Medicaid Secondary Claims User Guide

Transcription

1 Medicaid Secondary Claims User Guide Version 6.0 Revised April 2011

2 Medicaid Secondary Claims Table of Contents OVERVIEW...4 Important Contact Information: Introduction...6 WHAT IS COORDINATION OF BENEFITS (COB)?...6 WHEN SHOULD I SUBMIT A COB CLAIM?...7 Filling a Medicaid/PeachCare for Kids COB Claim...7 Identification of Other Insurance...7 HOW ARE COB CLAIMS REIMBURSED?...8 Medicaid Reimbursement When Another Insurer s Payment is Involved...8 When a Managed Care Plan is the Primary Insurer...8 Tort/Casualty (Personal Injury) Liability...9 MEDICARE What is Medicare?...11 Medicare is a federal health insurance program for:...11 Original Medicare has two parts: Part A and Part B...11 WHAT IS A CROSSOVER?...11 Medicare Crossover Claims - Helpful Information...12 Medicare Part D Plan...12 Medicare Part A, B and C Plans...12 MEDICARE COVERED SERVICES...12 Part A Medicare covered services that Medicaid also covers:...12 Part A Medicare covered services that Medicaid does not cover:...13 Part B Medicare covered services:...13 Medicare Payment Guidelines...14 The original Fee-for-Service Medicare Part A:...14 The original Medicare Part B:...14 Medicare Advantage Plans (MAP), Part C:...14 CROSSOVER BILLING CONSIDERATIONS:...14 Claims will not crossover automatically...15 Medicare Eligibility Discrepancies...16 ADDITIONAL INDUSTRY STANDARDS AFFECTING COB AND CROSSOVER CLAIMS...16 National Provider Identifier...16 National Drug Code and Injectable Drug for Outpatient Services Submitting a Paper Claim...18 CMS Health Insurance Claim Form - Field Descriptions...18 CMS-1500 Form Field Descriptions...19 The following is an example of the CMS-1500 Health Insurance Claim Form...30 TIPS FOR SUBMITTING PAPER CMS-1500 COB AND CROSSOVER CLAIMS...31 UB-04 Form - Field Descriptions...32 UB-04 Form Field Descriptions...36 TIPS for SUBMITTING PAPER UB-04 COB and CROSSOVER CLAIMS Adjustments Involving COB and Crossover Claims...38 WHEN SHOULD I FILE AN ADJUSTMENT ON A CLAIM?...38 Page 2 of 51

3 HOW TO COMPLETE AN ADJUSTMENT?...38 Adjustment Request Form (DMA-501)...38 COB or Crossover claim adjustments specific instructions using the Adjustment Request Form (DMA-501): COB and Medicare Notification Forms...41 TIPS FOR SUBMITTING THE DMA-410 AND THE DMA460 FORMS...41 Copies of the COB Notification Form (DMA- 410) and the Medicare Notification Form (DMA- 460) are shown on the following pages...42 DMA-410-TPL...43 DMA-460: 06- EOMB Submitting COB and Crossover Attachments...45 SPECIFIC GUIDELINES FOR SUBMITTING COB AND CROSSOVER ATTACHMENTS Special Billings for Certain COB and Crossover Claims...47 SPECIAL BILLINGS FOR CROSSOVER CLAIMS...47 Inpatient Part B only hospital claims...47 Example:...47 Understanding the edits that denied the Part B only claim...48 Reasons the claim will be Returned to Provider (RTP)...48 Outpatient crossovers over 63 lines... Error! Bookmark not defined. Medicare Part B Retail Drugs...49 SPECIAL BILLINGS FOR COB CLAIMS...49 Mother and Baby billed as One to the Health Insurance Carrier...49 SCENARIO:...49 Partial Hospital Stay Scenario Scenario ACRONYMS...51 Page 3 of 51

4 OVERVIEW The purpose of this guide is to assist Georgia Medicaid Fee-For-Service providers with submitting Medicaid secondary paper claims. A Medicaid secondary claim is a claim where there is potentially another payer with primary responsibility for payment. The guide accompanies Part 1 Policies and Procedure Manual, primarily Appendix J (Billing Manual), Section 8. Instructions for filing secondary claims using PES (Provider Electronic Solution) and the Web Portal are found in manuals published by HP Enterprise Services (HPES). Some very general information for these media types is included in this guide. NOTE: Billing for members who are enrolled in a Care Management Organization (CMO) must follow the billing requirements of the member's CMO. The policies in this guide do not apply to members in a CMO. Some of the procedures covered in the guide are how to: Complete a paper claim for CMS-1500 and UB-04 Complete an Adjustment Request Form (DMA-501) for Crossovers and COB Complete a COB Notification Form (DMA-410) Complete a Medicare Notification Form (DMA-460) Complete a Coordination of Benefits/Third Party Liability Accident Information Form (DMA-312) Correctly submit claim attachments Page 4 of 51

5 Important Contact Information: Rev. 01/10 Customer Interaction Center (CIC) Claims Questions Provider Enrollment Prior Authorizations General Concerns Fax for Attachments and COB updates Fax for Provider Enrollment Fax for Georgia Medical Care Foundation (GMCF) Prior Authorizations (800) or (678) Electronic Date Interchange (EDI) Gateway Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Clearinghouse Electronic Transactions Other Electronic Transactions Provider Training Courses Page 5 of 51

6 1. Introduction Chapter WHAT IS COORDINATION OF BENEFITS (COB)? By federal law, Medicaid is the payer of last resort in most circumstances. Medicaid considers payment on a claim after a third party resource is billed. A third party resource is any individual, entity or program that is or may be liable for payment of part or all of the expenses for medical care furnished to a Medicaid member. It is the obligation of any legally liable third party other than Medicaid or the member to pay the primary cost of the member s medical care. COB is the process of determining the primary payer. When an individual applies for Medicaid in Georgia he/she automatically assign his/her rights to medical payments from a third party resource to the Department of Community Health (DCH). Third party resources for members generally come from two sources: COB (commercial, individual and group health plans; government sponsored plans such as Tricare; supplemental policies; casualty related coverage s; Federal Employees Health Benefit Plan (FEHBP); and Workmen s Compensation; to name a few); and Medicare Part A, B and/or C. Pricing and processing methodologies for these two types of claims are very different. Since Medicaid is most often the payer of last resort, providers must, with limited exceptions, submit an initial claim for reimbursement of services to the member s primary plan (See NOTE below). Once the primary plan processes the claim, providers can submit a claim to Medicaid with information showing how the primary plan processed the claim. The claim processing information from the primary plan is usually provided on an Explanation of Benefits (EOB) form or, for Medicare, on an Explanation of Medicare Benefits (EOMB) form. Medicaid will coordinate the primary plan s payment, if any, with the Medicaid maximum allowable amount for the service. If the primary plan paid more than the Medicaid maximum allowable amount, no additional payment will be made by Medicaid. If the primary plan paid less, in most cases Medicaid will pay the difference. NOTE: Providers are not required to initially file claims with the primary insurance carrier if the services are for non-institutionalized pregnancy related care or if the services are for preventive and pediatric services under the Health Check program (also know as EPSDT). Page 6 of 51

