IlliniCare Health Plan - Quick Billing Guide

Transcription

1 IlliniCare Health Plan - Quick Billing Guide This guide explains how to submit a claim online using IlliniCare Health Plan s (IlliniCare) secure provider portal, as well as examples of paper claims. This guide should be used by home and community-based service providers and supportive living facilities. In order to submit claims online, you must create an account. To access IlliniCare s secure provider portal, visit Step 1: Click Claims on the top navigation bar. Step 2: Click Create Claim. Step 3: Enter the member s ID Number or their last name, and their birth date. Click find. Step 4: You will then be prompted to choose a claim type. Choose CMS 1500, Professional Claim. Step 5: Enter in the Patient s Account Number. This would be the number you associate with this member s record in your system. Step 6: Enter in prior authorization number. This information will be provided to you by our Integrated Care Team. Step 7: Enter in the diagnosis code. This will be provided to you by our Integrated Care Team. Step 8: Click Next.

2 Step 9: Enter in the dates of service. Step 10: Enter in the place of service. Step 11: Enter in procedure code and any necessary modifiers. This is based on the service provided. Please reference codes provided in this document. Step 12: Place a check mark next to the diagnosis code. Step 13: Enter in the TOTAL charges for this service, as well as the number of units. Be sure to reference the Service Package II Coding Guide, which defines the unit increments and total charges. Step 14: Select Save/Update. This will add this service line to your claim. If you have additional services to include for this specific member, repeat steps Questions? Contact us! Provider Services: (866) Step 15: Once you have completed adding service lines to this claim, click Next.

3 Step 16: Search for rendering provider information using your Tax ID Number. Choose the correct provider, and it will appear under Selected Provider. Step 17: If the billing provider and service facility location are the same as the rendering provider, select that option to fill in the relevant information. If not, enter in the information for the billing provider and service facility location. Step 18: Click Next. Final Steps: 19. Upload any necessary attachments. 20. Review your claim to ensure it is correct. 21. Press submit! Questions? Contact us! Provider Services: (866)

4 CMS 1500 Form Billing Instructions The instructions below explain the fields required on a CMS 1500 form for home and community-based service providers. Item Field Description/Instructions Required? 1 Required Indicate the type of health insurance for which the claim is being submitted. For members of the Integrated Care Program, check Medicaid. 1a Required Enter the member s Medicaid ID number in this field. 2 Required Enter in the member s full name. Enter last name, first name and middle initial. 3 Required Enter in the member s date of birth and sex. For the date of birth, follow this format: MMDDYYYY. Check the appropriate box indicating the member s gender. 5 Optional Enter in the member s address. This information is not used in claim s processing, but can be entered if desired. 6 Required Checkmark self. 21 Required Enter in diagnosis code of member. If you have a diagnosis code available, you can use the code you have for that member. If you do not have the diagnosis code, the Integrated Care Team can provide it for you. 23 Optional Enter in the prior authorization number. All home and community-based services require prior authorization. When services are setup for a member, the Integrated Care Team will provide this number to you. 24A-G Introduction Section 24: This section is comprised of six service lines. The six service lines have been divided horizontally. A valid claim must have at least one completed service line. The instructions for each field on the service line (24A-G) apply to all six lines. 24A Required Enter in the dates of service. A from date of service must be entered. If a to date of service is not entered, the from date of service will be used as the to date of service as well. All dates must be entered in the MMDDYYYY format. All dates of service must have occurred after the date the claim is submitted. 24B Required A two-digit place of service is required. Examples include: 12: Home; 13: Assisted Living. 24D Required Enter in the appropriate procedure/service code based on the service provided. For a list of codes, see the Service Package II Coding Guide included in this document. Also enter in any modifiers, if applicable. 24E Required Enter 1 in this field. This points to the diagnosis code you placed in field 21. Diagnosis codes will be provided by the Integrated Care Team. 24F Required Enter in the total charges for the service. Enter in the dollars to the left of the dashed line and cents to the right of the dashed line. To determine the total charges for service, reference the Service Package II Coding Guide. This will help you determine the number of units, and total charges for a service. Services with no charges will be denied. 24G Required Enter in the amount of units of service being billed as appropriate. Please reference the Service Package II Coding Guide to determine the Standard Increment that should be billed. 25 Required Enter in provider Tax ID Number. Also check the box to determine which type of Tax ID Number is being used. 26 Optional This is your reference number for the member. This is an optional field. 27 Required Check mark Yes. 28 Required Enter in the total of all service line charges. The total charge amount MUST equal the same of all service line charges.

