ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim

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2 ebilling Support ebilling Support webinar: ebilling terms ebilling enrollment Lifecycle of a claim 2

3 Terms EDI Electronic Data Interchange Flow of electronic information, specifically claims information X12 HIPAA file files containing sensitive information formatted for HIPAA compliance, unreadable by naked eye. Require conversion software to read 3

4 Terms X12 Files 837 Claim file Types I Institutional (UB-04 equivalent) P Professional (1500 equivalent) D Dental (Dental claim equivalent) 820 Payment File, contains check number and date 835 Electronic remittance advice, explanation of payment/denial 4

5 Terms DDE Direct Data Entry Log into portal and directly key in the claim information ebilling option if unable to create the 837 file preferable for smaller companies no charge for utilizing this service EFT (Electronic Funds Transfer) direct deposit of payments. 5

6 How to sign up for ebilling Complete online application Go to our website: Click on Providers click on Electronic Billing link (left hand side) 6

7 How to sign up for ebilling Enter your company s name and primary contact Contact person Representative who has the access and authority to set up 837 or person who will be utilizing the DDE service Generally someone from your IT Department or Billing Department Name, Title, Phone Number, address primary method of contact during e-billing set up Answer questions pertaining to billing set up Comment optional Click on Send button when done. You will receive a confirmation . 7

8 How to sign up for ebilling 8

9 Provider Portal AEC s Provider Portal is used for both DDE and 837 submission methods Once all necessary information is received, AEC s ebilling Support will set up your company in our Provider Portal User name and initial password will be created One user name per company unless otherwise requested DDE User Guide and 837 Companion Guides will be made available once you receive your user name 9

10 837 Test File Submission After receiving your user name and password, if submitting an 837, a test file will be required. To submit your test file: Log into the AEC Provider Portal Click on 837 Batch Upload You will be directed to the test upload page 10

11 837 Test File Submission Click on Upload File to upload your test file Your file will be reviewed by an AEC ebilling Support Specialist and notified whether your file passed or not. If your file passes, you will be switched to production. The next time you login you will be able to follow the same steps to upload live claim files. 11

12 837 Test File Submission Test File Requirements File should contain no more than 1-2 claims Upload errors mean the file does not meet standard format guidelines Ramp Manager can help diagnosis issues. Information on Ramp Manager available on the AHCA website 5010 only, not accepting 4010 version 12

13 Lifecycle of a Claim Providers Submit claim to AEC -> processed within 10 days Payable-> AEC sends payment information to fiscal agent (AHCA) -> payment issued to provider directly from AHCA) with remit. Denied -> Paper remit explaining denial sent to provider. 13

14 Lifecycle of a Claim 14

15 Lifecycle of a Claim Remits/Payments AHCA offers electronic remits (835) and EFT. AEC will be issuing paper remits only and paper checks only (this may change based on interest and volume). 15

16 Lifecycle of a Claim Claim Status Inquiries: AEC plans to offer the ability to view claim status information online - release date to be announced. 16

17 Who to Contact: Topic Accessing/Utilizing Provider Portal: Payment status: AEC Department to Contact ebilling Support: p: (561) f: (561) e: Claims Customer Service: p: (561) ext.1987 Provider Relations: Authorizations: Call localaec Branch - Provider Relations Specialist: For Office Listings: (copy and paste into browser) ernalweb/ltcmc/officelist.aspx Care Management: Call local AEC Branch -For office listings: (copy and paste into browser) ernalweb/ltcmc/officelist.aspx 17

18 E-Billing Contact E-Billing Support Sims Road Delray Beach Fl

19 Verifying Recipient Eligibility AVRS (Automated Voice Response System) MEVS (Medicaid Eligibility Verification System) vendors AHCA Eligibility Presentation une_2013.pdf 19

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21 AMERICAN ELDERCARE CUSTOMER SERVICE & BILLING Claims status Customer Service will assist you with Claims payment information Claims reconsideration information Any non claims related requests we will direct you to the appropriate departments

22 NPI Requirements All providers who must obtain an NPI (typical providers) and who bill Medicaid electronically, must use their NPI exclusively for the pay-to, billing, and rendering Provider identifiers. Medicaid Provider IDs for these fields will not be accepted. Please note: Atypical providers, such as case management waiver providers, are not required to obtain an NPI. 22

