Kentucky Medicaid - kymmis.com Relations/UB Spring... · Enter the appropriate indicator, describing SHPS determination of Medical Necessity for the stay. ... Form Locator 6 is not

Kentucky MedicaidSpring 2009

Billing Workshop

UB04

Cabinet for Health and Family Services 2

Agenda• Representative List• Reference List• UB Claim Form• Detailed Billing Instructions• NDC (Hospitals and Renal Dialysis)• Forms• Timely Filing• FAQ’S• Did You Know?• Top Denials• Questions• Evaluation


Representative List


Representative List


Reference List

Helpful Phone Numbers

EDI Helpdesk [email protected]

Provider Billing Inquiry800-807-1232

[email protected]

Web Addresses

EDS Website www.kymmis.com

KyHealthnethttp://home.kymmis.com

KY Medicaidwww.chfs.ky.gov/dms


Top Half of UB Claim


Required Information Form Locators and Descriptions

1 Provider Name, Address and TelephoneEnter the complete name, address, and telephone number (including area code) of the facility.

3 Patient Control NumberEnter the patient control number. The first 14 digits (alpha/numeric) will appear on the remittance advice as the invoice number.

4 Type of BillEnter the appropriate code to indicate the type of bill. Please refer to billing instructions for the appropriate type of bill.1st Digit Enter zero.2nd Digit (Type of Facility) 3rd Digit (Bill Classification)4th Digit (Frequency) 0 = Non-paymentTOB 0111 for inpatient hospital claims except for Critical Access, Rehab and Psychiatric Hospitals.TOB 0110 is for newborn claims while mom and newborn are in the same facility (Inpatient Hospital only)DPU’s are inpatient claims only


Required InformationForm Locators and Descriptions

6 Statement Covers PeriodFROM: Enter the beginning date of the billing period. THROUGH: Enter the ending date of the billing period.

10 Date of BirthEnter the member’s date of birth.

12 Admission DateEnter the date on which the Member was admitted to the facility in numeric format (MMDDYY).

13 Admission HourEnter the code for the time of admission to the facility. Admission houris required for both inpatient and outpatient services. (Inpatient Hospital, Mental Hospital, PRTF, DPU, Nursing Facility ONLY)

14 Admission TypeEnter the appropriate type of admission(Hospital Only)



16 Discharge HourEnter the hour the member was discharged. (This is now a requirement and will result in claim denials for Provider Types Inpatient Hospitals, Mental Hospital, and DPU’s.)

17 Patient Status CodeEnter the appropriate two digit patient status code indicating thedisposition of the patient as of the “through” date in Form Locator 6.

18-28 Condition CodesPeer Review Organization (PRO) IndicatorEnter the appropriate indicator, describing SHPS determination of Medical Necessity for the stay.For Home Health Providers enter a Y1 whenever a MAP 34 has been completed and is available in the member’s records.

31-34 Occurrence Codes and DatesEnter the appropriate code (s) and date (s) defining a significant eventrelating to this bill. Reference the UB-04 Training Manual for additionalcodes.Discharge Code and DateEnter “42” and the actual discharge date when the “THROUGH” date inForm Locator 6 is not the actual discharge date and Form Locator 4indicates “Final Bill.” (Inpatient Hospital’s Only)


Required InformationForm Locators and Description

35-36 Occurrence Span Code and DatesEnter occurrence span code “MO” and the first and last days approvedby the PRO/UR when condition code C3 (partial approval) has beenentered in Form Locators 18-28.

37 Medicare EOB Date (cross-overs only)Enter Medicare EOMB date when Medicare allow the service. (leave blank if Medicare Denies)

39-41 Value Codes80 = Covered Days - Enter the total number of covered days from Form Locator 682 = Coinsurance Days - Enter the number of coinsurance days billed to KY Medicaid during this billing period. 83 = Life Time Reserve Days -Enter the Lifetime Reserve days the patient has elected to use for this billing period. A1 = Deductible Payer A-Enter the amount as shown on the EOMB to be applied to the Member’s deductible amount due. A2 = Coinsurance Payer A - Enter the amount as shown on the EOMB to be applied toward Member’s coinsurance amount due. B1 = Deductible Payer B - Enter the amount as shown on the EOMB to be applied to the Member’s deductible amount due. B2 = Coinsurance Payer B - Enter the amount as shown on the EOMB to be applied toward Member’s coinsurance amount due.



