu of using this form; and, To check claim status, call the EDS Voice Response on Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 17

22 4 Additional Information and Forms PROVIDER INQUIRY FORM EDS P.O. Box 2100 Please remit both copies Frankfort, KY of the Inquiry Form to EDS 1. Provider ID 3. Member Name (first, last) 2. Provider Name and Address 4. Medical Assistance Number 5. Billed Amount 6. Claim Service Date 7. RA 8. Internal Control Number 9. Provider s Message 10. Signature Date EDS Response: This claim has been resubmitted for possible payment. EDS can find no record of receipt of this claim as indicated above. Please resubmit. This claim paid on in the amount of This claim was denied on with EOB code This claim denied on with EOB KenPAC Member. Referring provider ID is missing or is not the KenPAC primary physician/clinic ID for the date(s) of service. This claim denied on with EOB KenPAC Member. Billing and/or referring provider ID is not the KenPAC primary physician/clinic for date(s) of service. This claim denied on with EOB Member has other medical coverage. Bill other insurance first or attach documentation of denial from the insurance carrier. Aged claim. Please see attached documentation concerning services submitted past the 12 month filing limit. Other: Signature Date Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 18

23 4 Additional Information and Forms 4.6 Prior Authorization Information The prior authorization process does NOT verify anything except medical necessity. The process does not verify eligibility. The process does not verify age. The prior authorization letter does not guarantee payment. It only indicates that the service is approved based on medical necessity. If the Member loses KyHealth Choices or if the member ages out of the program eligibility, services are not reimbursed even though they have been authorized based on medical necessity and a prior authorization letter had been issued. Services should only be post authorized in case of: Retro-active Member eligibility Retro-active provider number Providers should always completely review prior to providing services or billing. If you determine that the services you are providing require prior authorization (based upon Department for Medicaid Services policies and regulations or from the Fee Schedule for your procedure/revenue code), you may contact: SHPS 9200 Shelbyville Road, Suite 100 Louisville, KY Telephone: Fax: Hours: 8:00 a.m. through 6:00 p.m. Or you may access the KYHealth Net website to obtain blank Prior Authorization forms. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 19

24 4 Additional Information and Forms 4.7 Adjustments And Claim Credit Request An adjustment is a change to be made to a PAID claim. The mailing address for the Adjustment Request form is: EDS Corporation P.O. Box 2108 Frankfort, KY Attn: Financial Services 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. For a Medicaid/Medicare crossover, attach an EOMB (Explanation of Medicare Benefits) with the claim; Do not send refunds on claims for which an adjustment has been filed; Be specific. Explain exactly what is to be changed on the claim; and, 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. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 20

25 4 Additional Information and Forms EDS ADJUSTMENT AND CLAIM CREDIT REQUEST FORM MAIL TO: EDS CORPORATION P.O. BOX 2108 FRANKFORT, KY ATTN: FINANCIAL SERVICES NOTE: A CLAIM CREDIT VOIDS THE CLAIM ICN FROM THE SYSTEM -- A NEW DAY CLAIM MAY BE SUBMITTED, IF NECESSARY. THIS FORM WILL BE RETURNED TO YOU IF THE REQUIRED INFORMATION AND DOCUMENTATION FOR PROCESSING ARE NOT PRESENT. PLEASE ATTACH A CORRECTED CLAIM AND REMITTANCE ADVICE TO ADJUST A CLAIM. CHECK APPROPRIATE BOX: 1. Original Internal Control Number (ICN) CLAIM CLAIM ADJUSTMENT CREDIT 2. Member Name 3. Member Medicaid Number 4. Provider Name and Address 5. Provider 6. From Date of Service 7. To Date of Service 8. Original Billed Amount 9. Original Paid Amount 10. Remittance Advice Date 11. Please specify WHAT is to be adjusted on the claim. You must explain in detail in order for an adjustment specialist to understand what needs to be accomplished by adjusting the claim. 12. Please specify the REASON for the adjustment or claim credit request. 13. Signature 14. Date Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 21

26 4 Additional Information and Forms 4.8 Cash Refund Documentation Form The Cash Refund Documentation Form is used when refunding money to Medicaid. The mailing address for the Cash Refund Form is: EDS Corporation P.O. Box 2108 Frankfort, KY Attn: Financial Services 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. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 22