23 NPI Hierarchy Cautionary Notes: 1. The header level billing/pay-to provider loops on the claims transaction includes the zip code. 2. The header level billing/pay-to provider share the same taxonomy code. 3. The header level and service level rendering provider loops includes taxonomy only 23

24 Blank UB-04 24

25 Paper Claim Submission Checklist In order for a claim to be paid, it must be a clean claim. Checklist for a clean claim: Has the claim been accurately and fully completed according to Medicaid billing guidelines? Is the claim accompanied by all necessary documentation and on an original claim form (no photocopies)? Can the claim be processed and adjudicated by Medicaid without obtaining additional information from the provider? 25

26 UB-04 Completion Rules Enter all information using black type or blue or black ink. Do not use highlighters. Be sure the information on the form is legible and aligned with the corresponding space. Only complete the fields that are required and applicable. If needed, use correction tape. Do not use whiteout fluid. Complete the form by referencing the service-specific coverage and limitations handbook and the UB-04 Reimbursement Handbook, as necessary. 26

27 Entering NPI on the UB-04 Claim Form As of January 1, 2011, National Provider Identifier (NPI) entries in the billing and rendering provider sections of UB-04 paper claims are required. If a taxonomy code is used to create a unique map from a provider s NPI to a Florida Medicaid ID number, the applicable taxonomy code and qualifier must be entered on paper claims. 27

28 Form Locators 1 & 3 Form Locator 1: Provider Name, Address, Telephone Number, Fax Number, and Country Code Line 1: Provider Name Line 2: Street Address or Post Office Box Line 3: City, State, and Zip Code (plus 4) Line 4: Telephone; Fax; Country Code (if other than USA) Form Locator 3a: Patient Control Number (PAT. CNTL #) Enter patient s unique (alphanumeric) number assigned by the provider. Any letter or number combination up to 20 digits is acceptable. This number will be included on the payment check or remittance. 28

29 Form Locators 4-6, LTC Facilities Form Locator 4: Type of Bill Enter the appropriate four-digit code for the type of bill. See Chapter 1 of the UB-04 Reimbursement Handbook for a complete listing of type of bill codes. Examples of Type of Bill Codes: 025X: Skilled Nursing Facility (SNF) Level I 026X: Skilled Nursing Facility (SNF) Level II 065X: Intermediate Care Facility (ICF) Level I 066X: Intermediate Care Facility (ICF) Level II Ending digit X: Form Locator 5: Federal Tax Number (FED. TAX NO.) 1: Original 7: Adjustment 8: Void Enter the federal tax identification number in the format NN-NNNNNNN. Form Locator 6: Statement Covers Period From Through Long Term Care Facilities: Enter the start and end service dates for the month being billed in MMDDYY format. (Ex. August 21, 1997, enter as ) 29

30 Form Locators 4-6, Hospice Form Locator 4: Type of Bill Enter the appropriate four-digit code for the type of bill. See Chapter 1 of the UB-04 Reimbursement Handbook for a complete listing of type of bill codes. Hospice Type of Bill Codes: 0813: Hospice Original Claims 0817: Hospice Replacement of Prior Claim (Adjustment) 0818: Hospice Voids Ending digit X: 1: Original 7: Adjustment 8: Void Form Locator 5: Federal Tax Number (FED. TAX NO.) Enter the federal tax identification number in the format NN-NNNNNNN. Form Locator 6: Statement Covers Period From Through Hospice: Enter the beginning and ending service dates in MMDDYY format for this bill. Do not show dates before the recipient s Medicaid eligibility began. For services received on a single day, the from and through dates must be the same. 30

31 Form Locators 10 & 11 Form Locator 10: Birthdate Enter the patient s date of birth in MMDDYYYY format. (Ex. August 21, 1997, enter as ) Form Locator 11: Sex Enter the letter M if the patient is male, F if the patient is female, or U if unknown. 31

32 Form Locator 12 Form Locator 12: Admission Date Long Term Care Facilities: Enter the patient s date of admission to the facility or to a new Level of Care in MMDDYY format. (Ex. August 21, 1997, enter as ) Hospice: Enter the patient s date of admission in MMDDYY format. This date must be the same as the effective date of hospice election or change of election. 32

