Medicaid Biller Training

For Out-of-state Providers

Resources New ProvidersNew Providers

Refer to Michigan Medicaid website, Refer to Michigan Medicaid website, Provider EnrollmentProvider Enrollment MI Eligibility Verification System MI Eligibility Verification System 1-888-696-3510

Prior Authorization – Prior Authorization – (All(All Non Emergency Services require PA) Non Emergency Services require PA) MA eligibility 517-335-5198 CSHCS eligibility 517-335-9440CSHCS eligibility 517-335-9440

Michigan Uniform Billing ManualMichigan Uniform Billing Manual Phone: 517-703-8622 | Fax:  517-327-4564Phone: 517-703-8622 | Fax:  517-327-4564 www.michigansubc.orgwww.michigansubc.org

Health Claim Form Association 1500Health Claim Form Association 1500 Refer to Michigan Medicaid website, Medicaid Provider Manual, Refer to Michigan Medicaid website, Medicaid Provider Manual, BILLING

& REIMBURSEMENT FOR PROFESSIONALS, section 3. section 3.Website – www.michigan.gov/mdch >> PROVIDERS >> Website – www.michigan.gov/mdch >> PROVIDERS >> INFORMATION FOR MEDICAID PROVIDERS INFORMATION FOR MEDICAID PROVIDERS

Medicaid Provider Medicaid Provider Explanation codesExplanation codes, Reason & Remark codes, Reason & Remark codes Provider Specific Information (Provider Specific Information (Fee-Screens)Fee-Screens)

Provider SupportProvider SupportPhone: 800-292-2550 Phone: 800-292-2550 Email: ProviderSupport@michigan.gov Email: ProviderSupport@michigan.gov

PROVIDERSPROVIDERS

Information for Information for Medicaid ProvidersMedicaid Providers

Click, Click, Click

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Provider Enrollment When to contact Provider Enrollment:• New Providers

• Refer to Michigan Medicaid website, Provider Enrollment for the enrollment form

• When any information associated with your Trading Partners Agreement changes

• Tax ID/Affiliation• Addresses• License (renewed, restored, additional)• Specialties• Billing Agents• NPI

PROVIDER ENROLLMENT UNIT

MEDICAID PAYMENTS DIVISION ProviderEnrollment@michigan.gov

MEDICAL SERVICES ADMINISTRATION

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

PO BOX 30238 Phone: 517-335-5492

LANSING, MI 48909 Fax: 517-241-8233 

National Provider Identifier (NPI)

Providers may now apply for their NPI through CMSMust have NPI by May 23, 2007MI Medicaid does not currently require NPI but greatly encourages applying nowMore NPI Information: https://nppes.cms.hhs.gov 1-800-465-3203 (NPI Toll-Free) customerservice@npienumerator.com

MMISMMISComing SoonComing Soon

Online Provider EnrollmentOnline Provider Enrollment Online EligibilityOnline Eligibility Online Claims SubmissionOnline Claims Submission Online Claim StatusOnline Claim Status And More, All Direct from And More, All Direct from MDCHMDCH

Eligibility Verification

Automated Voice Response System (AVRS) – Free (1-888-696-3510) Need Provider Type/ID and beneficiary information

WebDenis - Free (www.bcbsm.com/providers)

Medifax - for a fee (www.medifax.com)

Healthcare Data Exchange (HDX) - for a fee (www.hdx.com )

Eligibility Verification Scope/CoverageLevel of Care (LOC)

Third Party Liability (TPL)

Scp/Cvrg – 2-digit alpha/numeric code indicating which Medical Assistance Program the beneficiary is enrolled (i.e. Medicaid, CSHCS, ABW, MOMS, etc.)LOC – A modifier to the patients Scope/Coverage indicating other circumstances (i.e. nursing facility or hospice patient, enrolled in HMO, beneficiary is incarcerated, etc.)TPL – Any other payers preceding Medicaid; Medicaid is always the payer of last resort.

