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October 11, 2022, 05:17 EDT

Chapter : Billing Instructions (Transport)

Updated: 10/3/2022

The purpose of this chapter is to explain the documentation procedures for billing the Virginia Medicaid Program.

Two major areas are covered in this chapter:

  • General Information - This section contains information about the timely filing of claims, claim inquiries, and supply procedures.
  • Billing Procedures - Instructions are provided on the completion of claim forms, submitting adjustment requests, and additional payment services.

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 (Transport)

The requirements for submission of emergency air and ground ambulance billing information and the use of the appropriate claim form or billing invoice are dependent 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:

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

Example     of     these     forms     may     be     viewed                   on    the        DMAS   website        at: http://www.dmas.virginia.gov/SEARCH.ASP. 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. To review the Medicaid allowed amount, providers may locate fees at: http://dmasva.dmas.virginia.gov/Content_pgs/trn-home.aspx

Billing Instructions: Automated Crossover Claims Processing (Transport)

Most claims for dually eligible members are automatically submitted to DMAS. The Medicare claims processor 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.

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.

To make it easier to match providers to their Virginia Medicaid provider record, providers are to begin including their Virginia Medicaid ID as a secondary identifier on the claims sent to Medicare. When a crossover claim includes a Virginia Medicaid ID, the claim will be processed by DMAS using the Virginia Medicaid number rather than the 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 Virginia Medicaid provider number and use qualifier “1D” in the appropriate reference (REF) segment for provider secondary identification on claims. Providing the Virginia Medicaid ID 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.

Effective with claims received on or after 5/23/08, DMAS can only process claims submitted with an NPI.

Medicare/Medicaid Crossover Ambulance Claim Calculation (Transport)

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.

DMAS is responsible for calculating and paying all Fee-for-Service Medicaid/Medicare Crossover payments for Emergency and Non-Emergency Ambulance Services.

DMAS rate tables used to calculate Ambulance crossover payments for A0425, A0427, A0429, A0430, A0431, A0433, A0434, A0435, and A0436 can be found at:

http://www.dmas.virginia.gov/#/ambulance.

DMAS rate table used to calculate Ambulance crossover payments for A0426, A0428, A0434, and A0425 (mileage code billed with service codes listed in this paragraph) can be found at http://www.dmas.virginia.gov/#/ambulance. The preceding rate table link for these three CPT service codes are for crossover payment calculation only.

DMAS Billing Instructions for Fractional Mileage Billed on Air and Ground Ambulance Claims (Transport)

DMAS will continue to require fee for  service ambulance claims  and  secondary  Medicare ambulance claims directly from the provider to be submitted with mileage procedure codes to be rounded up to the next highest number. DMAS will only accept the claims with a decimal directly from Medicare (GHI). At this time, DMAS will continue to round up to the next highest number until our MMIS (claims system) is able to accept decimals.

DMAS will notify providers in advance when MMIS is able to accept fractional mileage on all ambulance claims.

Billing Instructions: Virginia Medicaid Web Portal (Transport)

DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register  through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov. If you have any questions regarding  the Virginia Medicaid Web Portal, please contact the Xerox Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 A.M. to 5:00 P.M. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.

Billing Instructions: Helpline

The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except holidays. The “HELPLINE” numbers are:

1-804-786 -6273         Richmond area and out-of-state long distance

1-800-552-8627          All other areas (in-state, toll-free long distance)

Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Number or your NPI number available when you call.

Billing Instructions: Billing Procedures (Transport)

Transportation 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 or is illegible.

When the emergency air or ground ambulance claim form is completed, claims must be mailed to:

 

DMAS-Transportation

P. O. Box 27444

Richmond, Virginia 23261-7444 Or

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444


 

Note: The Pre-hospital Patient Care Report (PPCR) is not required to be attached.

Image removed.The DMAS Fee Schedule for Emergency Air or Ground transportation is available on the DMAS website at the following address: http://www.dmas.virginia.gov/#/ambulance.