27 4 Additional Information and Forms EDS Mail To: EDS P.O. Box 2108 Frankfort, KY ATTN: Financial Services CASH REFUND DOCUMENTATION 1. Check Number 2. Check Amount 3. Provider Name/ID /Address 4. Member Name 5. Member Number 6. From Date of Service 7. To Date of Service 8. RA Date 9. Internal Control Number (If several ICNs, attach RAs) Research for Refund: (Check appropriate blank) a. Payment from other source - Check the category and list name (attach copy of EOB) Health Insurance Auto Insurance Medicare Paid Other b. Billed in error c. Duplicate payment (attach a copy of both RAs) If RAs are paid to two different providers, specify to which provider ID the check is to be applied. d. Processing error OR overpayment (explain why) e. Paid to wrong provider f Money has been requested date of the letter (attach a copy of letter requesting money) g. Other Contact Name Phone Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 23

28 4 Additional Information and Forms 4.9 Return To Provider Letter Claims and attached documentation received by EDS are screened for required information (listed below). If the required information is not complete, the claim is returned to the provider with a Return to Provider Letter attached explaining why the claim is being returned. A claim is returned before processing if the following information is missing: Provider ID; Original provider or authorized representative signature; Member Identification number; Member first and last names; and, EOMB for Medicare/Medicaid crossover claims. Other reasons for return may include: Illegible claim date of service or other pertinent data. Claim lines completed exceed the limit. and, Unable to image. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 24

29 4 Additional Information and Forms EDS RETURN TO PROVIDER LETTER Date: - - Dear Provider, The attached claim is being returned for the following reason(s). These items require correction before the claim can be processed. 01) PROVIDER NUMBER A valid 8-digit provider number must be on the claim form in the appropriate field. Missing Not a valid provider number 02) PROVIDER SIGNATURE All claims require an original signature in the provider signature block. The Provider signature cannot be stamped or typed on the claim. Missing Typed signature not valid Stamped signature not valid. 03) Detail lines exceed the limit for claim type. 04) UNABLE TO IMAGE OR KEY Claim form/eomb must be legible. Highlighted forms cannot be accepted. Please resubmit on a new form. Print too light Print too dark Highlighted data fields Not legible Dark copy 05) Medicaid does not make payment when Medicare has paid the amount in full. 06) The Member s Medicaid Identification number is missing 07) Medicare EOMB does not match the claim Dates of Service Member Number Charges Balance due in Block 30 08) Other Reason- Claims are being returned to you for correction for the reasons noted above. Helpful Hints When Billing for Services Provided to a Medicaid Member The Member s Medicaid Identification number on the CMS must be entered Field 9A The Member s Medicaid Identification number on the UB92 must be entered in Block 60 Medicare numbers are not valid Medicaid numbers Please refer to your billing manual if you have any concerns about billing the Medicaid program correctly. Please make the necessary corrections and resubmit for processing. If you have any questions, please feel free to contact our Provider Relations Group, 8:00 a.m. until 6:00 p.m. eastern time, at , Monday through Friday, except Holidays. If you are interested in billing Medicaid electronically, please contact the EDS helpdesk at :00 a.m. to 6:00 p.m. eastern time, Monday through Friday except holidays. Initials of clerk Provider Name Provider Number Reason Code Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 25

30 4 Additional Information and Forms 4.10 Provider Representative List Phone Numbers and Assigned Counties VICKY HICKS MICHELLE GOINS STAYCE TOWLES BRENDA ORBERSON JANET SPERRY ASSIGNED COUNTIES ASSIGNED COUNTIES ASSIGNED COUNTIES ASSIGNED COUNTIES ASSIGNED COUNTIES ANDERSON BOONE BATH ADAIR BALLARD BOURBON CARROLL BELL ALLEN BRECKINRIDGE CAMPBELL GALLATIN BOYD BARREN BULLITT CLARK GRANT BRACKEN BOYLE BUTLER FAYETTE HENRY BREATHITT CASEY CALDWELL FRANKLIN JEFFERSON CARTER CLINTON CALLOWAY GARRARD OLDHAM CLAY CUMBERLAND CARLISLE HARRISON OWEN ELLIOTT EDMONSON CHRISTIAN JESSAMINE SHELBY ESTILL GREEN CRITTENDEN KENTON SPENCER FLEMING HART DAVIESS MADISON TRIMBLE FLOYD LARUE FULTON MERCER GREENUP LINCOLN GRAVES PENDLETON HARLAN MARION GRAYSON SCOTT JACKSON MCCREARY HANCOCK WOODFORD JOHNSON METCALFE HARDIN KNOTT MONROE HENDERSON KNOX PULASKI HICKMAN LAUREL ROCKCASTLE HOPKINS LAWRENCE RUSSELL LIVINGSTON LEE SIMPSON LOGAN LESLIE TAYLOR LYON LETCHER WARREN MARSHALL LEWIS WAYNE MCCRACKEN MAGOFFIN MARTIN MASON MENIFEE MCLEAN MEADE MUHLENBERG NELSON Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 26