33 Form Locator 17 Form Locator 17: Discharge Status (STAT) Long Term Care Facilities: Enter one of the below codes indicating patient status as of the discharge date. Examples of Long Term Care Discharge Status Codes: 01: Home 03: Discharge or transfer to Skilled Nursing Facility 09: Hospital 20: Death 30: Still a patient Hospice: Please refer to the UB-04 Reimbursement Handbook for a complete listing of patient status codes. 33

34 Form Locators Form Locators 39-41: Value Codes Long Term Care Facilities: If the patient has a patient responsibility, enter value code 31 and the amount. The amount entered should be amount for the month even when billing a partial month. Hospice: Enter the value code and amount if applicable. If the hospice patient has a patient responsibility, enter value code 31 and the amount. The amount entered should be the amount for the entire month even when billing a partial month. The Medicaid computer system will do a prorated calculation for partial days. Always enter value code 80 for covered days and the number of days covered by the primary payer as qualified by the payer. 34

35 Form Locator 42, LTC Facilities Form Locator 42: Revenue Code Long Term Care Facilities: Enter the appropriate four-digit revenue code: 0101 Long Term Care days 0185 Hospital leave days (Bed-hold days) 0182 Home leave days (Therapeutic bed-hold days) 35

36 Form Locator 42, Hospice Form Locator 42: Revenue Code Hospice: See Chapter 3 in the Florida Medicaid Hospice Coverage and Limitations Handbook for covered hospice revenue center codes. Use revenue center code 0657 to identify provider charges for services furnished to hospice patients by physicians employed by the hospice or receiving compensation from the hospice. When billing revenue code 0657, enter the corresponding 5-digit CPT-4 procedure code in Form Locator

37 Form Locator 46 Form Locator 46: Units of Service (SERV. UNITS) Long Term Care Facilities: Enter the number of days associated with each revenue code. Medicaid reimburses for the date of admission, but not for the date of discharge. Include the date of admission, but do not include the date of discharge in the total number of days. If the recipient is admitted and discharged on the same day, count it as one day. Hospice: Enter the number of units of service for each type of service. Units are measured in days for codes 0651, 0655, and 0656; in hours for code 0652; and in procedures for

38 Form Locator 47, LTC Facilities Form Locator 47: Total Charges Long Term Care Facilities: Enter the total charge for each revenue code or procedure code entry. This entry must be the sum of the individual charges. Long Term Care facilities should not deduct the patient responsibility. Line 23: Enter the total of all revenue code charges on the final page of the claim, along with revenue code For Medicare crossover claims (level of care X), compute the total charge using the Medicare rate instead of the Medicaid per diem. If the Medicare rate for a recipient changed during the month, use the weighted average Medicare rate (weighted based on the number of days each rate is paid). 38

39 Form Locators 47 & 48, Hospice Form Locator 47: Total Charges Hospice: Enter the total charge for each revenue code or procedure code entry. This entry must be the sum of the individual charges. Long Term Care facilities should not deduct the patient responsibility. Line 23: Enter the total of all revenue code charges on the final page of the claim, along with revenue code Form Locator 48: Non-Covered Charges Hospice: Enter the total payment received or expected to be received from a primary insurance payer identified in Form Locator 50A. If the primary insurance payer pays a lump sum payment, enter a prorated amount on each line. If there is more than one other private payer, lump all amounts together in Form Locator 48 and attach each company s Explanation of Benefits or remittance. 39

40 Form Locators 50 & 51 Form Locators 50 A-C: Payer Name Long Term Care Facilities and Hospice: Enter Florida Medicaid for the Medicaid payer identification. Enter the name of the third party payer if applicable: Form Locators 51 A-C: Health Plan ID Long Term Care Facilities and Hospice: For Medicaid, leave blank. If the health plan in Form Locator 50 has a number, report the number in 51 A, B, or C depending if the insurance is primary, secondary, or tertiary. If the number is unknown, leave blank. 50A: Primary Payer 50B: Secondary Payer 50C: Tertiary Payer 40

41 Form Locators 52 & 54 Form Locators 52 A-C: Release of Information (REL INFO) Long Term Care Facilities and Hospice: Indicate whether the patient or patient s legal representative has signed a statement permitting the provider to release data to other organizations. Form Locators 54 A-C: Prior Payments Long Term Care Facilities and Hospice: Enter the amount that the provider has received toward payment of this bill prior to the billing date on this claim. Do NOT put the Medicaid amount due in this form locator. Code Structure: I: Informed consent to release medical information for conditions or diagnoses regulated by Federal statutes Y: Provider has a signed statement permitting release of medical billing data related to a claim 41