Billing Instructions: More Than One Emergency Air or Ground Transport Within the Same Day of Service

Please complete second/third claims using the same billing instructions as the first. Please provide a cover letter explaining the claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of CMS 1500 for the second/third claim with attachments and mail to:

DMAS

Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219

Billing Instructions: Emergency Ground Ambulance Transports 200 Miles and Over

Emergency ground ambulance transports 200 miles and over must be reviewed and approved by the DMAS transportation unit before processing. Please send claim to street address listed above with attachments (PPCR report) justifying emergency transport 200 miles and over.

Billing Instructions: Air Ambulance Claims Paid at Ground Ambulance Rate and Request for Re-Review on Claims With a Date of Service October 31st, 2009 and Before

Air ambulance claims submitted that do not establish air ambulance medical necessity will be paid at DMAS emergency ground ambulance rates.

In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be re-reviewed if the original claim was missing attachments or other medical information. For re-review please write a brief description or explanation as to why the claim was resubmitted.

Please mail the letter, a new original CMS 1500 with attachments to: DMAS

Transportation Unit, Suite 1300

600 East Broad Street

Richmond, Virginia 23219

If re-review is denied then please first use the informal appeal (IFFC) process listed below. If needed, the formal appeal process is listed below as well.

TELEMEDICINE ORIGINATING SITE FEE

DMAS will reimburse an originating site fee to emergency ambulance transport providers for facilitating a telemedicine consultation between a Medicaid member and a Medicaid-enrolled provider for the purposes of identifying whether the Medicaid member is in need of emergency ambulance transportation. Specifically, emergency ambulance transportation providers may submit a claim for providing a telemedicine “originating site fee” service (CPT Q3014) under the following conditions:

  • The Emergency Ambulance Transport provider is licensed as a Virginia Emergency Medical Services (EMS) ambulance provider.
  • The Emergency Ambulance Transport provider must be enrolled as such with DMAS.
  • The Medicaid member is in a physical location where telemedicine services can be received per requirements set forth in the Telehealth Supplement.
  • The member and provider of telemedicine services are not in the same physical location during the consultation.
  • The Emergency Ambulance Transport provider assists with initiation of the visit but the presence of the Emergency Ambulance Transportation provider in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.

Emergency Ambulance Transport providers should submit a claim for providing an originating site fee service in one of two ways:

  • If the Member receives emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit two claims: one claim for Q3014 on a CMS-1500 and a separate claim for emergency transportation services.
  • If the Member does not receive emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit one claim for Q3014 on a CMS-1500.

Emergency Ambulance Transport providers should maintain the Pre-hospital Patient Care Report (PPCR) documentation that includes identifying information of the Provider of telemedicine services (e.g., NPI), evidence that emergency transportation was or was not recommended by the telemedicine provider, and whether the member did or did not receive emergency ambulance transportation services subsequent to and based on the facilitated telemedicine consultation.

Billing Instructions: Fee-for-Service (FFS) Non-Emergency Transportation Broker

DMAS has contracted with a Broker to manage FFS Non-Emergency Medical Transportation (NEMT) for the Commonwealth of Virginia. All FFS non-emergency trips must be arranged with and confirmed by the Broker. There are seven types of transportation services available:

    • Sedan/Taxi for Ambulatory (able to walk)
    • Wheelchair Transportation
    • Non-emergency ambulance
    • Stretcher Van
    • Non-emergency Neonatal transports
    • Gas Reimbursement
    • Mass transit bus tickets/passes
    • Volunteer Driver

A Broker Customer Service Representative is available to discuss with you the specific details for each type of arrangement. To access trip request services, call the reservation line at 1-866-386-8331 or go on line http://trasportation.dmas.virginia.gov

Remember ambulance trips must be medically necessary (Ex: doctor appointment, counseling, dialysis, dental appointments, etc.). Reservations for routine appointments  must be made with at least five (5) business days notice prior to the scheduled medical appointment with the FFS or MCO broker or internal transportation service. Verifiable “Urgent” trips may be accepted with less than five (5) day notice.

Billing Instructions: Transportation for Managed Care Organizations

Virginia Medicaid enrolls eligible Medicaid members in Managed Care Organizations (MCO). Eligible enrollees receive emergency air ambulance, emergency ground ambulance and   non-emergency   transportation   services   through the  MCO.                                                   Please contact the appropriate MCO for service authorization or billing instructions. You can access MCO information and MCO transportation telephone numbers at: http://www.dmas.virginia.gov/#/nemtservices.    Select    “Transportation Contacts” under the “Information” heading.