42 Revenue CodesEnter the three digit revenue code identifying specific accommodationand ancillary services.NOTE: Total charge Revenue code 0001 must be the final entry in column 42, line 23.Total charge amount must be shown in column 47, line 23.

43 DescriptionEnter the standard abbreviation assigned to each revenue code.Effective July 1, 2009 for Outpatient Hospital and Renal Dialysis, the NDC is required when billing outpatient services for revenue codes 250-259 and 634-636. The N4 qualifier proceeds the NDC. Do not use dashes or spaces. When billing a revenue code which requires more than one NDC, the NDC detail attachment form must be used.

44 CPT/RATESEnter the CPT if required.



45 Service DateEnter the date the service was provided. Field 45, line 23 is to be used to indicate invoice date.

46 UnitEnter the quantitative measure of services provided per revenue code.

47 Total ChargesEnter the total charges relating to each revenue code for the billing period. The detailed revenue code amounts must equal the entry “total charges”.Claim total must be shown in field 47, line 23.

48 Non-Covered ChargesEnter the charges from Form Locator 47 that are non-payable by KY Medicaid.


Bottom Half of Claim form



50 Payer IdentificationEnter the names of payer organizations from which the provider receives payment. All other liable payers, including Medicare, must be billed first. * KY Medicaid is payer of last resort.

54 Prior PaymentsEnter the amount the facility has received toward payment of the claim.Third party payor or Medicare payment.

55 Est. Amount DueEnter Medicare’s allowed amount only when Medicare allows the charges. (Medicaid uses this field for crossover claims only. Leave blank for all other circumstances)

56 NPIEnter the Pay To NPI number.

57 TaxonomyEnter the Pay To Taxonomy number.

57B OtherEnter the facilities zip code.



58 Insured’s NameEnter the Member’s name in Form Locators 58 A, B, and C that relatesto the payer in Form Locators 50 A, B, and C.

60 Identification NumberEnter the Member Identification number in Form Locators 60 A, B, andC that relates to the Member’s name in Form Locators 58 A, B, and C.

63 Prior Authorization NumberEnter the prior authorization number assigned by the SHPS.

67 Principal Diagnosis CodeEnter the ICD-9-CM Vol. 1 and 2 code describing the principal diagnosis.

67A-Q Other Diagnosis CodeEnter the ICD-9-CM Vol. 1 and 2 codes that co-exist at the time theservice is provided.

69 Admitting Diagnosis (Inpatient Only)Enter the ICD-9-CM diagnosis code describing the admitting diagnosis.



74 Principal Procedure Code and DateEnter the ICD-9-CM (Vol.3) procedure code that identifies the principal obstetrical or surgical procedure performed during the billing period. Enter the date the procedure was performed in numeric format (MMDDYY). (Hospital Inpatient only)

74A Procedure Code (s) and Date (s)Enter the ICD-9-CM (Vol.3) procedure codes identifying the procedures,other than the principal obstetrical surgical procedure, performed duringthe billing period. Enter the date the procedures were performed innumeric format (MMDDYY). (Hospital Inpatient only)

76 Attending Physician IDEnter the Attending Physician NPI number.

77 OperatingEnter the Operating Physician NPI number.

78 OtherEnter the NPI number of the Nursing Facility. (For Hospice Providers Only)

79 Other (NPI)Enter the KenPAC NPI number. (When billing revenue code 450, KenPAC approval is not required, Outpatient Hospital only)


NDC (National Drug Code)Effective DOS July 1, 2009, Outpatient Hospitals and Freestanding

Renal Dialysis Clinics will be required to bill NDC codes with Physician administered drugs. May start billing 4/1/09.

The required revenue codes are 250-259 and 634-636.

