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Developmental Disabilities Waivers (BI, FIS, CL) Services

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September 22, 2022, 09:42 EDT

Chapter 5: Billing Instructions (DD)

Updated: 7/31/2015

The purpose of this chapter is to explain the procedures for billing the Department of Medical Assistance Services (DMAS) for Individual and Family Developmental Disabilities (DD)  Waiver services. Billing procedures for DD Waiver services are identical except for the procedure codes used to identify the type of service rendered.

Two major areas are covered in this chapter:

  • General Information - This is information about the timely filing of claims, claims inquiries, and billing supply procedures; and
  • Billing Procedures - Instructions are provided on the completion of the claim forms and the submission of adjustment requests.

Electronic Submission of Claims

Electronic billing using Electronic Data Interchange (EDI) is an efficient way to submit Medicaid claims. Providers use EDI software that enables the automated transfer of data in a specific format following specific data content rules directly to DMAS. For more information, go to https://vamedicaid.dmas.virginia.gov/edi.

The mailing address, phone number and fax number for the EDI program are:

EDI Coordinator

Virginia Medicaid Fiscal Agent

P.O. Box 26228

Richmond, Virginia 23260-6228

Phone: (866) 352-0766

Fax number: (888) 335-8460

The email to use for technical/web support for EDI is MESEDISupport@dmas.virginia.gov.

Billing Instructions: Direct Data Entry

As part of the 2011 General Assembly Appropriation Act - 300H which requires that all new providers bill claims electronically and receive reimbursement via Electronic Funds Transfer (EFT) no later than October 1, 2011 and existing Medicaid providers to transition to electronic billing and receive reimbursement via EFT no later than July 1, 2012, DMAS has implemented the Direct Data Entry (DDE) system. Providers can submit claims quickly and easily via the Direct Data Entry (DDE) system.  DDE will allow providers to submit Professional (CMS-1500), Institutional (UB-04) and Medicare Crossover claims directly to DMAS via the Virginia Medicaid Web Portal. Registration thru the Virginia Medicaid Web Portal is required to access and use DDE. The DDE User Guide, tutorial and FAQs can be accessed from our web portal at:  www.virginiamedicaid.dmas.virginia.gov. To access the DDE system, select the Provider Resources tab and then select Claims Direct Data Entry (DDE).  Providers have the ability to create a new initial claim, as well as an adjustment or a void through the DDE process. The status of the claim(s) submitted can be checked the next business day if claims were submitted by 5pm.  DDE is provided at no cost to the provider.

Timely Filing

Federal regulations [42 CFR § 447.45(d)] require the initial submission of all Medicaid claims (including accident cases) within 12 months from the date of service. Only claims that are submitted within 12 months from the date of service are eligible for Federal financial participation. To request a waiver of timely filing requirements, providers billing electronically must submit a Claim Attachment Form (DMAS-3) with the appropriate attachments.

DMAS is not authorized to make payment on claims that are submitted late, except under the following conditions:

Retroactive Eligibility - Medicaid eligibility can begin as early as the first day of the third month prior to the month in which the individual makes application for benefits. All eligibility requirements must be met within that period for retroactive eligibility to be granted. In these instances, unpaid bills for that period may be submitted to DMAS as Medicaid claims.

Delayed Eligibility - Initial denials of an individual’s Medicaid eligibility application may be overturned or other actions may cause an eligibility determination to be delayed. DMAS may make payments for dates of service more than 12 months in the past when the claims are for an individual whose determination of eligibility was delayed.

It is the provider’s obligation to verify the individual’s Medicaid eligibility. The individual’s local department of social services will notify providers who have rendered care during a period of delayed eligibility. The notification will indicate notification of the delayed eligibility and include the Medicaid ID number, and the time span for which eligibility has been granted. The provider must submit a claim within 12 months from the date of the notification of the delayed eligibility. A copy of the “signed and dated” letter from the local department of social services indicating the delayed claim information must be attached to the claim.

Denied claims - Denied claims must be submitted and processed on or before 13 months from the date of the initial claim denial where the initial claim was filed according to the timely filing requirements. The procedures for resubmission are:

  • Complete invoice as explained in this billing chapter.
  • Attach written documentation to justify/verify the explanation. If billing electronically and waiver of timely filing is being requested, submit the claim with the appropriate attachments. (The DMAS-3 form is to be used by electronic billers for attachments. See exhibits).

Accident Cases - The provider may either bill DMAS or wait for a settlement from the responsible liable third party in accident cases. However, all claims for services in accident cases must be billed to DMAS within 12 months from the date of the service. If the provider waits for the settlement before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS shall make no reimbursement.

