HCA/MEDICAID AND ABCD BILLING TRAINING OUTLINE Revised: November 2011 (Depending on specific needs and experience with Medicaid/ABCD billing, the order and extent to which topics in this outline are addressed can be modified. While every effort has been made to provide accurate information, the information below is subject to revision and is always superseded by the most current online Medicaid Billing Instructions & ProviderOne Billing & Resource Guide http://hrsa.dshs.wa.gov/provider/links.shtml For easy access to key information on the WA State Healthcare Authority Medicaid Website, go to the Medicaid Provider Service Links Web-page: http://hrsa.dshs.wa.gov/provider/links.shtml (see pg 4 below) All web-links and downloadable documents referenced below, along with other important information and updates, can be accessed via the Provider Links web-page. The Dental Services link takes you to the Medicaid/HCA Dental Services Provider Webpage: http://hrsa.dshs.wa.gov/dentalproviders/dentalindex.html Bookmark this web-page for easy access to some relevant dental links and updates (see pg 5 below.) 1. Review ProviderOne Billing & Resource Guide @ http://hrsa.dshs.wa.gov/download/providerone_billing_and_resource_guide.html (This guide can be accessed from multiple locations.) Broken down into four main sections with appendixes, this guide offers step-by-step materials & resources for practices to ensure that clients are eligible for services, and that providers receive timely and accurate payments for covered services: Medical Assistance Overview (including links to key resources starting pg 13) Client Eligibility, Benefit Packages, and Coverage Limits (Updated 09/02/11) Submit Fee-for-Service Claims to Medical Assistance The HCA Remittance Advice o Numerous Appendices including Appendix K - Completing 2006 ADA Claim Form 2. Reference current HCA/ Medicaid Dental Billing Instructions through age 20 @ Dental Program for Clients Through Age 20 Review ABCD Supplemental Billing Instructions, with special attention to Family Oral Health Education (FOHE), @ ABCD Dentistry, ABCD Dental or http://hrsa.dshs.wa.gov/download/billinginstructions/abcd/abcd_dental_bi.pdf If relevant, reference Medicaid Oral Health/ Dental Services for Age 21 & Older. For dental service eligibility for DDD adults & pregnant/ postpartum women, see Decision making tool, Program Coverage Table & Eligibility Expedited Prior Authorization Criteria (10/1/11) on Dental Services Provider Webpage,. For Emergency Oral Health Services for all other Medicaid adults, access the current Billing Instructions for age 21 and over @ Physician-Related Services/Healthcare Professional Services (Oct. 1, 2011) pgs B.31 44. 3. Reference the current HCA/ Medicaid Dental Program Fee Schedule Review attached 7/09 ABCD Fee Schedule Summary (Note: this document cannot be accessed from the HCA Medicaid website) Reference fee schedule for all dental services: o Access all fee schedules: Professional Payments or Professional Services Rates (via Links web-page) o For rates for children, see Dental Program October 1, 2011 Dental Program Fee Schedule o For Oral Health/ Dental Services for Age 21 & Older, see Physician-Related/Professional and Emergent Oral Healthcare Services July 1, 2011 Physician and Related Services Fee Schedule Updated on October 19, 2011 Page 1 of 5
4. Review Dental Claim Form Some KEY points: ADA claim forms 2006 or newer are required; Claims are electronically processed, so all required information must be in the correct boxes or it will be processed incorrectly and/or claims may be denied. Box 29: Use code D9999 for Family Oral Health Education (FOHE). No EPA# is needed. This code will be paid accordingly for FOHE for all Medicaid identified ABCD dentists. Note: If Medicaid is secondary insurance, it will pay for FOHE after denial by primary insurance. NOTE: FOHE is billable two times per 12-months per child, but only once per day per family. Documentation of FOHE in patient chart is required; see ABCD Current Billing Instructions. Box 35 (Remarks): Only use if necessary to process claim, as comments here will significantly slow down processing time. Box 48-52A: Billing (group) provider information. Box 52A is for taxonomy code. Box 53-57: Individual treating dentist information. Box 56A is for taxonomy code. Box 58: No longer used If solo practice, the billing # & treating dentist will be the same. See Appendix K - Completing 2006 ADA Claim Form. Please try Direct Data Entry (DDE) claims into ProviderOne (if not already doing so). 