7 However, providers may choose to bill the primary plan initially for these types of services. pediatric services under the Health Check program (also known as EPSDT). However, providers may choose to bill the primary plan initially for these types of services. WHEN SHOULD I SUBMIT A COB CLAIM? Filling a Medicaid/PeachCare for Kids COB Claim When a member has other insurance coverage that is potentially legally liable for payment of a claim, a COB claim is usually required prior to billing Medicaid. A COB claim submitted to Medicaid will be processed in one of two ways: cost avoid or pay-and-chase. Cost avoid Requires providers to bill the primary payer before billing Medicaid. If a COB claim is required to cost avoid, Medicaid will deny the claim until the primary payer processing information is included on the claim. Pay-and-chase This method of claims processing is limited to certain claims. Claims that payand-chase are claims for either non-institutionalized prenatal care services or for preventive and pediatric services under Health Check (formerly EPSDT). For these claims, Medicaid pays the members medical bills and then attempts to recover from the liable third party. Thus, providers are allowed to bill Medicaid first and then Medicaid, not the provider, will seek reimbursement from the primary payer. If a provider chooses to bill Medicaid for these services instead of the primary payer, the provider must not bill the third party resource/primary payer if Medicaid pays the claim. NOTE: Even though Medicaid will pay these claims initially, Medicaid is not the primary payer on these charges. Medicaid will pay the maximum allowable amount and then Medicaid will bill the primary payer for reimbursement of the payments for the services. Identification of Other Insurance Providers must make reasonable efforts to collect funds from any insurance/benefit plan that is the primary payer to Medicaid. Reasonable efforts include, but are not limited to: Questioning the member to identify any other insurance so that a claim to the primary payer can be filed; Checking (GHP) Web site for insurance coverage on the member so that a claim to the primary payer can be filed; Questioning the member regarding any updates to the coverage(s) shown on Web site; Filing a claim with the known primary insurance(s) prior to filing with Medicaid. Yhe discount amount reported on the EOB from the primary payer Page 7 of 51

8 HOW ARE COB CLAIMS REIMBURSED? Rev. 04/10 DCH takes into account many factors when determining the amount of payment on a Medicaid COB claim. Factors include, but are not limited to: the payment amount from a primary payer, the Medicaid maximum allowable amount for a specific covered service. the discount amount reported on the EOB from the primary payer Medicaid Reimbursement When Another Insurer s Payment is Involved Any items or services for which another insurance carrier s reimbursement amount is equal to or greater than the Medicaid maximum allowable amount will be paid at zero by Medicaid. Claims that pay at zero are considered to be paid claims, not denied claims. When the payment from another insurance carrier is less than the Medicaid maximum allowable amount, Medicaid can pay up to the Medicaid maximum allowable amount. The sum of the Medicaid payment and the other insurance payment(s) will not exceed the Medicaid maximum allowable amount. Medicaid will consider making full payment for a covered service(s) when the primary insurance carrier denies payment for any reason or when there is no payment by the primary carrier because of the member s coinsurance and/or deductible. Full payment means an amount up to the Medicaid maximum allowable amount. The reason for the primary insurance carrier denial or non-payment is part of the consideration of payment by Medicaid. Rev. 04/10 When a Managed Care Plan is the Primary Insurer It is a member s responsibility to remain abreast of the physicians, pharmacies, hospitals and other providers who participate in his or her managed care plan. When a member s claim is denied by the managed care plan for failure to comply with the rules, policies, and procedures of the plan, the member, not DCH, is responsible for payment to the provider. Providers should inform members if they are not a network provider in the member s managed care plan. Some services denied by a primary managed care plan may be paid by Medicaid up to the Medicaid maximum allowable amount. Whether or not Medicaid will pay depends on the reason for the denial by the primary plan. Examples of services denied by the primary payer that Medicaid may pay include, but are not limited to, the following situations: o have provisions that allow Medicaid to cover the service when the primary plan will not pay. Claims denied by the primary plan because of a recommendation unique to Medicaid may be covered by Medicaid; however, the service must be a Medicaid covered service in order for Medicaid to pay. o The primary plan does not provide appropriate services. For example, a child needs pediatric therapy services, but the plan does not have a network pediatric therapist and a network adult therapist does not have the specific skills needed to provide the therapy. This forces the member to go out-of-network to receive the Page 8 of 51

9 Rev. 04/10 o appropriate care. If the primary plan will not pay the out-of-network pediatric therapist, Medicaid will consider payment. The member s annual or lifetime service limitations have been exhausted so the primary plan will not pay. Tort/Casualty (Personal Injury) Liability In certain situations, the cause of a member s medical condition may invoke a third party s legal liability. These situations might include, but is not limited to injuries resulting from an automobile accident, injuries suffered on-the-job, medical malpractice, or slip and fall injuries. In such situations and pursuant to O.C.G.A , DCH is subrogated or substituted for the member or his/her representative s right to recovery against the person or entity legally liable for the injury and subsequent treatment of the member (i.e., the Department has the right to recover any Medicaid payments from settlement awards). When a provider learns that a third party might be responsible for reimbursement associated with a Medicaid/PeachCare for Kids member s medical costs, the provider must choose between billing Medicaid and billing the third party or third party carrier. Providers are prohibited from: 1) Filing claims with Medicaid and subsequently billing the third party carrier (or the member) for the same service, even if the provider refunds Medicaid; and 2) Billing Medicaid, the third party carrier, or member for the difference between the amounts Medicaid has paid and the amount the provider charged. In the event that a provider is aware that a member s condition was the result of an accident at the time of submission of the associated claims, a Coordination of Benefits/Third Party Liability Accident Information Form (DMA-312) should be submitted with the claim. A DMA-312 must also be submitted when a request is made for a copy of the bill. See Appendix F. This form may be mailed to the address listed at the bottom of the form or may be faxed to (770) , Attention: Recovery Unit. NOTE: A copy of the letter sent by an attorney or insurance carrier to the provider requesting Information will suffice in lieu of the DMA-312, but it must clearly indicate 09-COB/Third Party Liability (TPL) Attachment. Rev. 04/10 If a provider chooses not to initially bill Medicaid, the provider may submit a DMA-312 Coordination of Benefits/Third Party Liability Accident Information Form, within six (6) months of the date of service, with a copy of the claim to request an extension to the timely filing limits, if necessary in order to pursue the liable third party. By completing and submitting the DMA-312 form, an extension of 12 months may be granted if the submitted form is approved. If a provider chooses to use the DMA-312 form, the provider must: complete the form and submit it to the Department. (On the DMA- 312 form, check the box Request Claim Filing Extension and attach a copy of claim) Submit the DMA-312 form and a copy of the claim to the address listed on the form. Page 9 of 51