Billing Instructions: DMAS Toll-Free Telephone Numbers for All Non-Emergency Medical Transportation (NEMT) Services

Transportation Reservation Telephone Numbers

Find the Medicaid Plan you are enrolled in below and call that number to make your transportation arrangements or check to see if you are eligible for transportation. Ask  about bus tickets or gas reimbursement for you, a friend, or neighbor to your Medicaid appointment.

 

FFS / MCO /CCC Plus/Medallion 4.0

Reservation Numbers

Details

Fee For Service (FFS)

*Including all CL, BI, & FIS Waived Services

(866) 386-8331

All ages and all levels of service

Aetna Better Health of VA - CCC Plus

(800) 734-0430

Option 1

All ages and all levels of

service

Aetna Better Health of Virginia (Medallion 4.0)

(800) 734-0430

All ages and all levels of service

Anthem HealthKeepers CCC Plus

(855) 325-7581

All ages and all levels of

service

Anthem HealthKeepers Plus (Medallion

4.0)

(877) 892-3988

All ages and all levels of

service

Magellan Complete Care of Virginia

(877) 790-9472

All ages and all levels of

service

Magellan Complete Care of Virginia

(Medallion 4.0)

(833) 273-7416

All ages and all levels of

service

Optima Family Care (Medallion 4.0)

(877) 892-3986

All ages ambulatory and

wheelchair

Optima Health CCC Plus

(855) 325-7558

All ages and all levels of

service

United Healthcare CCC Plus

(844) 604-2078

All ages and all levels of service

United Healthcare Community Plan

(Medallion 4.0)

(833) 215-3884

All ages and all levels of

service

Virginia Premier CCC Plus

(855) 880-3480

All ages and all levels of

service

Virginia Premier Elite Individual

(Medallion - 4.0)

(855) 880-3480

All ages and all levels of

service

 

 

Transportation Ride Assist/Customer Service Telephone Numbers

If you need to cancel your ride, ask questions about your ride or transportation. Have a compliment or complaint, please call the appropriate Medicaid plan you are enrolled with that is listed below.

 

FFS / MCO /CCC Plus/Medallion 4.0

Ride Assist/Where’s My Ride Telephone Numbers

Fee For Service (FFS)

*Including all CL, BI, & FIS Waived Services

(866) 246-9979

Aetna CCC Plus and Medallion 4.0

(800) 734-0430 Option 2

Anthem HealthKeepers CCC Plus

(855) 325-7581 Option 1

Anthem HealthKeepers Plus (Medallion

4.0)

(877) 892-3988 Option 2

Magellan Complete Care of Virginia

(877) 790-9472 (TTY – (866) 288-3133

Magellan Complete Care of Virginia

(Medallion 4.0)

(833) 273-7416

Optima Family Care (Medallion 4.0)

(877) 892-3986 Option 1

Optima Health - CCC Plus

(855)-325-7558 Option 1

United Healthcare CCC Plus

(844) 525-1491 (TTY – (844) 525-

1491

UnitedHealthcare Community Plan (Medallion 4.0)

(833) 215-3885

Virginia Premier CCC Plus

(855) 880-3480

Virginia Premier Elite Individual

(Medallion 4.0)

(855) 880-3480

 

FFS Rider Handbook, Frequently Asked Questions (FAQs), and FFS on line reservations: http://transportation.dmas.virginia.gov

*Special Note for CL, BI, & FIS Members: For waivered services transportation questions and/or concerns call the FFS telephone number. For your medical appointments please call the CCC Plus MCO in which you are enrolled.

Billing Instructions: In-State and Out-of-State Medicaid Member Travel (Transport)

Medicaid members enrolled in a Managed Care Organization (MCO) must contact the MCO for in-state and out-of-state travel prior authorization and travel reimbursement instructions. MCO contacts can be found at: http://www.dmas.virginia.gov/#/nemtservices Look under heading Information and click on “Transportation Contacts.”