31 4 Additional Information and Forms MONTGOMERY MORGAN NICHOLAS OWSLEY PERRY PIKE OHIO TODD TRIGG UNION WASHINGTON WEBSTER POWELL ROBERTSON ROWAN WHITLEY WOLFE PROVIDER RELATIONS Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 27

32 4 Additional Information and Forms This page left intentionally blank. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 28

33 5 HIPAA Information for Billing 5 HIPAA Information for Billing The Health Insurance Portability and Accountability Act (HIPAA) Information for Billing Standard Transaction Formats for Billing KY Medicaid To simplify the electronic exchange of financial and administrative health care transactions, the Health Insurance Portability and Accountability Act (HIPAA) transactions standards require all health plans, health care clearinghouses and health care providers to use or accept the following electronic transactions. Prior to the passage of HIPAA in 1996, Congress determined that to improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (that is, medical practices, hospitals, and health care plans) it was necessary to have national standards for the electronic exchange of health care transactions. The following formats replace the hundreds of proprietary and local formats used throughout the health insurance industry. The transaction standards took effect for KY Medicaid on October 16, 2003: Code Sets The regulation also requires the use of standardized procedure/diagnosis coding to represent the data to be transmitted. Code Sets include at a minimum: 1. Current Procedure Terminology (CPT-4); 2. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM); 3. HCFA Common Procedure Coding System (HCPCS); 4. ADA Codes on Dental Procedures and Nomenclature, 2nd Edition (CDT-2); and, 5. Revenue Codes NOTE: Please be aware that no Medicaid local codes are accepted after October 16, Printed 4/25/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 29

34 5 HIPAA Information for Billing HIPAA Transaction Standards The HIPAA transactions and code set standards are rules to standardize the electronic exchange of patient-identifiable, health-related information. They are based on electronic data interchange (EDI) standards, which allow the electronic exchange of information from computer to computer without human involvement. These standards apply to nine types of administrative and financial health care transactions used by payers, physicians and other providers, including claims submission, claims status reporting, referral certification and authorization, and coordination of benefits. HIPAA EDI Transactions Health Care Eligibility Inquiry and Response (270 & 271) Health Care Claim Status Inquiry / Response (276 & 277) Unsolicited (277) Health Care Service Review (278) Health Care Claim (837 & NCPDP Standard) Health Care Claim Payment and Remittance Advice (835) NOTE: The standard transaction for the Coordination of Benefits using the 837 is not HIPAA mandated and therefore not currently a requirement for HIPAA compliance. Health Care Eligibility Inquiry and Response (270 & 271) A provider uses the 270-benefit inquiry transaction to inquire about Medicaid eligibility for a Member. Effective October 16, 2003 this replaces the Medicaid Eligibility Verification Systems (MEVS) transaction. It can also be used to check benefits, deductibles, and copays of the patient's health plan and verify that the patient is on file and currently covered by the plan. The 271 is a response from KY Medicaid to the inquiry. The response is conditional. It is not a guarantee of payment. Health Care Claim Status Inquiry and Response (276 & 277) A provider uses the 276 claim status inquiry to ask about the status of processing for a particular claim or claims that remain outstanding within its accounts receivable system. The 277 is the response from KY Medicaid. Unsolicited (277) KY Medicaid is using this transaction to transmit the status of a suspended or pended claim back to the provider. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 30