10 The DMA-312 form will be reviewed and either stamped APPROVED or returned to the provider for additional information if form is incomplete. If the DMA-312 form is approved and returned to the provider, the provider must maintain this approved copy and submit it with the Medicaid claim(s) when or if the provider decides to cancel the lien and bill for Medicaid s payment. NOTE: The approved DMA-312 form is considered a 09-COB/TPL attachment. DCH will stamp 09-COB/TPL at the top of the approved DMA-312 form. If the DMA-312 form is returned to a provider for additional information, the provider must complete the unanswered questions on the form and resubmit to DCH. Approval of the DMA-312 form grants the requesting provider an additional twelve (12) months in which to file their Medicaid claim. This extension will not exceed twenty four (24) months from the month of service for tort related claims. The provider may also use the DMA-312 form to inform the Department of the potential tort related claim. (On the DMA-312 form check the box For information only ) Checking the For information only box indicates that a provider is not requesting an extension but is notifying the Department that there is a potential casualty recovery case. The provider may later submit the tort related claim to Medicaid in accordance with all billing guidelines. Once the hospital claim is billed to the Department, the provider must release their hospital lien since the Department, and not the provider, has the right to seek reimbursement from the liable third parties. If a provider elects not to bill Medicaid initially and subsequently receives a liability payment less than the Medicaid allowable amount for the claims, the provider may bill Medicaid for the balance between the liability payment amount and Medicaid allowable amount. Providers may not keep any liability payment in excess of Medicaid s payment. Should the Department discover that a provider has attempted to receive payment from both a third party, or third party carrier after having received reimbursement from Medicaid/PeachCare for Kids, the Department will recoup their reimbursement, regardless of whether the provider ultimately received any payment from that liable third party. For additional requirements, see Part II, Policies and Procedures for Hospital Services, Part II, Policies and Procedures for Nursing Facility Services and/or O.C.GA PLEASE SEE PART 1 POLICIES AND PROCEDURES TO OBTAIN A COPY OF THE DMA 312. Page 10 of 51

11 MEDICARE What is Medicare? Medicare is a federal health insurance program for: People age 65 or older. People under age 65 with certain disabilities, and People of all ages with End-Stage Renal Disease (ESRD). Original Medicare has two parts: Part A and Part B Part A (Hospital Insurance) Included services are Hospital Inpatient care, Hospice, Skilled Nursing Facility and blood pints. Part B (Medical Insurance) - Included services are Outpatient Services provided in a doctors office, outpatient facility or inpatient facility. Medicare Advantage plans / Medicare Part C: This combines parts Part A and Part B and sometimes the Medicare prescription program (Medicare Part D). These plans cover the same benefit as the Original Medicare plans; however, they are administered by private health insurance payers. Some of these plans offer additional services beyond what the Original Medicare plans offer. These claims do not automatically cross-over to Medicaid; the provider must submit the claim to Medicaid along with the EOMB from the Medicare Advantage Plan. WHAT IS A CROSSOVER? A crossover (x-over) claim is any claim that is approved by Medicare and then forwarded or sent to Medicaid for consideration of payment not to exceed the sum of the Medicare deductible, copayment and/or coinsurance. There are three very important implications made by this definition. 1. The claim must be approved by Medicare in order to be considered a crossover claim. Approved means that the charges are covered by the Medicare program, are provided by an appropriately enrolled Medicare provider, and are provided to a Medicare entitled beneficiary. Approved does not necessarily mean paid; sometimes all of the charges approved by Medicare are applied to the deductible. In these situations, the claim is approved, but no payment is made by Medicare. It is important to remember that claims that are not approved by Medicare, in other words, denied claims, are not crossover claims. If a member is Qualified Medicare Beneficiary (QMB) (aid categories 460 or 660) and Medicare denies the claim, do not bill Medicaid. QMB members are only eligible for crossover claims. 2. The claim must be sent to Medicaid. There are two ways this can occur: Medicare s Coordination of Benefits Contractor (COBC) can automatically send the claim to Medicaid (called an auto-crossover claim) or the provider can file a paper, Web portal or PES (Provider Electronic Solution) 2003 claim that includes the Medicare payment information. Page 11 of 51

12 3. The receipt of a crossover claim by Medicaid does not mean that Medicaid will make a payment on the claim. If Medicaid approves the claim, a payment of the sum of the coinsurance and deductible may be made up to the Medicaid maximum allowable amount for the provider type and/or procedure code. If the Medicare payment on a claim is equal to or greater than the Medicaid maximum allowable amount, Medicaid will not pay anything on the claim, but the claim will still be a paid Medicaid claim. NOTE: For QMB eligible members Medicaid will be reimbursed payments for the Medicare coinsurance, deductible, and HMO Sub Copay amounts, less applicable third party liabilities and patient Medicaid co-payments. Medicare Crossover Claims - Helpful Information Providers should bill Medicaid in the same manner in which they bill Medicare. Do not change any codes to match the Medicaid requirements. The system has been adapted to Medicare s coding for crossover claims. Exceptions: Medicaid does require National Drug Codes (NDC s) for outpatient injectable drugs. Medicare does not require NDC codes for outpatient services Medicaid does not require a National Provider Identifier ( NPI) number with CMS-1500 professional paper submissions; therefore, when you send your claim to Medicare include your NPI number along with your Medicaid rendering provider number. Medicare Part D Plan Georgia Medicaid members are automatically enrolled in a Medicare Part D plan for prescription drug coverage. Medicaid does not pay any cost share amounts for Part D plans so Part D claims do not crossover to Medicaid. Medicare Part A, B and C Plans Medicaid pays the Medicare medical cost share portion for members enrolled in a Part A, B and C plan up to the Medicaid maximum allowable amount for that service or procedure. The member is still responsible for the Georgia Medicaid co-payment amount, where applicable. Exceptions: Members who live in a long-term care nursing facility and are enrolled in Medicare Part D and Medicaid, but do not have a Medicaid co-payments. MEDICARE COVERED SERVICES Part A Medicare covered services that Medicaid also covers: semiprivate room meals Page 12 of 51

13 regular nursing services rehabilitation services drugs medical supplies lab tests x-rays operating room recovery room intensive care coronary care blood pints medically necessary services and supplies Part A Medicare covered services that Medicaid does not cover: telephone television private duty nurses amount between a semiprivate and private room rate unless it is medically necessary Part B Medicare covered services: doctor services (including surgery) provided at a hospital, a doctor's office, or home mammograms, pelvic exams, bone density tests, and PAP smears for women an annual flu shot a one-time physical exam (called a "wellness exam") done within six months of the patient s enrollment date for Medicare Part B medical services provided by nurses, surgical assistants, or laboratory or X-ray technicians outpatient hospital treatment, such as emergency room or clinic charges, X-rays, injections, and lab work an ambulance, if required for a trip to or from a hospital or skilled nursing facility drugs or other medicine administered at a hospital or doctor's office medical equipment and supplies, such as splints, casts, prosthetic devices, body braces, heart pacemakers, corrective lenses after a cataract operation, glucose monitoring equipment, therapeutic shoes for diabetics, and equipment (such as ventilators, wheelchairs and hospital beds) some types of oral surgery some costs for outpatient physical and speech therapy a limited number of services by podiatrists and optometrists some care and counseling by psychologists, social workers, and daycare personnel some preventative screening exams if the doctor says the patient is at risk manipulation of out-of-place vertebrae by a chiropractor Page 13 of 51

14 Alzheimer's-related treatments scientifically proven obesity therapies and treatments, and Part-time skilled nursing care, physical therapy, and speech therapy provided in your home. Ancillary services for inpatient hospital care Medicare Payment Guidelines The original Fee-for-Service Medicare Part A: For Skilled Nursing Care, Medicare pays for the first 20 days if the patient goes directly from the hospital to the skilled nursing care facility. Medicare will pay a portion of the care for the 21st through the 100th day. Medicare will not pay any benefit after the 100th day. For Inpatient Hospital Care during the first 60 days, Medicare will pay all covered costs except the deductible. For days , Medicare pays a set dollar amount. After the 150 th day, Medicare will not pay any of the costs. Bill Medicaid for any costs that Medicare does not pay. For Dually eligible members utilizing their Medicare benefits in a nursing home, Medicare should be the primary payer until the Member no longer meets the requirements of skilled services under the Medicare guideline. The original Medicare Part B: Pays only 80% of approved charges; Medicaid will pay the remaining 20% (coinsurance) up to Medicaid s maximum allowable amount for the service. Medicare pays 50% of outpatient psychiatric care. Medicare Advantage Plans (MAP), Part C: Previously known as Part C or Medicare Health Maintenance Organizations (HMO s), these Medicare replacement plans now include several different types of plans including HMO s, Preferred Provider Organizations (PPO s) or private fee-for-service (FFS) plans with a variety of co-payments and benefit packages. Plans vary so the allowed services and payments for each plan will not always be the same. Medicaid will pay eligible cost share amounts up to the Medicaid maximum allowable amount for the service. CROSSOVER BILLING CONSIDERATIONS: Crossover claims must be received by the Department within 24 months of the month of service. Medicaid providers must accept Medicare assignment in order to submit claims to Medicaid for consideration of payment. If Medicare denies the claim, providers have 90 days from the Medicare denial date to Page 14 of 51