FFS Medicaid covered services may require in state or out of state long distance travel. Medical necessity for in state and out of state services must be established prior to travel. Medicaid members must obtain prior authorization before travel begins.

FFS In-state long distance travel or travel to surrounding cities out of state must have prior authorization from the Non-Emergency Transportation Broker before travel begins. Please contact the transportation broker at 1-866-386-8331 for prior approval. The non- emergency transportation broker is responsible for travel arrangements and reimbursement for in state and surrounding areas to the State of Virginia.

FFS out-of-state travel not covered by the broker must have prior authorization before travel begins. Please contact DMAS Medical Support Unit at (804) 786-8056 thirty (30) days prior to travel. Out-of-State travel days will be approved by Medical support. Travel Reimbursement will be reimbursed at the state employee travel, hotel, per diem, mileage reimbursement rate. Once approved the FFS DMAS Transportation unit can answer travel questions. Please send questions to Transportation@DMAS.Virginia.gov

BIlling Instructions: FFS and MCO Psych Transports

FFS ambulance providers who transport FFS Psych members are to bill DMAS directly with A0429 BLS and A0425 mileage. You do not need to contact FFS broker for approval. However, ensue your PPCR include this was a PSYCH transport.

The ambulance company transporting MCO Psych patients must contact the MCO or MCO internal transportation service for billing instructions.

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 Special Note: Taxonomy (Transport)

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 adjudicated and paid based on the service type, the Department’s system must determine which service type the provider intended to assign 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.

 

Taxonomy Code

Description

3416A0800X

 

Transportation – Emergency Air

3416L0300X

 

Transportation     –     Emergency Land

Billing Instructions: Negative Balance Information

Negative balances occur when one or more of the following situations have occurred:

 

        Provider submitted adjustment/void request

        DMAS completed adjustment/void

        Audits

        Cost settlements

        Repayment of advance payments made to the provider by DMAS

 

In the remittance process the amount of the negative balance may be either off set by the total of the approved claims for payment leaving a reduced payment amount or may result in a negative balance to be carried forward. The remittance will show the amount as, “less the negative balance” and it may also show “the negative balance to be carried forward”. 

The negative balance will appear on subsequent remittances until it is satisfied. An example is if the claims processed during the week resulted in approved allowances of $1000.00 and the provider has a negative balance of $2000.00 a check will not be issued, and the remaining $1000.00 outstanding to DMAS will carry forward to the next remittance.

Billing Instructions: Instructions for Completing the Paper CMS-1500 (02-12) Form for Medicare and Medicare Advantage Plan Deductible, Coinsurance and Copay Payments for Professional Services (Effective 11/02/2014)

The Direct Data Entry (DDE) Crossover Part B claim form is on the Virginia Medicaid Web Portal. Please note that providers are encouraged to use DDE for submission of claims that cannot be submitted electronically to DMAS. Registration thru the Virginia Medicaid Web Portal is required to access and use DDE. The DDE User Guide, tutorial and FAQ’s 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. Paper claim submissions should only be submitted when requested specifically by DMAS.

Purpose: A method of billing Medicare’s deductible, coinsurance and copay for professional services received by a Medicaid member in the Virginia Medicaid program on the CMS 1500 (02-12) paper claim form. The CMS1500 (02-12) claim form must be used to bill for services received by a Medicaid member in the Virginia Medicaid program. The following instructions have numbered items corresponding to fields on the CMS1500 (02-12)
NOTE: Note changes in locator 11c and 24A lines 1-6 red shaded area. These changes are specific to Medicare Part B billing only.