35 5 HIPAA Information for Billing Health Care Service Review (278) This transaction is used to transmit referral information between providers and between provider and payer. Note: A referral from provider to provider is one of the most attractive transactions for providers. Health Care Claims (837 & NCPDP Standard) Effective October 16, 2003 health care claims for pharmaceuticals use the NCPDP v5.1 standard to bill KY Medicaid. Other claims use the X format. There are separate Implementation Guides (the official standard) for institutional claims, professional and dental claims. The 837 replaces electronic versions of the uniform billing claim and the CMS It can carry HMO medical encounter accounting information as well as billing claims. A key consideration for coordination with payer claim systems is a requirement for systems to retain all of the information received on the claim. Health Care Claim Payment and Remittance Advice (835) The Payment and Remittance Advice transaction is frequently used in separate functions. In the payment role, it is a payment order directing a bank to effect payment to a provider; in this role, the remittance advice is primarily payment reference information to enable the provider's systems to match up the payment with claims paid. Payments are frequently made in aggregate to cover several claims. In the electronic remittance advice role, it explains payment, partial payment, or denial, item by item for each claim. The remittance advice is intended to support automatic reconciliation of claims in provider accounts receivable systems and is one of the most attractive transactions from a provider's viewpoint. Implementation Guides for the Standards The implementation guides for the ASC X12N standards may be obtained from: Washington Publishing Company 806 W. Diamond Ave., Suite 400 Gaithersburg, MD, Telephone: FAX: These guides are also available at no cost through the Washington Publishing Company on the Internet at The implementation guide for retail pharmacy standards is available from: National Council for Prescription Drug Programs 4201 North 24th Street, Suite 365 Phoenix, AZ, Telephone: FAX: It is also available from the NCPDP s website at Printed 4/25/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 31

36 5 HIPAA Information for Billing Medicaid Companion Guides EDS and the Department have prepared companion guides for Medicaid Services. The companion guide specifies unique data fields necessary to correctly submit standard transactions for KY Medicaid processing. They are used in conjunction with the implementation guides. Companion guides are available on KY Medicaid s website located at Attachments At this time, claims requiring attachments must still be billed via paper. Each claim is processed separately; therefore, each individual claim needs the required or supporting documentation. Attachments are handled in the same manner as the current process standard for KY Medicaid. EOB/Adjustment Reason/Remark Codes The EOB/Adjustment reason/remark codes change to HIPAA compliant codes. These codes are included on ASC X12N835 electronic remit and/or paper remittance advice. The purpose of the EOB/Adjustment Reason/Remark Codes is to communicate the status and disposition of the claim to the provider. EDS Technical Support All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner, contact the EDS Electronic Data Interchange Technical Support Help Desk at between the hours of 8:00 a.m. and 6:00 p.m. Monday through Friday except holidays. If you have a general HIPAA question, please call between the hours of 8:00 a.m. to 6:00 p.m. EST Monday through Friday except holidays. Additional Resources HRSA HIPAA Website DHHS Administrative Simplification Website Centers for Medicare and Medicaid Services (CMS) Southern HIPAA Administrative Regional Process (SHARP) workgroup Workgroup for Electronic Data Interchange s (WEDI) Strategic National Implementation Process (SNIP) Washington Publishing Company (Implementation Guides) Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 32

37 6 Completion of UB-92 Billing Form 6 Completion of UB-92 Billing Form Following are billing instructions for QMB services provided by Comprehensive Outpatient Rehabilitation Facilities (CORF). Comprehensive Outpatient Rehabilitation Facility (CORF) providers must bill on the UB-92 billing form. Only the billing instructions required for EDS processing or the Medicaid Program information are included. Instructions for Fields not used by EDS or the Medicaid Program can be found in the UB-92 Training Manual. The UB-92 Training Manual and UB-92 billing forms may be obtained from the Kentucky Hospital Association. Kentucky Hospital Association P.O. Box Louisville, KY Telephone: An original UB-92 billing form must be sent to: EDS P.O. Box 2106 Frankfort, KY Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 33