15 submit the Medicaid primary claim. NOTE: Medicare denied claims are straight Medicaid claims, not crossovers. All Medicaid billing requirements must be followed. Claims submitted to Medicare Carriers or Fiscal Intermediaries will be forwarded to the Department s third party administrator by automatic transfer via the COBC. When claims automatically crossover to Medicaid, providers do not have to submit a Medicaid secondary claim to the Department. Medicare identifies claims selected for automatic crossover from eligibility files that Medicaid forwards to the COBC monthly. The provider s Medicare number must be on file with the Department and associated with only one Medicaid location in order for the automatic crossover of claims to occur. If the Remittance Advice (RA) indicates Remark Code MA07, the claim has been forwarded to (crossover) Medicaid for adjudication. If the forwarded claim is not processed by the Department within forty-five (45) days from the receipt of Medicare payment, a claim may be submitted directly to the Department s third party administrator (paper or electronic). If providers do not wait the allotted 45 days, the claims will be returned without further processing. NOTE: There is no 45 day waiting period if the RA does not show the MA07. Claims will not crossover automatically if any of the following situations exist: The Medicare rendering provider number is not on file with the Department or is not associated with an active Medicaid provider number; The Medicare provider number is associated with more than one Medicaid location - it can only be associated with one. If you use your Medicare ID# when billing for multiple locations, you must choose one Medicaid location for all your crossover claims; The member was not listed on the eligibility file sent to Medicare for the month the claims were processed; The provider did not include the beneficiary s Medicaid ID number when billing Medicare; The provider did not correctly show Medicaid as the secondary payer; Medicare denied the claim; The member is enrolled in a MAP these claims must be billed on paper directly to Medicaid write 06 in the top right corner of the EOMB. The DMA-460 is also an acceptable attachment for these claims, but do not use both on the same claim; When Medicare adjusts a Medicare claim, the adjusted claim does not automatically crossover. Thus, when Medicare adjusts a claim and Medicaid has not yet paid on it, submit a claim to Medicaid using the adjusted EOMB information. If Medicaid has already paid on the claim that Medicare adjusted, submit an Adjustment Request Form, DMA-501, to Medicaid using the new Medicare payment information. See Part I of the Policies and Procedures Manual, Appendix J, Billing Manual, for additional information on adjustments; and Medicaid is the tertiary payer: Another insurer/third party made a payment on the claim. Medicare is primary, the other insurer/payer is secondary, and Medicaid is tertiary. Page 15 of 51

16 Medicare Eligibility Discrepancies Occasionally a member will be shown as eligible for Medicare benefits in Medicaid s system when they are not eligible or the member may be shown as not eligible when they are eligible. The DMA-460 can be used by providers to notify Medicaid of these discrepancies. The notice only begins the validation process. Medicaid cannot update the Medicare eligibility files in the MMIS. Medicare eligibility data can only be updated in the MMIS by the monthly interface with the Centers for Medicare & Medicaid Services (CMS). Information from the Common Working File (CWF) cannot be used to update the MMIS. Claims may remain suspended until Medicare eligibility issues are resolved. ADDITIONAL INDUSTRY STANDARDS AFFECTING COB AND CROSSOVER CLAIMS National Provider Identifier In accordance with federal regulations Georgia Medicaid is accepting the National Provider Identifier NPI as the provider identifier on all standard HIPAA electronic transactions. The NPI is a 10 digit national identifying number assigned to health care providers that is required to be used in all electronic claims submission in Georgia using PES (Provider Electronic Solution). Providers must ensure that their NPI number is on file with Georgia Medicaid. NOTE: Providers who do not offer medical services are excluded from having a NPI. Contact Provider Enrollment at the DCH if you are not sure if you need a NPI number for Georgia Medicaid. Other provider-based activities will continue to be managed with the Provider Medicaid ID. These activities include: Paper claim submissions for the CMS-1500 and UB-04 Web Portal submissions Resubmission of electronic claims on paper IVR system inquiries Telephone inquiries Prior authorization requests National Drug Code and Injectable Drug for Outpatient Services In order to comply with the Deficit Reduction Act (DRA) of 2005, section 6002, Georgia Medicaid requires providers to bill an accompanying NDC code with a HCPCS code for outpatient claims with service dates on or after January 1, PLEASE DO NOT PLACE A NDC ON THE CLAIM FOR NON- OUTPATIENT INJECTABLE HCPCS CODES. Georgia Medicaid providers must submit claims with the 11 digit NDC code that corresponds with the HCPCS code for the injectable drugs that are administered in an outpatient setting. Page 16 of 51

17 Rev. 04/10 Provide the NDC number with claims for the below medias: 837 P- Electronic Professional Claims Submission 837 I Electronic Institutional Claims Submission GAMMIS Web Portal PES (Provider Electronic Solution) Paper claims using the DMA 501 claim form, the UB-04, and the American Dental Association (ADA) Page 17 of 51

18 Chapter 2. Submitting a Paper Claim The following information details the requirements for paper claim submissions. To ensure proper payment, providers must complete and submit the appropriate claim forms. Claims must be submitted timely for reimbursement. Timely for COB means submitted within 12 months from the month of service. Medicare crossovers must be submitted within 24 months from the month of service. Paper claims are billed by completing the appropriate claim form (CMS-1500, UB-04 or ADA) and attaching the required documentation. COB and Medicare paper claims are submitted to: CMS 1500 Claims HPES PO BOX Tucker, Georgia Crossover Claims HPES PO BOX Tucker, Georgia UB04 Claims HPES PO BOX Tucker, Georgia ADA 2006 Dental Claims HPES PO BOX Tucker, Georgia NOTE: Although paper claims are accepted, providers are encouraged to submit claims electronically through the Web or through PES (Provider Electronic Solution). CMS Health Insurance Claim Form - Field Descriptions A brief description of each field on the CMS Health Insurance Claim Form is shown below. Keep in mind that these descriptions may be specific to claims billed to Medicaid. The columns are: Form Locator - numbers each field on the CMS Form Field Name - specifies the information to be entered in that field Required Field - indicates, by alpha character, whether the information is required for Medicaid secondary billings. The alpha characters denote R - Required or C - Conditionally required/if applicable. Comments - provides more details regarding what information should be entered in each field Page 18 of 51

19 CMS-1500 Form Field Descriptions Form Field Name Required Guidelines Locator Fields 1 Health insurance coverage R Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicaid claim is being filed, enter an X in the Medicaid box. 1a Insured s ID number R Enter the member s number from the Medicaid identification card and/or eligibility verification response exactly as it appears. For instructions on performing an eligibility verification transaction, please refer to Chapter 3, Verifying Member Eligibility. Page 19 of 51