5 CMS 1500 Form Billing Instructions - Continued Item Field Description/Instructions Required? 31 Required A signature and date are required. The signature can be an original signature, a stamped signature, a typewritten signature, or a printed signature, but it MUST be the name of a person. It cannot be signature on file or the name of a facility. Enter date in MMDDYYYY format. 32 Required Enter in the service location name and address. 33 Required Enter in the billing provider s name, address and phone number in this field. The next page shows a blank CMS 1500 form, so you can see where the fields described in these instructions are on the form. After that page, please find an example claim form. This includes dummy fields to show a properly filled out form. Billing Dos Submit your claim within 90 days of the date of service Submit on a proper original form CMS 1500 Mail to the correct PO Box number Submit all claims in a 9 x 12 or larger envelope Type all fields completely and correctly Use typed black or blue ink only at 9-point font or larger Include all other insurance information (policy holder, carrier name, ID number and address) when applicable Billing Don ts Submit handwritten claims Use red ink on claim forms Don t circle data on claim forms Don t add extraneous information to any claim form field Don t use highlighter on any claim for field Don t submit photocopied claim forms (no black and white claim forms) Don t submit carbon copied claim forms Don t submit claim forms via fax Questions? Contact us! Provider Services: (866)

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7 EAMPLE PAPER CLAIM Member, Joseph, M W. Illinois Street SAME Westmont SAME IL SIGNATURE ON FILE SIGNATURE ON FILE S T S James Provider Adult Day Care, Inc 1000 W. Oakdale Ave Orland Park IL Adult Day Care, Inc 1000 W. Oakdale Ave Orland Park IL

8 IlliniCare Service Package II Coding Guide Rate (per Service Code Modifier HFS Increment Standard Increment unit) for Claims Example Adult Day Service S5100 per hour 15 min $ hour = 4 units (4 x $2.26 = $9.04) Adult Day Service Transportation T unit = one way trip 1 unit = one way trip $8.30 Round trip = 2 units (2 x $8.30 = $16.60) Environmental Home Adaptations S5165 per service per service varies varies Supported Employment T2019 per diem 15 min $ hour = 4 units (4 x $11.00 = $44.00) Home Health Aide Agency T1004 per hour 15 min $ hour = 4 units (4 x $3.44 = $13.76) Home Health Aide Agency CAN T1004 SC per hour 15 min $ hour = 4 units (4 x $3.44 = $13.76) Home Health Aide Individual G0156 per hour 15 min $ hour = 4 units (4 x $3.25 = $13.00) Home Health Aide Individual CAN G0156 SC per hour 15 min $ hour = 4 units (4 x $3.25 = $13.00) Home Health Intermittent Nursing RN, LPN (Agency Provider) G0154 one visit up to two hours 15 min $ hour = 8 units (8 x $8.16 = $65.28) Home Health Intermittent Nursing RN, LPN (Agency Provider) G0154 SC one visit up to two hours 15 min $ hour = 8 units (8 x $8.16 = $65.28) Nursing, Skilled LPN Agency T1003 TE per hour 15 min $ hour = 4 units (4 x $6.37 = $25.48) Nursing, Skilled LPN Individual T1000 TE per hour 15 min $ hour = 4 units (4 x $5.00 = $20.00) Nursing, Skilled Multi Customer T1002 TT per hour 15 min $ hour = 8 units (8 x $5.91 = $47.28) Nursing, Skilled RN Agency T1003 TD per hour 15 min $ hour = 4 units (4 x $7.39 = $29.56) Nursing, Skilled RN Individual T1000 TD per hour 15 min $ hour = 4 units (4 x $6.50 = $26.00) Occupational Therapy G0152 UC per hour 15 min $ hour = 4 units (4 x $9.25 = $37.00) Physical Therapy G0151 UC per hour 15 min $ hour = 4 units (4 x $9.25 = $37.00) Speech Therapy G0153 UC per hour 15 min $ hour = 4 units (4 x $7.50 = $30.00) Speech Therapy Hospital G0153 UC per hour 15 min $ hour = 4 units (4 x $12.50 = $50.00) Prevocational Services T2014 per diem per diem $43.25 $43.25 Habilitation Day T2020 per diem per diem $43.25 $43.25 Homemaker S5130 per hour 15 min $ hour = 4 units (4 x $4.29 = $17.16) Homemaker with Insurance S5130 per hour 15 min $ hour = 4 units (4 x $4.69 = $18.76) Home Delivered Meals S5170 one unit = 2 meals per meal $ meals delivered at one time 2 x $7.50 = $15.00 Personal Assistant S5125 per hour 15 min $ hour = 4 units (4 x $2.89 = $11.56) Personal Emergency Response Install S5160 per install per install $30.00 $30.00 Personal Emergency Response Monthly Charge S5161 per month per month $28.00 $28.00 Respite RN T1005 TD per hour 15 min $ hour = 4 units (4 x $7.39 = $29.56) Respite LPN T1005 TE per hour 15 min $ hour = 4 units (4 x $5.00 = $20.00) Respite C N A T1005 SC per hour 15 min $ hour = 4 units (4 x $3.44 = $13.76) Respite Homemaker T1005 HM per hour 15 min $ hour = 4 units (4 x $3.83 = $15.32) Respite Personal Assistant T1005 per hour 15 min $ hour = 4 units (4 x $2.89 = $11.56) Specialized Medical Equipment T2028 RR per service per service varies varies Example: Joe Member goes to adult day service for three hours every week day. Sunrise Day Center needs to bill for his stays for the previous month. Sunrise Day Center would need to submit a claim to IlliniCare with the code, S5100. In the previous month, there were 22 days that Joe went to the center. The total number of hours would be calculated by: 22 x 3 = 66 hours. However, IlliniCare's units are in 15 minute increments. Since there are four 15 minute increments in an hour, that means: 66 hrs x 4 = 264 units. This is how many units Joe used in one month. To find the total cost, it would be the number of units multiplied by the rate. 264 x $2.26 = $ *rates subject to change. Please check the IlliniCare website for the most up to date rates. These rates effective as of 11/12/2012.