42 Form Locators 56 & 57 Form Locator 56: NPI Enter the unique NPI number assigned to the provider submitting the bill. NOTE: If the taxonomy code is used to create a unique map from a provider s NPI to a Florida Medicaid ID number, it is entered in Locator 81 with qualifier B3. Form Locators 57 A-C: Other Provider ID (OTHER PRV ID) Use for an identification number other than NPI. The provider may enter its nine-digit Medicaid provider number in Form Locator

43 Form Locators 58 & 59 Form Locators 59 A-C: Patient s Relationship (P. REL) Form Locators 58 A-C: Insured s Name Long Term Care Facilities and Hospice: Enter the insured s last name, first name, and middle initial exactly as it appears on the Medicaid ID card or other proof of eligibility. Long Term Care Facilities: Enter the code indicating the relationship of the patient to the identified insured. Line A: Primary Payer, Required Line B: Secondary Payer, Situational Line C: Tertiary Payer, Situational Code Examples: 01: Spouse 18: Self 19: Child 21: Unknown 43 UB-04 Claims for Long Term Care Updated: 03/01/2013

44 Form Locator 60 Form Locator 60 A-C: Insured s Unique ID Long Term Care Facilities and Hospice: Enter all of the insured s unique identification numbers assigned by any payer organizations. The recipient s ten-digit Medicaid ID number must be verified and entered. This entry must correspond with the Medicaid payer entry in Form Locators 50 A, B, or C. If Medicaid is primary, enter the recipient s Medicaid ID number in Form Locator 60A. If Medicaid is secondary, enter the recipient s Medicaid ID number in Form Locator 60B. 44

45 Form Locator 65 Form Locators 65 A-C: Employer Name Enter the name of the employer who provides or might provide health care coverage for the patient. 45

46 Claim Submission A clean claim for services rendered must be received by Florida Medicaid or its fiscal agent no later than 12 months from the Date of Service (DOS). Third Party Liability Claims (TPL) Providers also have 6 months from the TPL Explanation of Benefits (EOB) date. Medicare Crossover Claims The filing limit for crossover claims is the greater of 36 months from the date of service or 12 months from Medicare s adjudication date. Adjustments Providers have 12 months from the payment date to make an adjustment. Voids Claims can be submitted directly to HP Enterprise Services with no time limit. Replacements for voids must be submitted to the area office within 6 months of the date of the void if over 12 months from the DOS. 46

47 LTC Discharge Claims When a patient has a change in level of care, a discharge claim must be billed. Because Florida Medicaid does not pay for the date of discharge, the thru date of service needs to correspond with the person s first date in the new level of care and a discharge status must be present on the claim. Then, a second claim should be billed indicating the new level of care and the admission date should reflect the first date of service that the patient received care under the new level of care. If a recipient transfers from your facility or is no longer a resident, a discharge claim (a claim that has a discharge status and time present) must be submitted. 47

48 LTC Bed Hold Days on Electronic Claims For electronically submitted claims, Nursing Homes must report actual/specific dates of service at the detail line level when submitting room and board (rev code 101) and Hospital Bed Hold (rev code 185) dates on the same claim. Failure to use specific dates for bed hold days may cause other provider's claims to deny inappropriately. There can be no overlapping dates of service at the line item level. Each line item must have dates of service that are unique to that line item s revenue center code. For example: Line item 1: Date of Service span: 07/01/ /14/2011, Revenue Code: 0101, Units: 14 Line item 2: Date of Service span: 07/15/ /18/2011, Revenue Code: 0185, Units: 4 48

49 SKILLED NURSING FACILITIES CODING REVENUE CODE DESCRIPTION LEAVE DAYS) LONG TERM CARE DAYS BED HOLD DAYS (HOSPITAL LEAVE DAYS) THERAPEUTIC BED HOLD DAYS (HOME REMEMBER TO ADD UNITS IN UNIT FIELD FOR DATES MEMBER WAS IN FACILITY AND UNITS FOR DAYS MEMBER WAS OUT OF FACILITY. UNITS MUST MATCH NUMBER OF DAYS IN BILLING CYCLE.