20 Form Field Name Required Guidelines Locator Fields 2 Patient s name R Enter the member name exactly as it is given to you as a result of the eligibility verification transaction. Please note that the member name on the claim form must match the name on file for the member number you entered in field 1. If a member has two initials instead of a first name, enter the first initial along with a long space, then the second initial and no periods. If a member first name contains an apostrophe, enter the first name including the apostrophe. Examples: For member A. B. Doe, enter Doe A B with no punctuation. For member D Andre Doe, enter Doe D Andre with an apostrophe and no spaces. 3 Patient s date of birth C Enter the month, day, and year (MM/DD/CCYY) the member was born. Indicate the member s sex by Patient s sex checking the appropriate box. 4 Insured s Name C If Medicaid is primary, leave blank. No entry required unless the member is covered by other insurance. If there is insurance primary to Medicaid, either through the patient s or spouse s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. 5 Patient s Address C Enter the patient s complete address as described (city, state, 6 Patient s Relationship to Insured C and ZIP code). Check the appropriate box for patient s relationship to insured when item 4 is completed. 7 Insured s Address C Enter the insured s address and telephone number. When the address is the same as the patient s, enter the word SAME. Complete this item only when form location items 4, 6, and 11 are completed. Page 20 of 51

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22 Form Field Name Required Guidelines Locator Fields 8 Patient Status R Check the appropriate box for the patient s marital status and whether employed or a student, if applicable. 9 Other insured s name C If the member has other health insurance coverage, enter all pertinent information. Providers must submit the claim to other insurers prior to submitting the claim to Medicaid. Note: Form locator items 9 9d should be completed for any coverage other than Medicare. 9a Other insured s policy or group number C Enter the primary insurance policy or group number. 9b Other insured s date of birth and sex C Enter the primary insurance subscriber/policyholder date of birth. 9c Employer s name/school name C Enter the primary insurance subscriber/policyholder s employer s name. 9d Insurance plan name or program name C Enter the primary insurance plan name. 10a Is patient s condition related to employment? (Current or previous) R Indicate by checking the appropriate box. If applicable, enter all available information in field 11, Other Health Insurance Coverage. Enter X if treatment related to employment. 10b Is patient s condition related to auto accident? R Enter X if treatment is related to auto accident. 10c Is patient s condition related to other accident? R Enter X if treatment is related to other accident. 10d Reserved for Local Use C Enter the Provider Medicare ID number when billing for Medicare/Medicaid Crossover services. A copy of the Medicare EOMB is required with your claim. 11 Insured s policy group or FECA number C Enter insured s policy and/or group number. When billing Medicaid/PeachCare for Kids, data is not required in this field. 11a Insured s date of birth and sex C Enter date of birth and gender, if applicable. Enter date using MM/DD/CCYY format. When billing Medicaid/PeachCare for Kids, data is not required in this field. 11b Employer s name/school name C Enter employer s name or school name, if applicable. Page 22 of 51

23 Form Locator 11c Field Name Insurance plan or benefit plan being billed Required Fields C Guidelines When billing Medicaid/PeachCare for Kids, data is not required in this field. Enter insurance plan or program name, if applicable. When billing Medicaid/PeachCare for Kids, data is not required in this field. 11d Other health benefit plan C Indicate whether another coverage or insurance plan exists. Do not mark yes when the other coverage is Medicare. If YES, the provider should complete form locator items 9 9d on the CMS-1500 form for the non-medicare coverage. 12 Patient s or Authorized Person s Signature R Enter the signature and date using the MM/DD/YY format. 13 Insured s or Authorized Person s Signature 14 Date of current illness, injury and/or pregnancy C R Enter signature, only if third party payer. Enter date in MM/DD/YY format. And, if for pregnancy, provide the date of last menstrual period (LMP). Note: If YES is indicated in form locator items 10a 10c, enter an accident date using this field. Page 23 of 51

24 Form Field Name Required Guidelines Locator Fields 15 Dates of Same or Similar Illness C Enter date in MM/DD/YY format, if applicable. 16 Dates Patient Unable to Work C Enter date in MM/DD/YY format, if applicable. 17 Name of referring physician or other source C Enter the name (first, middle initial and last) and credentials of the professional who referred or ordered the service(s) or supply(s) being billed on the claim. Do not use periods or commas within the name. A hyphen can be used for hyphenated names. For example: Jane A Smith MD or Jane Anthony-Smith Leave blank if the procedure for which you are billing was not referred. 17a Referring Physician s ID number C Enter the referring physician s Medicaid provider number, or Universal Provider Identification Number (UPIN) or state license number and if GBHC member, enter the qualifier 9F and the 12 digit GBHC referral number, if applicable. 17b Referring NPI number C Enter either qualifier ID and the Medicaid provider number form locator item 17a or enter the NPI in 17b. If you enter the NPI in 17b, leave 17a blank unless the taxonomy is needed to identify the referring physician in the Georgia Medicaid claims processing system. If yes, enter qualifier ZZ and the taxonomy in 17a. Georgia Medicaid recommends that you enter the Medicaid provider number on paper claims, if applicable. 18 Hospitalization Dates Related to Current Services R Enter hospitalization dates related to current services, using the from-through format, if applicable. 19 Reserved for Local use C Enter the Health Check referral codes. Valid Health Check Referral codes: N, NU Y, AV Y, ST Y, S2 20 Outside Lab C Check YES or NO. The charges are not necessary. 21 Diagnosis or nature of illness or injury C Enter International Classification of Disease, 9th Revision, Clinical Modification (ICD-9 CM) code(s) related to service billed. List code(s) priority order (primary, Page 24 of 51

25 Form Locator Field Name Required Fields Guidelines secondary, and so forth). Page 25 of 51

26 Form Field Name Locator 22 Medicaid resubmission code/original reference number Required Fields C Enter the ICN/TCN of the previous/original claim, if this is for an adjustment. 23 Prior Authorization Number C Enter the prior authorization number or precertification number (PA/PC) issued by Georgia Medical Care Foundation (GMCF), if applicable. Do not use for any other number. Leave blank if this does not apply. 24a Shaded Area only: enter the VP qualifier followed by the Serial number for specified DME equipment (see DME Part II Policy and Procedures Manual for list). R Guidelines In the shaded area only enter the qualifier VP followed by the complete serial number. There is no space between the qualifier and the serial number, example: VPXXXXXXXXXXXX Procedure/services/supplies (in the shaded area ONLY) Enter in the shaded area only, the 11-digit NDC number, preceded by the two-digit qualifier N4 (the unique two-digit qualifier used to bill injectable drugs), example N4XXXXXXXXXXX. The NDC number should correspond with the HCPCS/CPT code(s) entered in form locator 24d. Page 26 of 51