Other Primary Insurance - The provider must bill other insurance as primary.  However, all claims for services must be billed to DMAS within 12 months from the date of the service. If the provider waits for payment before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS will make no reimbursements. If payment is made from the primary insurance carrier after a payment from DMAS has been made, an adjustment or void should be filed at that time.

Other Insurance - The member can keep private health insurance and still be covered by Medicaid. The other insurance plan pays first. Having other health insurance does not change the co-payment amount that providers may collect from a Medicaid member. For members with a Medicare supplemental policy, the policy can be suspended with Medicaid coverage for up to 24 months while the member has Medicaid without penalty from their insurance company. The member must notify the insurance company within 90 days of the end of Medicaid coverage to reinstate the supplemental insurance.

Billing Instructions: Billing Invoices (IFDD)

The requirements for submission of billing information and the use of the appropriate billing invoice depend upon the type of service being rendered by the provider and/or the billing transaction being completed. Listed below is the billing invoice to be used for billing assisted living services:

    • Health Insurance Claim Form CMS-1500 (02-12)

If submitting on paper, the requirement to submit claims on an original CMS-1500 claim form is necessary because the individual signing the form is attesting to the statements made on the reverse side of this form; therefore, these statements become part of the original billing invoice.

Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid members who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid.

Billing Instructions: Automated Crossover Claims Processing (IFDD)

Most claims for dually eligible members are automatically submitted to DMAS. The Medicare claims processors will submit claims based on electronic information exchanges between these entities and DMAS. As a result of this automatic process, the claims are often referred to as “crossovers” since the claims are automatically crossed over from Medicare to Medicaid.

To make it easier to match to providers to their Virginia Medicaid provider record, providers are to begin including their Virginia Medicaid Identification as a secondary identifier on the claims sent to Medicare. When a crossover claim includes a Virginia Medicaid Identification, the claim will be processed by DMAS using the Virginia Medicaid number rather the Virginia Medicare vendor number. This will ensure the appropriate Virginia Medicaid provider is reimbursed.

When providers send in the 837 format, they should instruct their processors to include the Medicaid provider number and use qualifier “1D” in the appropriate reference (REF) segment for provider secondary identification on claims. Providing the Virginia Medicaid Identification on the original claim to Medicare will reduce the need for submitting follow-up paper claims.

DMAS has established a special email address for providers to submit questions and issues related to the Virginia Medicare crossover process. Please send any questions or problems to the following email address: Medicare.Crossover@dmas.virginia.gov.

Billing Procedures (Hospital)

Hospitals and other practitioners must use the appropriate claim form or billing invoice when billing the Virginia Medicaid Program for covered services provided to eligible Medicaid enrollees. Each enrollee's services must be billed on a separate form.

The provider should carefully read and adhere to the following instructions so that claims can be processed efficiently. Accuracy, completeness, and clarity are important. Claims cannot be processed if applicable information is not supplied, in correct national form and format, or is illegible. Completed claims should be mailed to:

Department of Medical Assistance Services

P.O. Box 27443

Richmond, Virginia 23261-7443

Or

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Billing Instructions: Electronic Filing Requirements

DMAS is fully compliant with 5010 transactions and will no longer accept 4010 transactions after March 30, 2012.

The Virginia MMIS will accommodate the following EDI transactions according to the specification published in the Companion Guide version 5010

270/271 Health Insurance Eligibility Request/ Response Verification for Covered Benefits (5010)

276/277 Health Care Claim Inquiry to Request/ Response to Report the Status of a Claim (5010)

277 - Unsolicited Response (5010)

820 - Premium Payment for Enrolled Health Plan Members (5010)

834 - Enrollment/ Disenrollment to a Health Plan (5010)

835 - Health Care Claim Payment/ Remittance (5010)

837 - Dental Health Care Claim or Encounter (5010)

837 - Institutional Health Care Claim or Encounter (5010)

837 - Professional Health Care Claim or Encounter (5010)

NCPDP - National Council for Prescription Drug Programs Batch (5010)

NCPDP - National Council for Prescription Drug Programs POS (5010) Although not mandated by HIPAA, DMAS has opted to produce an Unsolicited 277 transaction to report information on pended claims.

All 5010/D.0 Companion Guides are available on the web portal: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/EDICompanionG… or contact EDI Support at 1-866-352-0766 or Virginia.EDISupport@conduent.com.

Although not mandated by HIPAA, DMAS has opted to produce an Unsolicited 277 transaction to report information on pended claims.

For providers that are interested in receiving more information about utilizing any of the above electronic transactions, your office or vendor can obtain the necessary information at our fiscal agent’s website: https://www.virginiamedicaid.dmas.virginia.gov.