5. Reference step-by-step instructions: Dental Fee for Service Claims. If you go to the Provider Training web-page, it is in the Fee for Service section at the top of the page. 6. Make sure to sign-up @ Email Distribution ( https://fortress.wa.gov/dshs/hrsalistsrvsignup/ ) to get the latest updates specific to your practice needs! You may subscribe, unsubscribe, and access the archive on a variety of topics. 7. There are multiple methods to check status info on: client eligibility, benefit packages, authorization, claims, and/or warrants. (See pg 3*) (See ProviderOne Billing & Resource Guide (updated 9/2/11) & relevant appendixes for details.*) 8. The best way to resolve specific billing/claims concerns or problems regarding: claims processing, payments, denials, etc. is via the ProviderOne web-form @ https://fortress.wa.gov/dshs/p1contactus Send your questions, changes, problems, etc. Submit only one issue per form. Each submitted communication will be promptly assigned a ticket #, which can will be logged and tracked until your concern is resolved. For the most efficient resolution be sure to provide detailed information in all communications. This may include a description of the concern, your NPI & claim number (TCN), etc. Include the ProviderOne message you received - copy and paste is ideal when relevant. 9. Promote Electronic Billing. HCA/ Medicaid encourages providers to bill electronically for the most efficient claim submission process and distribution of payment. 10. Review change to new HIPPA claim format, 5010 Providers who submit or receive a HIPAA transaction to/from HCA will have to switch formats from the current 4010 to 5010 by 01/01/2012. This will affect providers who use a clearinghouse or submit claim batches to HCA directly. HCA/Medicaid is now testing the new 5010 format; that information is available on the HCA HIPAA web site at http://hrsa.dshs.wa.gov/dshshipaa/. There will not be testing of the DDE claim entry. Page 2 of 5
*Options to check status info of client eligibility, benefit packages, authorizations, claims, and/or warrants, include: H.1. ProviderOne Portal ( https://www.waproviderone.org ) H.2. Interactive Voice Response (IVR) 360-562-3022; IVR Shortcut # Reference: (1) English or (2) Spanish > (5) Provider > (5) Client Eligibility (See Appendix B in Billing & Resource Guide.) (2) Authorization Status (See Appendix A in Billing & Resource Guide.) (3) Claim Status (See Appendix N in Billing & Resource Guide.) (4) Warrant Status (See Appendix O in Billing & Resource Guide.) H.3. Magnetic Card Reader (See Appendix A in Billing & Resource Guide.) H.4. MEV Services (Medical Eligibility Verification); (See Appendix H in Billing Resource Guide). H.5. Customer Service M-F 7:30am-4:30pm @ 1-800-562-3022; (expect a long hold time). H.6. Individual or batch inquiry to ProviderOne. Refer to the ProviderOne Billing and Resource Guide (updated 9/2/11), for more info: Current Guide (Updated 9/2/11) Note: Please do not print this document. The Health Care Authority will be making changes. Your paper copy may become outdated if you print the document rather than utilize the webpage. Please use this webpage and check it frequently. Prior Authorization (PA) Chapter Glossary New Glossary @ http://hrsa.dshs.wa.gov/download/medical_assistance_glossary.htm Introduction Medical Assistance Overview Client Eligibility, Benefit Packages, and Coverage Limits (Updated 9/2/11) Submit Fee-for-Service Claims to Medical Assistance The HCA Remittance Advice Appendix A - Verifying Eligibility Using a Magnetic Card Reader Appendix B - Use Interactive Voice Response (IVR) to Verify Eligibility Appendix C - Medical Assistance Managed Care Plan Appendix D - Casualty Claims and Health Insurance Claims Appendix E - Benefit Services Packages Appendix F - General Information for Authorization Appendix G - Cover Sheets Appendix H - Medical Eligibility Verification (MEV) Services Appendix I - Completing Claim Form CMS 1500 Appendix J - Completing Claim Form UB-04 Appendix K - Completing Claim Form 2006 ADA Claim Form Appendix L - Taxonomy and ProviderOne Appendix M - Medicare Crossover Claim Payment Methodology Appendix N - Use IVR to Check Claims Status Appendix O - Use IVR to Check Warrant J. For dentist or practice that hasn t yet applied to be a HCA/Medicaid Provider, See Provider Enrollment or http://hrsa.dshs.wa.gov/provider/newprovider.shtml#provider. Page 3 of 5