 

 

 

 

Locator Instructions
1 REQUIRED Enter an "X" in the MEDICAID box for the Medicaid Program. Enter an “X” in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO).
1a REQUIRED Insured's I.D. Number - Enter the 12-digit Virginia Medicaid Identification number for the member receiving the service.
2 REQUIRED Patient's Name - Enter the name of the member receiving the service.
3 NOT REQUIRED Patient's Birth Date
4 NOT REQUIRED Insured's Name
5 NOT REQUIRED Patient's Address
6 NOT REQUIRED Patient Relationship to Insured
7 NOT REQUIRED Insured's Address
8 NOT REQUIRED Reserved for NUCC Use
9 NOT REQUIRED Other Insured's Name
9a NOT REQUIRED Other Insured's Policy or Group Number
9b NOT REQUIRED Reserved for NUCC Use
9c NOT REQUIRED Reserved for NUCC Use
9d NOT REQUIRED Insurance Plan Name or Program Name
10 REQUIRED

Is Patient's Condition Related To: - Enter an "X" in the appropriate box.

a. Employment?

b. Auto accident

c. Other Accident? (This includes schools, stores, assaults, etc.) NOTE: The state should be entered if known.

10d Conditional

Claim Codes (Designated by NUCC)

Enter “ATTACHMENT” if documents are attached to the claim form. Medicare/Medicare Advantage Plan EOB should be attached.

11 NOT REQUIRED Insured's Policy Number or FECA Number
11a NOT REQUIRED Insured's Date of Birth
11b NOT REQUIRED Other Claim ID
11c REQUIRED

Insurance Plan or Program Name

Enter the word ‘CROSSOVER

IMPORTANT: DO NOT enter ‘HMO COPAY’ when billing for Medicare/Medicare Advantage Plan copays! Only enter the word ‘CROSSOVER’

11d

REQUIRED

If Applicable

Is There Another Health Benefit Plan?

If Medicare/Medicare Advantage Plan and Medicaid only, check “NO”. Only check “Yes”, if there is additional insurance coverage other than Medicare/Medicare Advantage Plan and Medicaid.

12 NOT REQUIRED Patient's or Authorized Person's Signature
13 NOT REQUIRED Insured's or Authorized Person's Signature
14 NOT REQUIRED

Date of Current Illness, Injury, or Pregnancy

Enter date MM DD YY format

Enter Qualifier 431 – Onset of Current Symptoms or Illness

15 NOT REQUIRED Other Date
16 NOT REQUIRED Dates Patient Unable to Work in Current Occupation
17 NOT REQUIRED Name of Referring Physician or Other Source – Enter the name of the referring physician.
17a shaded red NOT REQUIRED I.D. Number of Referring Physician - The ‘1D’ qualifier is required when the Atypical Provider Identifier (API) is entered. The qualifier ‘ZZ’ may be entered if the provider taxonomy code is needed to adjudicate the claim. Refer to the Medicaid Provider manual for special Billing Instructions for specific services.
17b NOT REQUIRED I.D. Number of Referring Physician - Enter the National Provider Identifier of the referring physician.
18 NOT REQUIRED Hospitalization Dates Related to Current Services
19 NOT REQUIRED

Additional Claim Information

Enter the CLIA #.

20 NOT REQUIRED Outside Lab?
21 A-L REQUIRED

Diagnosis or Nature of Illness or Injury - Enter the appropriate ICD diagnosis code, which describes the nature of the illness or injury for which the service was rendered in locator 24E. Note: Line ‘A’ field should be the Primary/Admitting diagnosis followed by the next highest level of specificity in lines B-L.

Note: ICD Ind. Not required at this time.

22

REQUIRED

If Applicable

Resubmission Code – Original Reference Number. Required for adjustment or void. Enter one of the following resubmission codes for an adjustment:

Code Description
1023 Primary Carrier has made additional payment
1024 Primary Carrier has denied payment
1025 Accommodation charge correction
1026 Patient payment amount changed
1027 Correcting service periods
1028 Correcting procedure/ service code
1029 Correcting diagnosis code
1030 Correcting charge
1031 Correcting units/visits/studies/procedures
1032 IC reconsideration of allowance, documented
1033 Correcting admitting, referring, prescribing, provider identification number
1053

Adjustment reason is in the Misc. Category

 

 

 

 

 

 

 

 

 

 

 

Enter one of the following resubmission codes for a void:

Code Description
1042 Original claim has multiple incorrect items
1044 Wrong provider identification number
1045 Wrong enrollee eligibility number
1046 Primary carrier has paid DMAS maximum allowance
1047 Duplicate payment was made
1048 Primary carrier has paid full charge
1051 Enrollee not my patient
1052 Miscellaneous
1060 Other insurance is available

 

 

 

 

 

 

 

 

Original Reference Number - Enter the claim reference number/ICN of the Virginia Medicaid paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted or voided. Only one paid claim can be adjusted or voided on each CMS-1500 (02-12) claim form. (Each line under Locator 24 is one claim).