27 Form Field Name Locator Procedure/services/supplies (in the shaded area ONLY) Required Guidelines Fields Enter in the shaded area only, the 11-digit NDC number, preceded by the two-digit qualifier N4 (the unique two-digit qualifier used to bill injectable drugs), example N4XXXXXXXXXXX. The NDC number should correspond with the HCPCS/CPT code(s) entered in form locator 24d. 24a Date of service (DOS) R Enter the date of service for each procedure provided in a MM/DD/YY format in the unshaded area. If identical services (and charges) are performed on the same day, enter the same date of service in both from and to spaces, and enter the units performed in form locator 24g. Note: See exception DOS requirements in section b Place of service (POS) R Enter a valid POS code for each procedure in the unshaded area. Note: See Place of Service Codes in section c EMG C If the procedure code billed was the result of an emergency, enter Y for Yes. Otherwise, enter N for No or leave blank. 24d Procedures, Services, or Supplies CPT/HCPCS and MODIFIER R Enter in the unshaded area, the appropriate five-digit Health Care Financing Administration Common Procedural Coding System (HCPCS) or Current Procedural Terminology (CPT) code(s) that describe procedure/services/supplies. If billing an injectable drug, the HCPCS/CPT code should correspond with the NDC number in form locator 24a. Use modifiers, if appropriate. 24e Diagnosis code R Enter in the unshaded area, the line item reference (1, 2, 3, or 4) for each service or procedure as it relates to the primary ICD-9 code identified in field 21. If a procedure is related to more than one diagnosis, the primary diagnosis to which the procedure is related must be the one identified. Enter only one digit in this field. Page 27 of 51

28 Form Field Name Required Fields Guidelines Locator 24f Charges R Indicate your usual and customary charges, in the unshaded area, for each service listed. Charges must not be higher than fees charged to private pay patients. In the shaded area, enter the third party liability payment. 24g Units R Enter in the unshaded area, the appropriate number of units. Be sure that span-billed daily hospital visits equal the units in this field. Use whole numbers only. 24h EPSDT Family Planning C If services were provided as a result of a referral from Health Check [also known as Early Periodic Screening, Diagnostic and Treatment (EPSDT)] enter ET. If services were for Family Planning purposes, enter FP. Note: This is not a required field. The Health Check program is only for those under 21 years of age. 24i ID Qual C Enter the individual rendering (treating) provider s qualifier code in the shaded area of form locator 24i. The rendering provider s other ID number is reported in form locator 24j in the shaded area. Enter the rendering provider s ID number only when it is different from the pay-to provider number that is entered in form locator 33a or 33b. If entering the rendering provider s Medicaid provider number, enter qualifier code 1D. If entering the rendering provider s NPI and the NPI is mapped to a taxonomy code that is needed to identify the provider in the Georgia Medicaid claims processing system, enter qualifier code ZZ and the taxonomy code in the shaded area of form locator 24j. Valid Qualifier Codes: 1D = Medicaid provider number ZZ = provider taxonomy number 1G = UPIN 0B = physician license number Page 28 of 51

29 Form Field Name Required Guidelines Locator Fields 24j Rendering provider ID R Enter Medicaid provider number in the non-shaded area. 24k Reserved for local use Leave blank. 25 Federal Tax I.D. Number R Enter Social Security Number (SSN) or Employee Identification Number (EIN). Enter the patient s record number used internally by your office. 26 Patient account number C 27 Accept Assignment R Billing Medicaid indicates acceptance of assignment. 28 Total charge R Enter the sum of all charges entered in form locator 24f, lines Amount paid C Enter any amount paid by an insurance company or other sources known at the time of submission. Do not enter Medicaid co-payment amount. Do not enter Medicare payments. 30 Balance due R Subtract field 29 from field 28 and enter the balance. 31 Signature of physician or supplier 32 Name and address of facility 32a Service Facility Mammogram Certification # 33 Billing Provider Info and Phone Number R R C R Provider must sign (or signature stamp) and provide degrees or credentials. Enter the current date. Note: Unsigned invoice/claims forms cannot be accepted for processing. Enter name and address where services were rendered (e.g., hospital, home, etc.). Enter service facility mammogram certification #, if applicable. 1st Line: Name of the Payee provider as it appears in the HP Enterprise Services system 2nd Line: Address 3rd Line: City, State, and ZIP Code (include ZIP+4) and phone number Page 29 of 51

30 The following is an example of the CMS-1500 Health Insurance Claim Form Page 30 of 51

31 TIPS FOR SUBMITTING PAPER CMS-1500 COB AND CROSSOVER CLAIMS 1. Do not highlight any information on the claim form or attachments. 2. Do not use liquid correction fluid on the form or attachments as it tends to flake off and may damage the imaging equipment. Use a dry correction tape instead. 3. Do not enter Medicare information in fields 9 to 9D.These fields are reserved for third party coverage other than Medicare. Data entered should reflect the policyholder s information. 4. Mark yes in field 11D to indicate that there is COB coverage other than Medicare. 5. In fields 24A to 24 G, enter actual claim data and charges. When billing a managed care co-payment, enter the co-payment amount in 24F. NOTE: Bill for the copayment only if you are an in-network provider for the member s managed care plan. 6. In field 28, enter the actual total charges. When billing for the managed care copayment, the amount in field 28 should equal the amount in 24F. 7. In field 29, enter the total payments from all third parties other than Medicare. The gross amount of the COB payments will be prorated across all lines of the claim. If you want the COB payment amounts to be applied to each line of the claim based on the EOB payments for each procedure, leave field 29 blank. The exact amount paid for each procedure will be entered manually when the claim is received. For crossovers, field 29 should be blank unless the provider is entering a payment from a secondary insurance. Do not enter Medicaid co-payments in field 29. Do not enter managed care co-payments in field Medicare denied claims: File a denied Medicare claim on paper as a straight Medicaid claim and attach the Medicare denial behind the claim form. The claim is not a crossover since Medicare denied the charges, which changes the timely filing limitation from 24 months to 12 months from the month f service. 9. The Medicare RA/EOMB is a required attachment for a paper crossover claim because the Medicare payment information on the form must be entered into the claims system. Write EB or EOMB or Crossover in bold print in the upper right hand corner of the attachment. 10. HIPAA privacy rules require that the names and identifying ID numbers of other patients listed on the EOB and the RA/EOMB be blacked out (redacted) prior to submission of a claim. The EOB and the Medicare RA/EOMB header information must not be redacted. 11. If the claim is COB it would be helpful if you write 09 or COB in the upper right hand corner of the CMS If the claim is a crossover, it would be helpful if you write EB or Crossover in the upper right hand corner of the CMS Use bold black print to ensure that the identification information shows up clearly. 12. In the upper right corner of attachments, write EOB or 09 or COB for COB attachments and EOMB or EB or Crossover for Medicare attachments. 13. If the primary plan denied the claim, submit the EOB to show the denial reason. If a nonstandard code is shown on the EOB, the explanation of the code must be clearly Page 31 of 51

32 shown on the EOB. Failure to provide an explanation of a non-standard code will result in the denial of the claim. 14. When submitting a claim with attachments the claim form must be on top with all attachments behind it. Otherwise, attachments for one claim will be linked to another claim which could result in the denial of one or both claims. UB-04 Form - Field Descriptions The following table provides a brief description of the fields located on the UB-04 Form. Keep in mind that some of these descriptions may be specific to claims billed to Medicaid. The columns are: Form Locator - numbers each field on the UB-04 Form. Field Name - specifies the information to be entered in that field. Required Field indicates, by alpha character, whether the information is required for Medicaid secondary billings. The alpha characters and meanings are: R Required C - Conditionally required/if applicable RI - Required inpatient RO - Required outpatient Blank - Not required Comments - provides more details regarding what information should be entered in each field. UB-04 Form Field Descriptions Form Field Name Locator 1. Provider Name, Address, Phone number and Fax number 2. Pay-to Name, Pay-to Address, Pay-to city, State 3a. 3b. Patient Control Number Medical Record Number Required Field R R C UB-04 Comments Enter the provider name, address, phone number, and fax number. Enter the member s unique alpha-numeric number assigned by the provider. Use the patient s medical record number printed on the remittance voucher. 4. R Enter the appropriate digit code and frequency for bill type. Type of Bill 5. Federal Tax Number R Enter the provider s federal identification number. 6. Statement Covers Period R Enter the dates of service covered by claim (from-through date). From/Through 7. Unlabeled 8. Patient Name R Enter the patient s name, first name and if any, middle initial 9. Patient Address R Enter the patient s full mailing address, including street number and name, post office box number or RFD, city, State and Zip Code 10. Patient Birth Date R Enter the member s date of birth (use MM/DD/YY format). 11. Patient Sex R Enter the sex of the patient as M for males or F for female. 12. Admission/Start of Care Date RI Enter the member s date of admission. 13. Admission Hour R Enter the member s time of admission. 14. Type of Admission/Visit RI Page 32 of 51