Eligibility Verification

Common Level of Care Code Blank (No LOC code) - fee-for-service (FFS). 02 - nursing facility services 11 - Adult Benefit Waiver (CHP) 07 - Medicaid Health Plan (MHP) 10 – Patient Pay amount 16 - hospice

Common Scope Code 1 - Medicaid 2 - Medicaid 3 - Adult Benefit

Waiver 4 - Refugees

and Repatriates

Scope/Coverage 0 (zero) - No Medicaid

eligibility/coverage (Deductible / Spend-down)

E - Emergency or urgent Medicaid coverage only

F - Full Medicaid coverage G - Adult Benefit Waiver

Eligibility PoliciesBeneficiary Eligibility Chapter, Medicaid Provider Manual

(Eligibility Code Descriptions)

Adult Benefits Waiver Chapter, Medicaid Provider Manual (Coverages and Limitations)

Children’s Special Health Care Services Program Chapter, Medicaid Provider Manual

Medicaid Health Plans, Medicaid Provider Manual (HMO responsibilities)

MI CHILD – www.michigan.gov/mdch >> Health Care Coverage >> Children and Teens (NOT MEDICAID)

Third Party Liability (TPL) at MDCH

Medicare “Buy-In” Unit at MDCH

Third Party Liability (TPL)

To remove or update other insurance To remove or update other insurance information from Third Party Liability information from Third Party Liability (TPL) file:(TPL) file:

Phone 800-292-2550 (option 4)Phone 800-292-2550 (option 4) Fax 517-346-9817Fax 517-346-9817 Email Email TPL_Health@Michigan.gov

Medicare “Buy-In” Unit (MDCH)

The Medicare Buy-In Unit is responsible for: Processing Medicare premium payments for

eligible Medicaid beneficiaries. Other Insurance Coding for Medicare on the

Medicaid system. Alien information for Medicaid beneficiaries that

are age 65 or over, must have the date of entry forwarded to the Buy-In Unit if the beneficiary has not been in the US for over 5 consecutive years.

The Medicare Buy-In unit will not be able to address questions from the beneficiaries.

Lewis Cass Building Phone: 517-335-5488

320 South Walnut Fax: 517-335-0478Lansing, MI 48913 Email BuyInUnit@Michigan.gov

Medicaid Billing Limitations

12 month limitation from Date of Service (DOS)

–Inpatient admission- 12 month from discharge date

Continuous Activity Within 120 days from last rejectionDocumentation is needed for:

–Claim replacements when Previously billed with incorrect:

Provider ID NumberBeneficiary ID Number

PAPER No confirmation

until CRN appears on RA

30-60 days to appear on Medicaid RA

Must attach EOB No paper clips,

white out or dot matrix printers

ELECTRONIC 997

Acknowledgement receipt from Medicaid

7-14 days to appear on Medicaid RA

No EOB needed A list of approved

billing agents is posted at Electronic Billing website

Claim Submission

Electronic BillingShopping for an Electronic Billing Agent

Billing Agent Authorization Form

835/277U Request Form

Billing Agent’s responsibilities

Billing And Reimbursement Chapters, Medicaid Provider Manual

AutomatedBilling@michigan.gov

Medicaid accepts electronic Primary, Secondary and Tertiary claims EOB’s are not needed when submitting

secondary/tertiary claims electronically CAS Codes are required

Complete Loop 2400 and 2430 for claim Procedure Code and Modifier (Professional)

Professional claims only need to be sent on paper when attachments (besides EOB’s) are needed

Electronic Claims

Medicaid is accepting crossover claims from WPS and AdminaStar

Bulletin All Provider 04-05, issued June 1, 2004 Bulletin MSA 05-02, issued January 1, 2005

Provider ID must be included in Loop 2010AA Example = REF*1D*108888888~

Medicaid will soon allow the Provider ID in Loop 2310B, Rendering Billing Provider IDFAQ’s posted at Provider Updates webpage

Crossover Claims(Special Services)

Crossover Claims(Special Services)

Troubleshooting Crossover Medicare EOB says that the “Claim was forwarded to

MDCH for Reimbursement” but claim never appears on Medicaid Remittance Advice: This means that your Medicaid Provider Type and ID were

not in the proper provider identifying field within your electronic claim

See your vendor for correction Rebill to Medicaid any crossover claims that do not appear

within 30 days of Medicare EOB

Groups of providers who submit batches of claims under one Medicare group ID but more than one Medicaid Provider ID should not attempt to crossover until further notice