NOTE: ICNs can only be adjusted or voided through the Virginia MMIS up to three years from the date the claim was paid. After three years, ICNs are purged from the Virginia MMIS and can no longer be adjusted or voided through the Virginia MMIS. If an ICN is purged from the Virginia MMIS, the provider must send a refund check made payable to DMAS and include the following information:

  • A cover letter on the provider’s letterhead which includes the current address, contact name and phone number.
  • An explanation about the refund.
  • A copy of the remittance page(s) as it relates to the refund check amount.
  • Mail all information to:

Department of Medical Assistance Services

Attn: Fiscal & Procurement 

Division, Cashier

600 East Broad St. Suite 1300

Richmond, VA 23219

23

REQUIRED

If Applicable

Prior Authorization (PA) Number – Enter the PA number for approved services that require a service authorization.

NOTE: The locators 24A thru 24J have been divided into open and shaded line areas. The shaded area is ONLY for supplemental information. DMAS has given instructions for the supplemental information that is required when needed for DMAS claims processing. ENTER REQUIRED INFORMATION ONLY.

24A lines 1-6 open area REQUIRED Dates of Service - Enter the from and thru dates in a 2-digit format for the month, day and year (e.g., 01 01 14).
24A-H lines 1- 6 red shaded

REQUIRED

If Applicable

NEW INFORMATION! DMAS is requiring the use of the following qualifiers in the red shaded for Part B billing:

  • A1 = Deductible (Example: A120.00) = $20.00 ded
  • A2 = Coinsurance (Example: A240.00) = $40.00 coins
  • A7= Copay (Example: A735.00) = $35.00 copay
  • AB= Allowed by Medicare/Medicare Advantage Plan (Example AB145.10) = $145.10 Allowed Amount
  • MA= Amount Paid by Medicare/Medicare Advantage Plan (Example MA27.08) see details below
  • CM= Other insurance payment (not Medicare/Medicare Advantage Plan) if applicable (Example CM27.08) see details below
  • N4 = National Drug Code (NDC)+Unit of Measurement

‘MA’: This qualifier is to be used to show Medicare/Medicare Advantage Plan’s payment. The ‘MA’ qualifier is to be followed by the dollar/cents amount of the payment by Medicare/Medicare Advantage Plan

Example: Payment by Medicare/Medicare Advantage Plan is $27.08; enter MA27.08 in the red shaded area

CM’: This qualifier is to be used to show the amount paid by the insurance carrier other than Medicare/Medicare Advantage plan. The ‘CM’ qualifier is to be followed by the dollar/cents amount of the payment by the other insurance.

Example: Payment by the other insurance plan is $27.08; enter CM27.08 in the red shaded area

NOTE: No spaces are allowed between the qualifier and dollars. No $ symbol is allowed. The decimal between dollars and cents is required.

DMAS is requiring the use of the qualifier ‘N4’. This qualifier is to be used for the National Drug Code (NDC) whenever a drug related HCPCS code is submitted in 24D to DMAS. The Unit of Measurement Qualifiers must follow the NDC number. The unit of measurement qualifier code is followed by the metric decimal quantity or unit. Do not enter a space between the unit of measurement qualifier and NDC. Example: N400026064871UN1.0

Any spaces unused for the quantity should be left blank.

Unit of Measurement Qualifier Codes:

  • F2 – International Units
  • GR – Gram
  • ML – Milliliter
  • UN – Unit

Examples of NDC quantities for various dosage forms as follows:

a. Tablets/Capsules – bill per UN

b. Oral Liquids – bill per ML

c. Reconstituted (or liquids) injections – bill per ML

d. Non-reconstituted injections (I.E. vial of Rocephin powder) – bill as UN (1 vial = 1 unit)

e. Creams, ointments, topical powders – bill per GR

f. Inhalers – bill per GR

Note: All supplemental information entered in locator 24A thru 24H is to be left justified.