33 Form Required Field Name Locator Field UB-04 Comments 15 Source of Admission RI Enter the member s source of admission. 16. Discharge Hour RI Enter the hour (00-23) that the patient was discharged from inpatient care if there is a discharge code in field Patient Discharge Status RI Enter the member s status at discharge Condition Codes RI Enter the condition code(s), if applicable. 29. Accident State 30. Unlabeled Occurrence Code/Date RI Enter occurrence code(s) and dates, if applicable Occurrence Span RI Enter occurrence code(s) and associated beginning and end dates. 37. Unlabeled 38. Responsible Party Name/Address C Enter name and address of responsible party, if applicable Value Code Code/Value Code Amount C Enter valid value code(s) and units related to the occurrence codes in FL 32 through Revenue Code R Enter appropriate revenue code Revenue Code Description Page _ of C R on all Using one line for each, enter description of service(s) / procedure(s) _ (Line 23) pages provided. 44. CTP/HCPCS/Rates/HIPP S Rate Codes R -on all pages 45. Creation Date (Line 23) Enter appropriate Current Procedural Terminology (CPT-4) or 11 digit National Drug Code (NDC) number. Effective for dates of service on and after January 1, 2007, use NDC numbers rather than HCPCS codes to bill/report Injectable drugs. 45. Service Date R Enter the line item service date. 46. Service Units R Enter the number of times the procedure for which you are billing was performed. 47. Total Charges R Enter the total amount of charges for service(s) / procedure(s) performed. 48. Non-Covered Charges C Enter charge, if applicable. 49. Unlabeled RO 50. A, B, C Payer Name: Primary R C Enter payers in order of benefit determination (A=Primary, B=Secondary, C=Tertiary). 51. A, B, C 52. A, B, C 53. A, B, C 54. A, B, C 55. A, B, C Health Plan ID C Enter provider number for each payer listed in 50. Release of Information Assignment of Benefits Prior Benefits C Other insurance and/or Medicare payments associated with payers in form locator 50 Estimate Amount Due C Enter the estimated amount due from Medicaid, generally equals the patient liability. 56. National Provider ID 57. A, B, C 58. A, B, C 59. A, B, C Other Provider ID C Enter other provider identifiers as assigned by the health plan as indicated in FL 50 A, B, C Insured s Name C Enter the last name, first name, and middle initial of the insured, if applicable, for each payer listed in Field Locator 50. Patient s Relationship to Insured C Enter relationship of the patient to the identified insurer, if applicable, for each payer listed in Field Locator 50. Page 33 of 51

34 Form Required Field Name Locator Field UB-04 Comments 60. A, B, C Insured s Unique ID R Enter Medicaid member s identification number on the Medicaid card or the approval letter (for the member being treated) to the line associated with Medicaid in field locator box 50. Enter appropriate ID numbers for any other payers identified in field locator box Insurance Group Name C Enter other payer s group/employer name. 62. Insurance Group Number C Enter group number, if applicable, for each coverage listed in Field Locator Treatment Authorization Code(s) C Enter prior authorization number, if applicable. The claim must be split if more than one prior authorization applies. 64. Document Control Number Enter the control number assigned to the original bill by the health plan or the health plan fiscal agent. 65. Employer Name Enter name, if applicable, for each payer listed in Field Locator Diagnosis and Procedure Code Qualifier (ICD Version Indicator) Enter the version of International Classification of Diseases (ICD) reported. GA Medicaid does not except ICD-10 codes; only ICD-9 codes. 67. Principle Diagnosis Code R Enter appropriate ICD-9 diagnosis code. 67. A Q Other Diagnosis Codes C Enter appropriate ICD-9 diagnosis codes, if applicable. 68. Unlabeled 69. Admitting Diagnosis Code C Enter appropriate ICD-9 diagnosis code describing the member s diagnosis at the time of, if applicable. 70. A-C Patient Reason for Visit Code RO Enter appropriate ICD-9 code for all unscheduled out patient visits. 71. Prospective Payment System Code 72. External Cause of Injury Code 73. Not Used 74. Principal Procedure Code/Date RI Enter appropriate CPT-4 procedure code, if applicable. 75. Not Used 76. Attending Provider Name and Identifiers (including NPI) 77. Operating Provider Name and Identifier (including NPI) 78 & 79. Other Provider Name and Identifiers (including NPI) 80.. Remarks R C C Enter attending physician Universal Provider Identification Number (UPIN), National Provider Identification (NPI), or Medicaid provider number, if applicable. Enter the name and identification number of the individual with the primary responsibility for performing a surgical procedure. Enter the name and ID number of the individual corresponding to the provider type qualifiers: DN: Referring Provider; ZZ: Other Operating MD; and 82: Rendering Provider. Secondary ID qualifiers: OB: State License number; 1G: Provider UPIN; and G2: Provider Commercial number, if applicable. Page 34 of 51

35 Form Locator Field Name 81. Code-Code Required Field UB-04 Comments Qual/Code Value Page 35 of 51

36 UB-04 Form Field Descriptions This is an example of the Centers for Medicare and Medicaid Services UB-04 form Page 36 of 51

37 TIPS for SUBMITTING PAPER UB-04 COB and CROSSOVER CLAIMS 1. Do not highlight any information on the claim form or attachments. 2. Do not use liquid correction fluid on the form or attachments as it tends to flake off and may damage the imaging equipment. Use a dry correction tape instead. 3. In field 50, enter the name of all payers in the following order: A) Primary Payer B) Secondary Payer C) Tertiary Payer 4. In field 51, enter the provider number used to bill each payer (see #3 above for order) 5. In field 54, enter the amounts actually paid by each payer. 6. In field 55, enter the amount you estimate is actually due from Medicaid. The amount is normally the patient liability. 7. In fields 58-66, enter valid data as it relates to each payer listed in field HIPAA privacy rules require that the name and identifying ID numbers of other patients listed on an EOB or an RA/EOMB be blacked out (redacted) prior to submission of the claim. The EOB and the Medicare RA/EOMB header information must not be redacted. 9. If the claim is a crossover, it would be helpful if EB or Crossover is written in the upper right hand corner of the UB-04. If the claim is COB, it would be helpful if 09 or COB is written in the upper right hand corner of the UB-04. Use bold black print to ensure that the identification information shows up clearly. 10. In the upper right corner of attachments, write EOB or EB or COB for COB attachments and EOMB or EB or Crossover for Medicare attachments. 11. When submitting a claim with attachments, the claim form must be on top with all attachments behind it. Otherwise, attachments for one claim will be linked to another claim which could result in the denial of one or both claims. 12. If the primary plan denied the claim, submit the EOB showing the reason for denial. If a non-standard code is shown on the EOB, the explanation of the code must be clearly shown on the EOB. Failure to provide explanations of non-standard codes will result in the claim being denied. A handwritten explanation of a code on the EOB is not acceptable the explanation must be printed on the EOB by the carrier. Page 37 of 51