Billing Instructions: ClaimCheck

 

        Effective June 3, 2013, DMAS implemented the Medicaid National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) and Medically Unlikely Edits

(MUE) edits.  This implementation was in response to directives in the Affordable Care Act of 2010. These new edits will impact all Physicians, Laboratory, Radiology, Ambulatory Surgery Centers, and Durable Medical Equipment and Supply providers. Effective January 1, 2014, all outpatient hospital claims will be subject the the NCCI edits thru the EAPG claim processing.   Please refer to the Hospital Manual, Chapter 5 for details related to EAPG.  The NCCI/ClaimCheck edits are part of the daily claims adjudication cycle on a concurrent basis.  The current claim will be processed to edit history claims.  Any adjustments or denial of payments from the current or history claim(s) will be done during the daily adjudication cycle and reported on the providers weekly remittance cycle.  All NCCI/ClaimCheck edits are based on the following global claim factors:  same member, same servicing provider, same date of service or the date of service is within established pre- or post-operative time frame.  All CPT and HCPCS code will be subject to both the NCCI and ClaimCheck edits.  Upon review of the denial, the provider can re-submit a corrected claim. Any system edits related to timely filing, etc. are still applicable.   

 

        PTP Edits:

CMS has combined the Medicare Incidental and Mutually Exclusive edits into a new PTP category. The PTP edits define pairs of CPT/HCPCS codes that should not be reported together. The PTP codes utilize a column one listing of codes to a column two listing of codes. In the event a column one code is billed with a column two code, the column one code will pay, the column two code will deny. The only exception to the PTP is the application of an accepted Medicaid NCCI modifier. Note: Prior to this implementation, DMAS modified the CCI Mutually Exclusive edit to pay the procedure with the higher billed charge. This is no longer occurring, since CMS has indicated that the code in column one is to be paid regardless of charge.

 

        MUE Edits:

DMAS implemented the Medicaid NCCI MUE edits. These edits define for each CPT/HCPCS code the maximum units of service that a provider would report under most circumstances for a single member on a single date of service and by same servicing provider. The MUEs apply to the number of units allowed for a specific procedure code, per day. If the claim units billed exceed the per day allowed, the claim will deny.  With the implementation of the MUE edits, providers must bill any bilateral procedure correctly. The claim should be billed with one unit and the 50 modifier. The use of two units will subject the claim to the MUE, potentially resulting in a denial of the claim. Unlike the current ClaimCheck edit which denies the claim and creates a claim for one unit, the Medicaid NCCI MUE edit will deny the entire claim.  

 

        Exempt Provider Types:

DMAS has received approval from CMS to allow the following provider types to be exempt from the Medicaid NCCI editing process. These providers are: Community Service Boards (CSB), Federal Health Center (FQHC),Rural Health Clinics (RHC), Schools and Health Departments.  These are the only providers exempt from the NCCI/editing process.  All other providers billing on the CMS 1500 will be subject to these edits.  

 

        Service Authorizations:

DMAS has received approval from CMS to exempt specific CPT/HCPCS codes which require a valid service authorization.  These codes are exempt from the MUE edits however, they are still subject to the PTP and ClaimCheck edits.    

 

        Modifiers:

Prior to this implementation, DMAS allowed claim lines with modifiers 24, 25, 57, 59 to bypass the CCI/ClaimCheck editing process. With this implementation, DMAS now only allows the Medicaid NCCI associated modifiers as identified by CMS for the Medicaid NCCI. The modifier indicator currently applies to the PTP edits. The application of this modifier is determined by the modifier indicator of “1”or “0” in the listing of the NCCI PTP column code. If the column one, column two code combination has a modifier indicator of “1”, a modifier is allowed and both codes will pay. If the modifier indicator is “0”, the modifier is not allowed and the column two code will be denied. The MUE edits do not contain a modifier indicator table on the edit table. Per CMS, modifiers may only be applied if the clinical circumstances justify the use of the modifier. A provider cannot use the modifier just to bypass the edit. The recipient’s medical record must contain documentation to support the use of the modifier by clearly identifying the significant, identifiable service that allowed the use of the modifier. DMAS or its agent will monitor and audit the use of these modifiers to assure compliance. These audits may result in recovery of overpayment(s) if the medical record does not appropriately demonstrate the use of the modifiers.

 

    Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include: E1 –E4, FA, F1 – F9, TA T1 – T9, LT, RT, LC, LD, RC, LM, RI, 24, 25, 57, 58, 78, 79, 27, 59, 91.  Modifiers 22, 76 and 77 are not Medicaid PTP NCCI approved modifiers. If these modifiers are used, they will not bypass the Medicaid PTP NCCI edits. 