Examples:

  1. Deductible is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $20.00, Medicare/Medicare Advantage Plan Paid Amt is $16.00, Coinsurance is $4.00.
    • Enter:A110.00 AB20.00 MA16.00 A24.00
  2. Copay is $35.00, Medicare/Medicare Advantage Plan Paid Amt is $0.00 Medicare/Medicare Advantage Plan Allowed Amt is $100.00
    • Enter: A735.00 MA0.00 AB100.00
  3. Medicare/Medicare Advantage Plan Paid Amt is $10.00, Other Insurance payment is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $10.00, Coinsurance is $5.00, NDC is 12345678911, Unit of measure is 2 grams
    • Enter: MA10.00 CM10.00 AB10.00 A25.00 N412345678911GR2

**Allow a space in between each qualifier set**

24B open area REQUIRED Place of Service - Enter the 2-digit CMS code, which describes where the services were rendered. 
24C open area REQUIRED If applicable Emergency Indicator - Enter either ‘Y’ for YES or leave blank. DMAS will not accept any other indicators for this locator.
24D open area REQUIRED

Procedures, Services or Supplies – CPT/HCPCS – Enter the CPT/HCPCS code that describes the procedure rendered or the service provided.

Modifier - Enter the appropriate CPT/HCPCS modifiers if applicable.

24E open area REQUIRED Diagnosis Code - Enter the diagnosis code reference letter A-L (pointer) as shown in Locator 21 to relate the date of service and the procedure performed to the primary diagnosis. The primary diagnosis code reference letter for each service should be listed first. NOTE: A maximum of 4 diagnosis code reference letter pointers should be entered. Claims with values other than A-L in Locator 24-E or blank will be denied.
24F open area REQUIRED Charges - Enter the Medicare/Medicare Advantage Plan billed amount for the procedure/services. NOTE: Enter the Medicare/Medicare Advantage Plan Copay amount as the charged amount when billing for the Medicare/Medicare Advantage Plan Copay ONLY.
24G open area REQUIRED Days or Unit - Enter the number of times the procedure, service, or item was provided during the service period.
24H open area REQUIRED If applicable

EPSDT or Family Planning - Enter the appropriate indicator. Required only for EPSDT or family planning services.

1 - Early and Periodic, Screening, Diagnosis and Treatment Program Services

2 - Family Planning Service

24I open REQUIRED If applicable NPI – This is to identify that it is a NPI that is in locator 24J
24 I redshaded REQUIRED If applicable ID QUALIFIER –The qualifier ‘ZZ’ can be entered to identify the provider taxonomy code if the NPI is entered in locator 24J open line. The qualifier ‘1D’ is required for the API entered in locator 24J red shaded line.
24J open REQUIRED If applicable Rendering provider ID# - Enter the 10 digit NPI number for the provider that performed/rendered the care.
24J redshaded REQUIRED If applicable Rendering provider ID# - If the qualifier ‘1D’ is entered in 24I shaded area enter the API in this locator. If the qualifier ‘ZZ’ was entered in 24I shaded area enter the provider taxonomy code if the NPI is entered in locator 24J open line.
25 NOT REQUIRED Federal Tax I.D. Number
26 REQUIRED Patient's Account Number – Up to FOURTEEN alphanumeric characters are acceptable.
27 NOT REQUIRED Accept Assignment 
28 REQUIRED Total Charge - Enter the total charges for the services in 24F lines 1-6
29 REQUIRED If applicable Amount Paid – For personal care and waiver services only – enter the patient pay amount that is due from the patient. NOTE: The patient pay amount is taken from services billed on 24A - line 1. If multiple services are provided on same date of service, then another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service.
30 NOT REQUIRED Rsvd for NUCC Use
31 REQUIRED Signature of Physician or Supplier Including Degrees or Credentials - The provider or agent must sign and date the invoice in this block.
32 REQUIRED If applicable Service Facility Location Information – Enter the name as first line, address as second line, city, state and 9 digit zip code as third line for the location where the services were rendered. NOTE: For physician with multiple office locations, the specific Zip code must reflect the office location where services given. Do NOT use commas, periods or other punctuations in the address. Enter space between city and state. Include the hyphen for the 9 digit zip code.
32a open REQUIRED If applicable NPI # - Enter the 10 digit NPI number of the service location.
32b red shaded REQUIRED If applicable Other ID#: - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier of ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 32a open line.
33 REQUIRED Billing Provider Info and PH # - Enter the billing name as first line, address as second line, city, state and 9-digit zip code as third line. This locator is to identify the provider that is requesting to be paid. NOTE: Do NOT use commas, periods or other punctuations in the address. Enter space between city and state. Include the hyphen for the 9 digit zip code. The phone number is to be entered in the area to the right of the field title. Do not use hyphen or space as separator within the telephone number.
33a open REQUIRED NPI – Enter the 10 digit NPI number of the billing provider.
33b red shaded REQUIRED If applicable