38 Chapter 3. Adjustments Involving COB and Crossover Claims WHEN SHOULD I FILE AN ADJUSTMENT ON A CLAIM? When a primary payer such as a commercial plan or Medicare adjusts a claim and a new EOB or EOMB is received, determine if that adjusted claim has been filed with Medicaid and paid. If yes, review the paid claim for a possible adjustment. To adjust a Medicaid claim, complete an Adjustment Request Form (DMA-501). Remember, only Medicaid paid claims can be adjusted. Medicaid processes these adjustments manually. Send the paper adjustment to Medicaid at the address shown on the DMA-501. Include a copy of the EOB or RA/EOMB showing the primary payer s adjustment. See below for information on the DMA-501. If the primary payer adjusts a claim that Medicaid denied, no adjustment is needed. If the primary payer s adjustment results in a claim that Medicaid will possibly pay, file a new claim to Medicaid and include the corrected EOB or RA/EOMB as an attachment. HOW TO COMPLETE AN ADJUSTMENT? Adjustment Request Form (DMA-501) The Adjustment Request Form is on the following page. Specific instructions are included following the form. Page 38 of 51

39 Page 39 of 51

40 COB or Crossover claim adjustments specific instructions using the Adjustment Request Form (DMA-501): 1. Blocks 1-3 must be completed for each claim adjusted. 2. In Block 4, check Box B for a COB adjustment or check Box D for a Medicare adjustment. 3. In Block 5A (Line to be Corrected), enter zero (0) if you are adjusting the total paid or the total patient liability for the claim. If you are only adjusting a line number, enter the line number corresponding to the claim that Medicaid has processed. 4. In Block 5B (Information to be Changed), show what data field of the paid claim is changing. For example, on a facility claim, if the prior payment is changing, enter Box 54 A - prior Payments. 5. In Block 5C (From (Current) Information), enter the incorrect information that was submitted on the original claim processed by Medicaid. This will be the same information that appears on the RA from Medicaid or Medicare. 6. In Block 5D (To (Corrected) Information), enter the corrected amount from the adjusted EOB or RA/EOMB. NOTE: See Part I of the Policies and Procedures Manual, Appendix J (Billing Manual), Section 11, for additional information on the completion of the form. Page 40 of 51

41 Chapter 4. COB and Medicare Notification Forms TIPS FOR SUBMITTING THE DMA-410 AND THE DMA460 FORMS NOTE: The DMA- 410 form is used only for COB claims; the DMA- 460 is used only for Medicare claims. When completing the COB Notification Form (DMA-410) and the Medicare Notification Form (DMA-460), follow these instructions: 1. The form must be signed and dated. The signature date must be within 12 months of the date of service. Forms with older dates will not be valid attachments for COB or crossover claims. The date must be the month, day and year. 2. The member name and Medicaid ID number must be on the form. If either is missing, the form is an invalid attachment to the claim and the information submitted will not be used in processing the claim. This could result in the claim denying. 3. Enter the Medicaid provider ID number in the space provided. The ID number is required for all information being reported. If the number is not shown, the form is not a valid attachment and will not be used for claims processing. 4. Complete separate forms for each insurance card if the member has multiple cards, such as a medical card, a pharmacy card or a Medigap/Medicare supplemental insurance policy. Changes to coverage s can be reported on the forms also. New coverage and change information is recorded in Part III of the forms. 5. Do not attach the COB Notification Form and the EOB to the claim attach only one. If the information on the EOB does not clearly show why the primary claim processed as it did, use the DMA-410 to clarify. If the EOB clearly shows how the claim was processed, attach the EOB. Do not attach the Medicare Notification Form and the RA/EOMB to the claim attach only the one that most clearly explains the claims processing. 6. When there is no EOB and the provider is billing for a managed care co-payment, complete Section I on the DMA-410 showing the insurance carrier and the copayment amount. When there is no EOMB and the provider is billing for a Medicare Advantage Plan co-payment, complete Section I of the DMA-460 showing the plan and the copayment amount. 7. When the EOB shows the carrier denied the claim due to Out-of-Network, but in reality the service is not covered even with a network provider, check the line on the DMA-410 showing Service is non-covered and use the DMA-410 as the attachment Page 41 of 51

42 rather than the EOB. Document the patient s file to show how it is known that the service is not covered. 8. When the COB information is in the form of a letter, include the information from the letter on the DMA-410 and keep the letter in the patient s file. When the Medicare information is in the form of a letter, include the information from the letter on the DMA-460 and keep the letter in the patient s file. NOTE: When the letter is used as the COB or Medicare attachment rather than the DMA-410 or the DMA-460, it might not be recognized as a COB or Medicare attachment and as a result be coded incorrectly. This incorrect coding could cause the claim to deny. 9. Always use the most current versions of the forms. The most current versions are available on the GHP Web Portal. If the most current versions are not used, the attachments will be invalid for processing the claims. Copies of the COB Notification Form (DMA- 410) and the Medicare Notification Form (DMA- 460) are shown on the following pages Page 42 of 51

43 DMA-410-TPL Page 43 of 51

44 DMA-460: 06- EOMB Page 44 of 51

45 Chapter 5. Submitting COB and Crossover Attachments SPECIFIC GUIDELINES FOR SUBMITTING COB AND CROSSOVER ATTACHMENTS There are specific guidelines that must be followed in order for claims submitted with attachments to process smoothly. 1. Do not highlight any areas on a COB or Crossover attachment or on the claim. When imaged, the highlighted areas will appear blacked out and unreadable. 2. Write 09 or EOB or COB in the upper right corner for COB attachments and EB or RA/EOMB or Crossover for Medicare attachments. The attachment code (EB) and other identifications will assist in the proper identification of the attachments and accurate claims processing. 3. For PES (Provider Electronic Solution) claims, submit COB and Medicare attachments as soon as possible. PES (Provider Electronic Solution) claims cannot be processed until the attachments are received. If the required attachments are not received within 30 days of claims submission, the claims will deny. Mail COB and Crossover attachments to the address below in #6. 4. For claims submitted electronically or via PES (Provider Electronic Solution), write the TCN clearly at the top of the attachment. 5. For paper claims, submit all attachments with the claim. Paper claims will not suspend to allow time for attachments to be sent. Always put the claim form on top and all attachments behind it. Each claim must have its own COB or Crossover attachment(s). The attachment may be exactly the same for every claim, but a separate copy must accompany each claim. 6. MAIL paper claim with COB or Crossover coded attachments to the HPES at: P.O. Box Atlanta GA When submitting an RA/EOMB attachment for a Medicare denial, write MEDICARE DENIAL clearly at the top of the RA/EOMB and submit as a straight Medicaid claim. 8. HIPAA privacy rules require that you cover up (redact) the names of other patients listed on the EOB or RA/EOMB prior to submission. Do not redact the column headings on these forms. 9. When the COB or Medicare information is received in the form of a letter, memo or any other communication instead of an EOB or EOMB, include the information from Page 45 of 51