  

Reconsideration

 

Providers that disagree with the action taken by a ClaimCheck/NCCI edit may request a reconsideration of the process via email (ClaimCheck@dmas.virginia.gov) or by submitting a request to the following mailing address:

 

 

Payment Processing Unit, Claim Check

Division of Program Operations

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219

 

There is a 30-day time limit form the date of the denial letter or the date of the remittance advice containing the denial for requesting reconsideration. A review of additional documentation may sustain the original determination or result in an approval or denial of additional day(s). Requests received without additional documentation or after the 30-day limit will not be considered. 

Billing Instructions Reference for Services Requiring Service Authorization

Please refer to the “Service Authorization” section in Appendix D of this manual.

Billing Instructions: Basis of Payment

A request for payment must be made under the Medicaid eligibility number of the person receiving the services and whose Medicaid eligibility number appears on the billing invoice.

Federal regulation 42 CFR 447.15 requires providers to accept Medicaid payment as payment in full for the service rendered. The provider may not bill DMAS or the member for the difference (if any) between the allowed charge and the provider's actual charge.

The provider must bill any other possibly liable third party prior to billing DMAS. Provider must submit a bill and it must be processed by DMAS within 12 months from date of service. DMAS will pay the difference between the Program's allowable fee and any payment made by another third party if that payment is less than the allowable fee.

Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid members who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the services if it were billed solely to Medicaid.

Billing Instructions: Special Note: Taxonomy (IFDD)

With the implementation of the National Provider Identifier (NPI), it will become necessary in some cases to include a taxonomy code on claims submitted to DMAS for all of our programs: Medicaid, FAMIS, and SLH. Prior to using the NPI, DMAS assigned a unique number to a provider for each of the service types performed. But with NPI, a provider may only have one NPI and bill for more than one service type with that number. Since claims are adjudication and paid based on the service type, our system must determine which service type the provider intended to be assigned to a particular claim. If the NPI can represent more than one service  type, a taxonomy code must be sent so the appropriate service type can be assigned.

 

Type of Service

Taxonomy Code(s)

Major Procedure Code Billed (required modifiers are not noted)

Comments

Private Duty

Nursing

163WC2100X

T1002, T1003

 

Personal Care

3747P1801X

H2021, T1005, T1019, S5126, S5135, S5136, S5150, S5160, S5161, S5165, S5185

 

Respite

385H00000X

 

T1002, T1003, T1005, S5135 S5136, S9125,

 

Home Health

251E00000X

0550, 0551, 0559, 0571, 0424,

0421, 0431, 0434, 0441, 0444,

0542

 

Family Care

Training

None

S5111

These providers must use their

DMAS-assigned API.

Adult Day Health

261QA0600X

S5102

 

Assisted Living

310400000X

311500000X

T1020 (Regular)

T2031 (Alzheimer’s)

 

 

Mental     Health- Mental Retardation Community Services

 

 

 

251C00000X

H0040, H2000, H2011, H2014, H2021, H2023, H2024, H2025, T1002, T1003, T1005, T1019, T1028, T1999, S5109, S5116, S5126, S5135, S5136, S5150, S5165, 97139, 97535, 97537,

99509, 99199

 

Case Management-

Baby Care

251B00000X

99420, G9001, G9002, A0160, S0215, S9442, S9446, 97802,

97803, S5131

 

Case Management Waiver

171M00000X

----------------- 251B00000X

 

H2000, S5109, S5116, S5135, S5165, T1016,T1028, 97139,

97535, 97537, 99199, 99509

For AIDS Waiver for Services Facilitator CM Services.

----------------------------------

For     all          other          waiver          case management services.

Treatment Foster Care

None

T1016

These providers must use their DMAS-assigned API.

 

 

 

Rejection Codes: (when the taxonomy is denied)

EDI Remark: Medicaid Edit- Reject

 

N94:       1359- Billing Taxonomy Code Does Not Cross-reference to Provider Type N94:     1392- Taxonomy Code Does Not Cross-reference to Provider Type

N288:     1393- No service Taxonomy Code on the Claim

N255:     1394- No Billing Provider Taxonomy Code on the Claim

Billing Instructions: Special Billing Instructions (IFDD)

SPECIAL BILLING INSTRUCTIONS

 

 

Locator 24D

Procedures, Services or Supplies

 

 

CPT/HCPCS – Enter the appropriate procedure code from the following list.

 

Rates can be retrieved on the DMAS website: www.dmas.virginia.gov.