The 835 is the only electronic format available Paper is still available

835 reports all paid and rejected claims 277U will report pended claims

MDCH edits no longer exist Nationally recognized Reason/Remark codes

Posted electronically and on paper RA Crosswalk available at website

www.michigan.gov/mdch >> Providers >> Information for Medicaid Providers >> Electronic Billing

835 – Electronic Remittance Advice

Remittance Advice

MSA Remittance Advice

Payment Information by beneficiaryIssued by MDCHDate, Provider Type/ID, & Amounts match Warrant Date, Provider Type/ID, & AmountsOne RA issued to each Provider ID

State of Michigan Remittance Advice

Attached to the “Check”Check and RA (AKA “Warrant”)Payment information by Provider Type/ID and Tax IDIssued by Department of Treasury“39S 391”= MDCH/MedicaidOne RA issued to each Tax ID

Checks and Remittance Advice (EOB) mailed separately

ReplacementReplacementExamples of when a claim may need to be replaced:

To return an overpayment (report "returning money" in Remarks section);

To correct information submitted on the original claim (other than to correct the Provider ID number and/or the beneficiary ID number). Refer to the Void/Cancel subsection below;

To report payment from another source after MDCH paid the claim (report "returning money" in Remarks section); and/or

To correct information that the scanner may have misread (state reason in Remarks section).

ReplacementReplacement

To replace a previously paid claim, UB-92-

indicate 7 (xx7) as the third digit in the Type of Bill Form locator frequency.

enter the 10-digit Claim Reference Number (CRN) of the last approved claim being replaced

the reason for the replacement in Remarks. The Provider ID number and beneficiary ID number on the replacement claim must be the same as on the original claim.

Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR INSTITUTIONAL, section 3.1

ReplacementReplacementTo replace a previously paid claim,

HCFA 1500- Report code 7 in the left side of Item 22 Report the ten-digit Claim Reference Number (CRN)

of the previously paid claim in the right side of Item 22

State reason in the Remarks sectionNOTE: If the resubmission code of 7 is missing the

claim cannot be processed as a replacement claim.If all service lines of a claim were rejected, the services must be resubmitted as a new claim, not a replacement claim.

Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR PROFESSIONALS, section 4.1

Void/Cancel Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number,providers must void/cancel the claim. UB-92

indicate an 8 in the Type of Bill (xx8) as the third digit frequency.

enter the 10-digit CRN of the last approved claim or adjustment being cancelled and

enter in Remarks Section the reason for the void/cancel.

A new claim may be submitted immediately using the correct provider or beneficiary ID number.

A void/cancel claim must be completed exactly as the original claim.Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR INSTITUTIONAL, section 3.2

Void/Cancel Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number,providers must void/cancel the claim. HCFA 1500

Report code 8 in the left side of Item 22 Report the ten-digit Claim Reference Number

(CRN) of the previously paid claim in the right side of Item 22

complete one service line and enter zero dollars

(000) in all money fields. State reason in the Remarks sectionRefer to Michigan Medicaid manual, BILLING &

REIMBURSEMENT FOR PROFESSIONALS, section 4.2

Prior Authorization Prior Authorization

All out of state services that have been prior authorized must

indicate in Remarks (F.L. 19) “OUT OF STATE”

prior authorization number in prior authorization field

AppealsAppeals

1. Claim is submitted to MDCH (PO Box (PO Box 30043)30043)

2. Claim is denied3. If necessary, correct claim information

indicated as insufficient/incorrect on RA and resubmit

4. If corrected claim is rejected contact Provider Support Hotline for counsel (1-800-292-2550)

AppealsAppeals

5. Hotline advice is followed, but claim is still processed improperly

6. Send paper claim with letter explaining situation/history and request for action to Special Payments’ Research and Analysis (PO Box 30731)

7. Research and Analysis either denies request or processes but system still rejects

AppealsAppeals

8. If all requirements have been satisfied and all instruction followed but claim continues to reject, MDCH Administrative Tribunal should be contacted

MDCH Administrative Tribunal & Appeals DivisionMDCH Administrative Tribunal & Appeals Division

PO Box 30763PO Box 30763

Lansing, MI 48909Lansing, MI 48909

Phone: 517-334-9500Phone: 517-334-9500