50 SKILLED NURSING FACILITIES TYPE OF BILL (TOB) CODES 0251 SNF Level 1 Original Claim 0257 SNF Level 1 Replacement of Original Claim Adjustment 0258 SNF Level 1 void 0261 SNF Level 2 Original Claim 0267 SNF Level 2 Replacement of Original Claim Adjustment 0268 SNF Level 2 void 0651 ICF Level 1 Original Claim 0657 ICF Level 1 Replacement of Original Claim Adjustment 0658 ICF Level 1 void 0661 ICF Level 2 Original Claim 0667 ICF Level 2 Replacement of Original Claim Adjustment 0668 ICF Level 2 Void

51 Sample: Long Term Care Facility UB-04 Claim

52 HOSPICE CLAIM CODING REVENUE CODE DESCRIPTION ROUTINE HOME CARE CONTINUOUS HOME CARE INPATIENT RESPITE GENERAL INPATIENT CARE THERAPEUTIC BED HOLD BED HOLD DAYS (HOSPITAL LEAVE DAYS)

53 Sample: Hospice UB-04 Claim 1 1

54 Adjustment Information You can only adjust a paid claim. A provider has 12 months from the payment date to adjust. The adjustment claim must match the original claim with the exception of the corrections. The adjustment will serve as a replacement to the original claim. If you have a claim where a line item was paid and a line item was denied, simply resubmit the denied line. 54

55 Void Information You can only void a paid claim. There is no time limit to submit a void claim. A provider has 6 months from the date of the void to request an exception from the area office if the claim is over 12 months from the Date of Service (DOS). A void will result in a complete recoupment of the original payment made under the ICN that is being voided. 55

56 AMERICAN ELDERCARE CLAIMS, CUSTOMER SERVICE & BILLING FAQ Can we get a copy of the Claims presentation This information can be found in your Provider Handbook under the Claims Section. You can also visit our website at What is the process for EDI and ebilling Your office must complete the electronic billing form to initiate the process, visit our website at complete the ebilling enrollment form. The two forms of electronic billing are DDE Direct Data Entry and electronically on the 837 file format.

57 FAQ con t Where is the resident liability amount reported on the UB04? Enter 31 in box 39 (allows two digits only) then enter the amount under value codes amounts (box next to box 39, but not box 40) What bill type do we use on the UB04 for Nursing Home claims? 251

58 FAQ con t What box on the UB04 can the authorization number be entered Authorization number can be entered in box number 63. Does AEC pay deductibles and co-insurance AEC process claims for secondary insurance for Medicare part A if our member is in a nursing home for skilled care. Claims will continue to follow the same Medicaid guidelines.

59 FAQ con t How will AEC provide acknowledgement that electronic claim was received for processing You can log into the web portal at any time and verify claims information. Medicaid allows providers to send electronic claims through clearinghouses At this time AEC is not using clearinghouses, please submit claims to American Eldercare in an electronic format. We will be looking into clearinghouses in the future.

60 FAQ con t What is the process for denied or short paid claims. First verify billing is in accordance with Service Request submitted by members Care Manager, if you have additional questions please contact Claims Customer Service at , or ext we will direct you on re-submissions.

61 AMERICAN ELDERCARE CLAIMS, CUSTOMER SERVICE & BILLING How is reimbursement determined, negotiable, or Medicaid rate The Provider Relations Specialist works directly with each provider to negotiate contracted rates. Nursing Homes and Hospice will be paid at the Medicaid rate for authorized services. Please contact your Provider Relations Specialist to review rates.

62 Handbooks and Medicaid Resources Florida Medicaid UB-04 Reimbursement Handbook: rovidersupport_providerhandbooks/tabid/42/default.aspx Florida Medicaid Hospice Coverage and Limitations Handbook: BOOKS/CL_07_070101_Hospice_ver1_2.pdf Florida Medicaid Nursing Facility Coverage and Limitations Handbook: BOOKS/CL_06_040701_Nursing_ver1_0.pdf Florida Medicaid Provider Alerts: rovidersupport_provideralerts/tabid/43/default.aspx Florida Medicaid PSN Information: 62

63 QUESTIONS? Claims Customer Service can be reached at Toll Free: Phone: ext 1987 Fax :