You may obtain a copy of the NDC Detail Attachment form at www.kymmis.com or by calling Provider Inquiry at 1-800-807-1232.

The NDC FAQ’s are on the website at www.kymmis.com

The NDC is required with all claims when billing Medicaid. Which includes, Medicare crossovers and TPL as primary.

For Medicare claims to crossover, you will need to bill the NDC’s on the Medicare claims.

http://www.kymmis.com/

http://www.kymmis.com/


NDCThe NDC is required when billing Outpatient services and Freestanding Renal Dialysis Clinics for revenue codes 250-259 and 634-636.

The N4 qualifier precedes the NDC on UB04 paper claims and 837I.

Do not use dashes or spaces. Example N4XXXXXXXXXXX

When billing a revenue code which requires more than one NDC, the NDC detail attachment form must be used when billing paper claims.

If the revenue code does not have an NDC billed along with it, the entire claim will deny.

The NDC billing is Date of Service specific. Example: DOS 7/1/09 bill claim with NDC; for DOS 6/30/09 do not bill claim with NDC.


EXAMPLE

NDC Detail Attachment


NDC Detail InstructionsFill out the top part of the NDC detail attachment form such as provider name, provider ID, member name, member ID and DOS.

Column 1 ~ Claim Line This is the claim line number on the UB-04 claim form for which you are billing the NDC. The claim line number must be in sequential order.

Column 2 ~ NDCEnter the appropriate NDC code that corresponds to the HCPCS code.

Columns 3-6 not applicable

**Return to provider reasons. There are two reasons why an NDC DetailAttachment form may be returned.The form must have a corresponding line number to the UB-04 claim form.The line number must be in sequential order.


Completed NDC Example

Revenue code 636 has 3 NDC’s associated with it. (1 on claim and other 2 on NDC sheet)

Revenue code 250 has 4 NDC’s associated with it. (1 on the claim and other 3 on NDC sheet)


Billing NDC on KyHealth Net

250


Summary Page of KyHealth Net131

250


Forms

• Third Party Liability

• Adjustment and Claim Credit

• Cash Refund


TPL Lead Form


TPL Helpful Hints • When to use the TPL Lead Form:

• When there is no response within 120 days from the insurance carrier.

When the other health insurance has not responded to a provider’s billing within 120 days from the date of filing a claim, a provider may complete a TPL Lead Form.Mark “no response in 120 days” on the TPL Lead Form.Attach it to the back of claim and submit it to EDS.EDS overrides the other health insurance edits and forwards a copy of the TPL Lead form to the TPL Unit. The TPL staff contact the insurance carrier to see why they have not paid their portion of liability.

• Used for Commercial Insurance Only

• Not to be used for Medicare

• Other section is obsolete

• Contact name and phone number is person and phone number at Commercial Insurance


Adjustment Claim Credit


Adjustment, Claim Credit/Void HintsAn adjustment/void is a change to be made to a “PAID” claim.

Please keep the following points in mind when filing an adjustment request:

• Attach a copy of the corrected claim and the paid remittance advice page to your adjustment form.

• Do not send refunds on claims for which an adjustment or void has been filed.

• Be specific. Explain exactly what is to be changed on the claim.• Claims showing paid zero dollar amounts are considered paid

claims by Medicaid.• If the paid amount of zero is incorrect, the claim requires an

adjustment.• Do not do a adjustment/void on KyHealth Net and paper. Do one

or the other.• A claim credit is on paper, a void is on the KyHealth Net. They are

the same.• Only a void/claim credit will re-set a Prior Authorization


Cash Refund


Cash Refund HintsThe Cash Refund Documentation Form is used when refunding

money to KY Medicaid.

Please keep the following points in mind when refunding:

• Attach to the Cash Refund Documentation Form a check for the refund amount made payable to the KY State Treasurer.

• Attach applicable documentation, such as a copy of the remittance advice showing the claim for which a refund is being issued.

• Do not send a refund and an adjustment/void on the same claim.

• A refund will NOT reset a Prior Authorization


Timely Filing Aged claims (those older than 12 months from date of service or 6 months from the

Medicare payment or denial date) may be considered for payment only when documentation is submitted behind the claim to support timely filing.