 

 

State Plan Services

 

 

National Code

Modifier

DESCRIPTION

FEES

 

T2023

U3

Support Coordination

 

 

 

Waiver Services

 

 

 

National Code

Modifier

DESCRIPTION

FEES

 

H2014

 

In-Home Residential Support

 

H2023

 

Supported Employment, Individual Placed Prevocational

 

H2024

 

Supported Employment, Enclave/Work Crew

 

 

97537

 

Day Support, Regular Intensity, Center Based

 

97537

U1

Day Support, High Intensity, Center Based

 

97537

 

Day Support, Regular Intensity, Non-Center Based

 

97537

U1

Day Support, High Intensity, Non- Center Based

 

97139

 

Therapeutic Consultation

 

 

N/A

 

(Environmental Modification, Rehab Engineer)

 

S5165

 

Environmental Modifications Only

 

 

N/A

 

(Environmental Modification, Supply Only)

N/A

 

(Environmental Modification, Transportation Mod.)

99199

U4

Environmental Modification, Maintenance Costs Only

N/A

 

(Assistive Technology, Rehab Engineer)

T1999

 

Assistive Technology Only

T1999

U5

Assistive Technology, Maintenance Costs Only

T1019

 

Personal Assistance Northern Virginia Rest of State

T1005

 

Respite Services Northern Virginia Rest of State

S5150

 

Consumer-Directed Respite Services

Northern Virginia Rest of State

H2000

 

Initial Comprehensive Visit

Northern Virginia Rest of State

S5109

 

Employee Management Training

Northern Virginia Rest of State

99509

 

Routine Home Visit Northern Virginia Rest of State

T1028

 

Reassessment Visit Northern Virginia Rest of State

S5116

 

Management Training

Northern Virginia Rest of State

 

 

99199

U1

Criminal Record Check

99199

 

CPS Registry Check

S5126

 

Consumer-Directed Personal Assistance

Northern Virginia Rest of State

S5135

 

Companion Services Northern Virginia Rest of State

S5160

 

PERS Installation Northern Virginia Rest of State

S5160

U1

PERS and Medication Monitoring Installation

Northern Virginia Rest of State

S5161

 

PERS Monitoring Northern Virginia Rest of State

S5185

 

PERS and Medication Monitoring

Northern Virginia Rest of State

H2021

TD

PERS Nursing Services/RN

Northern Virginia Rest of State

H2021

TE

PERS Nursing Services/LPN

Northern Virginia Rest of State

S5111

 

Family/Caregiver Training

H0040

 

Crisis Supervision

H2011

 

Crisis Stabilization

T1002

 

Skilled Nursing Services/RN

Northern Virginia Rest of State

 

 

T1003

 

Skilled Nursing Services/LPN

Northern Virginia Rest of State

S5136

 

Consumer-Directed Companion Services

Northern Virginia Rest of State

H2025

 

Pre-vocational Services, Regular Intensity

H2025

U1

 

Pre-vocational Services, High Intensity

Billing Instructions: EDI Billing (Electronic Claims)

Please refer to X-12 Standard Transactions & our Companion Guides that are listed in the chapter.

 

Special Billing Instructions for Personal/Respite Care

Locator 14

Date of Current Illness, Injury, or Pregnancy

Date care began is located on the DMAS-93 (P.A. Letter)

Locator 24D

Procedures, Services or Supplies

 

CPT/HCPS – Enter the appropriate procedure code from the following list:

 

T1019

Personal Care

 

T1005

Respite care services, aide/hr.

 

S9125

Respite care services, LPN/hr.

 

 

 

 

 

 

Locator 29 for

 

CMS-1500 (02-12)

Amount Paid

 

Enter the patient pay amount except for Personal Care. (For Personal Care see instructions for Locator 29). Patient pay and primary carrier payments can be combined if applicable. EOB should be attached to claim.

Locator 29

Amount Paid

 

Enter the patient pay amount for Personal Care only.

Billing Instructions: Invoice Processing (IFDD)

The Medicaid invoice processing system utilizes a sophisticated electronic system to process Medicaid claims. Once a claim has been received, imaged, assigned a cross-reference number, and entered into the system, it is placed in one of the following categories:

  • Remittance Voucher
    • Approved - Payment is approved or placed in a pended status for manual adjudication (the provider must not resubmit).
    • Denied - Payment cannot be approved because of the reason stated on the remittance voucher.
  • No Response - If one of the above responses has not been received within 30 days, the provider should assume non-delivery and rebill using a new invoice form. The provider's failure to follow up on these situations does not warrant individual or additional consideration for late billing.