Reference: Medicaid Provider Service Links (web-page) @ http://hrsa.dshs.wa.gov/provider/links.shtml Health and Recovery Services Administration (web-page) Providers home Training Fact Sheets Links Claims and Billing New Provider ProviderOne ProviderOne Manuals Programs and Services Directory Client Services Eligibility Health Care for Children Healthy Options Maternity and Infants Provider Services Billing Instructions Durable Medical Equipment Hospital Payments Professional Payments Enrollment Reports Forms News Publications Reports Budget Health Care Authority Medicaid State Plan WACs and Proposed Changes Medicaid Provider Services Links Here are some information links that may be useful to a Medicaid Provider: Alien Emergency Medical Program (AEM) Authorization Services Billing Instructions Coordination of Benefits Dental Services Department of Social and Health Services (DSHS) DSHS Division of Behavioral Health & Recovery (DBHR) Document Cover Sheets Drug Use Assistance Durable Medical Equipment Electronic Health Record Incentive Program Emergency Rooms Federal EOB and Taxomony Code list Federally Qualified Health Centers and Rural Health Clinics Frequently Asked Questions (FAQ) Health Care Programs & Services Healthy Options (Managed Care) HIPAA Home Page Hospital Payments Interpreter Services Kidney Disease Program Medicaid News Medicaid Rule Making Actions Medicaid State Plan Mental Health Services NPPES Numbered Memos Pharmacy Information Site Professional Services Rates ProviderOne Billing and Resource Guide Provider Enrollment ProviderOne Log-In ProviderOne System Manuals Patient Review & Coordination Program Regional Support Networks (RSN) Substance Abuse Help Swipe Card Readers Tribal Health Washington Administrative Code (WAC) Page 4 of 5
Reference: Dental Services (web-page) @ http://hrsa.dshs.wa.gov/dentalproviders/dentalindex.html Services for Clients For Providers Important notices and memos for providers: Dental coverage for pregnant women now includes a post partum period. Budget changes access to dental services for some clients Provider Memo Glossary of Terms Emergency Oral Healthcare Benefit (see page B.29 for all clients Age 21 and Older) Effective October 1, 2011: Changes in coverage for some DDD Medicaid Adults: Decision making tool Eligibility Expedited Prior Authorization Criteria Program Coverage Table Frequently Asked Questions and Answers for DDD Effective July 1, 2011: Restoration of Dental Services for some Medicaid adults: Decision making tool (July 2011 - September 2011) Eligibility Expedited Prior Authorization Criteria (Includes DDD January 2011 - September 2011) Program Coverage Table (Includes DDD January 2011 - September 2011) Frequently Asked Questions and Answers (July 2011) Other Dental specific topics: ABCD Dental Orthodontics Dental Program for Clients Through Age 20 Dental Program for Clients Age 21 and Older (As of 1/1/11, only applicable to clients of the Division of Developmental Disabilities) Physician Related Services/Healthcare Professional Billing Instructions Data Common Forms Fee Schedules Frequently Asked Questions Training: Authorization Webinar (PowerPoint slideshow) ProviderOne Billing and Resource Guide Provider Training Billing: Dental Related Memos: o 10-86 Year 2011 Benefit Changes as a Result of Budget Reductions Coverage Changes & Hospital Visit Policy Changes. o 10-29 Fee Schedule Updates and Benefit Changes. o 10-01 New Form to Initiate Request for Prior Authorization. Centers for Medicare & Medicaid Services Response to Frequently Asked Questions (billing clients, accepting Medicaid clients) Electronic Billing: Medicaid encourages providers to bill electronically for the most efficient claim submission process and distribution of payment. Page 5 of 5