38 6 Completion of UB-92 Billing Form 2 3 PATIENT CONTROL NO. 4 TYPE OF BILL Home Any Street 5 FED TAX NO 6 STATEMENT COVERS PERIOD FROM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 11 Here, KY PATIENT NAME 13 PATIENT ADDRESS JANE DOE 14 BIRTHDATE 15 SEX 16 MS ADMISSION 21 D HR 22 STAT 23 MEDICAL RECORD NO. CONDITION CODES DATE 18 HR 19 TYPE 20 SRC /1/ OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH A B C 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 120 ROOM & BOARD LABORATORY /01/ XRAY /01/ OXYGEN E /02/ OXYGEN-PORTABLE E /02/ PHYSICAL THERAPY /20/ PHYSICAL THERAPY /20/ PHYSICAL THERAPY /20/ SPEECH HEARING EVALUATION /15/ SPEECH THERAPY /15/ SPEECH THERAPY /15/ TOTAL PAYER 51 PROVIDER NO. 52 REL 53 ASG INFO BEN KENTUCKY MEDICAID PRIOR PAYMENTS 55 EST. AMOUNT DUE DUE FROM PATIENT 58 INSURED S NAME 59 P. REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. JANE DOE TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION Y PRIN. DIAG. CD. OTHER DIAG. CODES 76 ADM. DIAG. CD. 77 E-CODE CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE P.C. 80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE 82 ATTENDING PHYS.ID CODE DATE CODE DATE CODE DATE C12345 DR. DAN A B OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE 83 OTHER PHYS. ID CODE DATE CODE DATE CODE DATE C D E A 84 REMARKS OTHER PHYS. ID 85 PROVIDER REPRESENTATIVE 86 DATE UB-92 HCFA-1450 OCR/ORIGINAL X James Biller 11/31/2003 I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95Page 34

39 6 Completion of UB-92 Billing Form 6.1 Detailed UB-92 Billing Instructions FIELD NUMBER FIELD NAME AND DESCRIPTION 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 20 digits (alpha/numeric) appear on the remittance advice as the invoice number. 4 Type of Bill Enter the appropriate three-digit codes to indicate the type of bill. 1st Digit (Type of Facility) 7 = Clinic 2nd Digit (Bill Classifications Clinics Only) 3rd Digit (Frequency) 4 = Outpatient Rehabilitation Facility (ORF) 5 = Comprehensive Outpatient Rehabilitation Facility (CORF) 1 = Admit through discharge 2 = Interim, first claim 3 = Interim, continuing claim 4 = Interim, final claim 6 Statement Covers Period FROM Enter the beginning date of the billing period in numeric format (MMDDYY). THROUGH Enter the last date of the billing period in numeric format (MMDDYY). 22 Patient Status Codes Enter the appropriate two digit patient status code indicating the disposition of the member as of the through date in Field 6. Status Codes Accepted by KY Medicaid 01 Discharged to Home or Self Care (Routine Discharge) 02 Discharged or Transferred to Acute Hospital 03 Discharged or Transferred to Skilled Nursing Facility (SNF) or NF 04 Discharged or Transferred to Intermediate Care Facility (ICF) 05 Discharged or Transferred to Another Type of Institution Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 35

40 6 Completion of UB-92 Billing Form FIELD NUMBER FIELD NAME AND DESCRIPTION 06 Discharged or Transferred to Home Under Care of Organized Home Health Service Organization 07 Left Against Medical Advice 10 Discharged or Transferred to Mental Health Center or Mental Hospital 20 Expired 30 Still a Member Value Codes The appropriate value code(s) for Medicare/Medicaid crossover claims. A1 = Deductible Payer A Enter the amount shown on the EOMB to be applied toward the member s deductible amount due. Attach EOMB. A2 = Coinsurance Payer A Enter the amount shown on the EOMB to be applied toward the member s coinsurance amount due. Attach EOMB. B1 = Deductible Payer B Enter the amount shown on the EOMB to be applied toward the member s deductible amount due. Attach EOMB. B2 = Coinsurance Payer B Enter the amount shown on the EOMB to be applied toward the member s coinsurance amount due. Attach EOMB. 50 Payer Identification Enter the names of payer organizations from which the provider expects payment. For Medicaid, use KY Medicaid. All other liable payers, including Medicare, must be billed first. * * Medicaid is payer of last resort. 51 Provider ID Enter the eight digit KY Medicaid provider ID for the payer shown in Field 50 on the corresponding line (A, B, or C). 54 Prior Payments Enter the amount the facility has received toward payment of the claim prior to the billing date. Third party payment shall be entered in this area. Do not enter Medicare payment amounts in this area. 58 Insured s Name Enter the member s name in 58 A, B, and C that relates to the payer in 50 A, B, and C. Enter the member s name exactly as it appears on the Member Identification card in last name, first name, and middle initial format. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 36