The ONLY Acceptable documentation will include a copy of one or more of the following:

• Remittance advices to verify timely filing within each 12 months from date of service.

• A Screen Print from KYHealth-Net to verify issue date of the eligibility. (this is the card issuance screen)

• A Screen Print from KYHealth-Net Summary Page, to verify timely filing within each 12 months from date of service.

• Medicare explanation of benefits (EOMB).• Commercial Insurance EOB


Timely Filing Examples

1 Year From Issue Date



KyHealth Net Search Criteria Screen

Not Acceptablefor timely filing



KyHealth Net Header Screen

Not Acceptablefor timely filing



KyHealth Net Summary Screen

Acceptable for timely Filing


FAQ’sIf you bill Medicare, remember to list your Medicare information on the UB claim form when Medicare allows, this would also include the Medicare Replacement Policy’s.

When billing Medicare electronically, you may bill with NPI and taxonomy and the claim will cross via 837. Medicare’s website about taxonomy is: www.cms.hhs.gov/manuals/

When submitting a paper claim with attachments, the claim must always be on top of any attachments. Except, when submitting paper adjustments, the form is to be on top of the claim.


FAQ’s Cont.Member Program Codes to watch for

Z-QMB Only-Medicaid only allows after Medicare, so if Medicare denies, Medicaid will deny.

ZJ, ZK, ZL, ZQ Buy-In Member-Medicaid is only paying the Medicare Premiums. No Medicaid coverage.

For Inpatient Hospitals, Medicaid does not want the DRG billed on the UB claim form.

Beginning July 1, 2009, for Inpatient Hospital, Mental Hospital, and DPU claims only, Medicaid will edit claims for the discharge hour.


FAQ’S Cont.Internal Control Number (ICN)

All claims, adjustment and Voids are given a unique number.First two digits are the Region, Second 2 digits is the Year theclaim was received and the 3rd three digits are the Julian Dateof receipt.

*Example 2009061123456-Claim received as an electronic claim, March 2, 2009.

If the ICN begins with:10-Paper claim with no attachments11-Paper claim with attachments20-Electronic claim 22-KyHealth billed claim50-Adjustment56-Claim Void


Did You Know?* Coming Soon--Paper checks are going to be mailed from the KY State Treasurer. Remittance Advices will continue to be mailed by EDS.

* GO GREEN--Did you know that you can opt not to receive paper RA's. You can download the RA from the KyHealth Net and keep an electronic copy.


Top DenialsEOB 0482-Exact duplicateResolution: The claim has already paid, a duplicate will not hit against a previously denied claim.

EOB 2003-Member not eligible for MedicaidResolution: Always check member eligibility.

EOB 0102-Timely filingResolution: You have 1 year from the date of service, attach documentation to the back of the paper claim to show proof of timely filing.

KY MMIS Project

Provider Evaluation – Provider Workshop Date:

Thank you for attending this session. We’d appreciate your feedback, as well as suggestions on how we can improve future sessions.

Please answer the following questions, rating them on a scale of 1-5, with 1 being strongly disagree and 5 being strongly agree.

Question 1 2 3 4 5 1. Material was appropriate for the audience.

Comments:

2. Presentation was well-organized and easy to follow.

Comments:

3. Session leader was easy to hear/understand.

Comments:

4. The Session leader was well-versed in their subject area and presented information in a clear, understandable manner.

Comments:

5. I was given appropriate material/handouts.

Comments:

6. Questions were answered to my satisfaction.

Comments:

7. I was able to see/hear the audiovisual portion with no trouble.

Comments:

If you would like to receive information via e-mail, please provide address below.

Comments:

Optional: if you would like a member of the KY MMIS team to contact you, please provide your contact information below.

Name: Department/Branch:

Phone Number: Email:

Strongly Disagree Somewhat

Agree Strongly Agree

Documents

Kentucky Medicaid - kymmis.com Relations/UB Spring... · Enter the appropriate indicator, describing SHPS determination of Medical Necessity for the stay. ... Form Locator 6 is not