41 FIELD NUMBER FIELD NAME AND DESCRIPTION 6 Completion of UB-92 Billing Form 60 Identification Number Enter the member s identification number in 60 A, B, or C. Enter the ten digit Member Identification number exactly as it appears on the Member s card. 82 Attending Physician ID Enter in Field 82B the unique physician identification number (UPIN) followed by the last name, first name, and middle initial for the attending physician. If the physician does not have a UPIN number, enter the appropriate license number in Field 82A. 85 Provider Certification and Signature The actual signature of the provider s authorized representative is required. Stamped or typed signatures are not accepted. 86 Date Bill Submitted Enter the date in numeric format (MMDDYY) that the UB-92 billing form was completed and signed. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 37

42 7 Completion of CMS-1500 (12/90) Paper Claim Form 7 Completion of CMS-1500 (12/90) Paper Claim Form The CMS-1500 (12/90) claim form is used to bill services provided by Licensed Clinical Social Workers, Psychologists, Physical Therapists, Physician Assistants, and Occupational Therapists to eligible QMB members. Following are billing instructions for required fields of information on the CMS-1500 (12/90) claim form. An original claim form and EOMB must be sent to: EDS P.O. Box 2101 Frankfort, KY Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 38

43 7.1 Completion of Invoice CMS-1500 (12/90) Crossover (Medicare/Medicaid) 7 Completion of CMS-1500 (12/90) Paper Claim Form Original Submission to Medicare The AdminaStar Medicare office and the Medicaid Program has been mandated by CMS to exclusively use the CMS-1500 (12/90) for billing respective plans. The CMS-1500 (12/90) is a two-part billing form. Submit one copy to: AdminaStar of Kentucky P.O. Box Louisville, KY Retain the second copy for your file. If both the Medicare and the Medicaid blocks in field one of the CMS-1500 claim form are checked; the YES block for accepting assignment in field 27 is checked; and the provider s Medicare provider ID is on the KY Medicaid cross-reference file, the claim may automatically be forwarded to EDS via magnetic tape by the Medicare office after Medicare has processed the claim. Providers shall accept assignment for members who have dual eligibility, Medicare/ Medicaid. Medicare guidelines for filing these claims shall be followed when the claims are initially submitted to Medicare for payment. In following Medicare guidelines, however, the provider must enter the member s ten digit Medicaid Identification number in the field as directed by Medicare if the claim is to automatically crossover to KY Medicaid as requested by the provider. NOTE: Claims will automatically crossover to KY Medicaid from Medicare ONLY when the provider(s) has made special arrangements for crossover with KY Medicaid enrollment division. Claims filed initially with Medicare carriers outside of KY shall not automatically crossover to KY Medicaid. These claims shall be billed on paper claim form (CMS-1500) and have attached an explanation of Medicare benefits (EOMB), issued from the Medicare carrier in the state where the service is provided. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 39

44 YES NO If yes, return to and complete item 9 a - d. 7.2 Completed CMS-1500 (12/90) Claim Form DO NOT STAPLE 7 Completion of CMS-1500 (12/90) Paper Claim Form AREA HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER HEALTH PLAN BLK LUNG x (Medicare #) (Medicaid #) (Sponsor s SSN) (VA File #) (SSN or ID) (SSN) (ID) Case, Marlene 2. PATIENT S NAME (Last Name, First Name, Middle Initial 5. PATIENT S ADDRESS (No., Street) 3. PATIENT S BIRTH DATE SEX MM DD YY M F 6. PATIENT RELATIONSHIP TO INSURED 1a. INSURED S I.D. NUMBER (FOR PROGRAM IN ITEM 1) 4. INSURED S NAME (Last Name, First Name, Middle Initial) 7. INSURED S ADDRESS (No., Street) Self Spouse Child Other CITY STATE 8. PATIENT STATUS STATE Single Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) ( ) 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) a. OTHER INSURED S POLICY OR GROUP NUMBER b. OTHER INSURED S DATE OF BIRTH SEX MM DD YY M F c. EMPLOYER S NAME OR SCHOOL Employed Full-Time Part-Time Student Student 10. IS PATIENT S CONDITION RELATED TO: IF APPLICABLE a. EMPLOYMENT? (CURRENT OR PREVIOUS) YES NO b. AUTO ACCIDENT? PLACE (State) YES NO c. OTHER ACCIDENT? ( ) 11. INSURED S POLICY GROUP OR FECA NUMBER a. INSURED S DATE OF BIRTH MM DD YY SEX M F b. EMPLOYER S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME YES NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED DATE 14. DATE OF CURRENT: 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS MM DD YY ILLNESS (First symptom) OR GIVE FIRST DATE MM DD YY INJURY (Accident) OR PREGNANCY (LMP) 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19. RESERVED FOR LOCAL USE 17a. I.D. NUMBER REFERRING PHYSICIAN 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SEVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $ CHARGES YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE) v MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 24. A B C D E F G H I J K MM DATE(S) OF SERVICE FROM TO DD YY MM DD YY Place of Service Type of Service PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER DIAGNOSIS DAYS CODE $ CHARGES OR UNITS EPSDT PLAN EMG COB RESERVED FOR LOCAL USE 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS apply to this bill and are made a part thereof.) SIGNED Betty Lou DATE May use up to 20 digits 27. ACCEPT ASSIGNMENT? YES NO x 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office) 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE $ $ $ 33. PHYSICIAN S, SUPPLIER S BILLING NAME, ADDRESS, ZIP CODE & PHONE# Doctors Place 100 Easy St. Anytown, KY PIN# QMB Provider ID # Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 40

45 7.3 Completion of CMS-1500 (12/90) Paper Claim Form 7 Completion of CMS-1500 (12/90) Paper Claim Form Detailed Instructions Claims are returned or rejected if required information is incorrect or omitted. The following fields must be completed: FIELD NUMBER FIELD NAME AND DESCRIPTION 2 Patient s Name Enter the member s last name, first name, and middle initial exactly as it appears on the Member Identification card. 9a Other Insured s Policy Group Number Enter the member s ten-digit Member Identification number exactly as it appears on the current card. 11 Insured s Policy Group or FECA Number Required if the member has insurance other than Medicare or Medicaid and the other insurance made a payment on the claim. Enter the policy number of the other insurance. 11c Insurance Plan Name or Program Name Required if the member has insurance other than Medicaid or Medicare and the other insurance has made a payment on the claim. Enter the name of the other insurance company. 24A Date of Service Enter the date in numeric format (MMDDYY). 24B Place of Service Enter the appropriate two-digit place of service code, which identifies the location where the service was rendered. 24D Procedure Code Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the member. 24E Diagnosis Code Indicator Enter 1, 2, 3, or 4, referencing the specific diagnosis for which the member is being treated as indicated in Field F Charges Enter the usual and customary charge for the service provided to 24G the Member. Days or Units Enter the number of units provided for the Member on this date of service. 26 Patient s Account No. Enter the patient account number. EDS keys the first 20 or fewer digits. This number appears on the remittance statement as the invoice number. 28 Total Charge Enter the total of all individual charges entered in Field 24F. Total each claim separately. 29 Amount Paid Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 41

46 7 Completion of CMS-1500 (12/90) Paper Claim Form FIELD NUMBER FIELD NAME AND DESCRIPTION Enter the amount paid, if any, by other insurance. NOTE: Do not enter Medicare payment. For Medicare involved claims attach a copy of the Medicare EOMB indicating either payment or denial. 30 Balance Due Required only if other insurance made payment on the claim. Subtract the insurance payment entered in Field 29 from the total charge entered in Field 28 and enter the balance due. 31 Signature of Physician or Supplier Including Degrees or Credentials The signature of the provider s authorized representative is required. Stamped signatures are not acceptable. Date Enter the date in a month, day, year numeric format (MMDDYY). This date must be on or after the date(s) of service billed on the claim. 33 Physician s, Supplier s Billing Name, Address, Zip Code, and Phone Number Enter the provider s name, address, zip code and phone number above PIN. Enter the eight-digit KY Medicaid providers ID beside the PIN. Group ID Enter the eight-digit KY Medicaid group providers ID if applicable. Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 42

47 7.4 New Completed CMS-1500 (08/05) Claim Form 7 Completion of CMS-1500 (12/90) Paper Claim Form Printed 4/25/2006 Provider Type-82, 87, 88, 89, 91, 95 Page 43