Other Billing ID - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 33a open line.

NOTE: DO NOT use commas, periods, space, hyphens or other punctuations between the qualifier and the number.

The information may be typed (recommend font Sans Serif 12) or legibly handwritten. Retain a copy for the office files. Mail the completed claims to:

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

 

The information may be typed (recommend font Sans Serif 12) or legibly handwritten.  Retain a copy for the office files.

Mail the completed claims to:

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Invoice Processing (PP)

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

 

           Remittance Voucher

 

           Approved - Payment is approved or Pended. Pended claims are 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.

 

           Pend – Payment is pended for claim to be manually reviewed by DMAS staff or waiting on further information from provider.

 

           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.

 

Please use this link to search for DMAS Forms: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch

 

 

Exhibit 1: Virginia Medicaid Fee-for-Service Emergency Air, Emergency Ground, and Neonatal Transportation CPT/HCPCS Codes

EXHIBIT 1: VIRGINIA MEDICAID “FEE FOR SERVICE” EMERGENCY AIR, EMERGENCY GROUND, AND NEONATAL TRANSPORTATION CPT/HCPCS CODES

 

Claims with a date of service November 1, 2009 and after DMAS uses a two-code system for billing. The first code is for the service (base rate) and the second code is for the number of loaded miles and charges. Claims submitted with a date of service October 31, 2009 and before will be paid using the one code system. Meaning the number of loaded miles is to be billed under the number of units on the service CPT code. DMAS will continue to require fee for service ambulance claims and secondary Medicare ambulance claims directly from the provider to be submitted with mileage procedure codes to be rounded up to the next highest number. DMAS will only accept the claims with a decimal directly from Medicare (GHI). At this time, DMAS will continue to round up to the next highest number until our MMIS (claims system) is able to accept decimals.

 

The DMAS Fee Schedule for Emergency Air or Ground transportation is available on the DMAS website at the following address: http://www.dmas.virginia.gov/#/ambulance

 

DMAS requires providers to bill all emergency air ambulance, emergency ground services, and neonatal ambulance using the following procedure codes.

 

CPT/HCPCS Codes                Description

 

A0225

 

Ambulance, Neonatal

A0425    “U1”

 

 

A0425

Ambulance, Neonatal Mileage – to receive Neonatal mileage rate please use modifier of “U1” in block 24d under modifier heading.

Ground Mileage, Statue Mile

A0427

Emergency Ambulance, Advanced Life Support (ALS)

A0429

Emergency Ambulance, Basic Life Support (BLS)

A0432

 

A0433

Paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company

Advanced Life Support, Level 2 (ALS 2)

A0430

Fixed Wing Air Transport

A0435

Fixed Wing Air Transport Mileage, Per Statute Mile

A0431

Rotary Wing Air Transport

A0436

Rotary Wing Air Transport Mileage, Per Statute Mile

A0999

Requires DMAS Approval Before Transport

Unlisted Ambulance/Transportation Service

 

 

 

 

The following NON-EMERGENCY Medicaid Transportation (NEMT) CPT/HCPCS codes are to be preauthorized and billed to the Non-Emergency Medicaid Transportation Broker (866) 386-8331. Call the Broker “BEFORE transport.

 

A0425                        Ground Mileage, Statute Miles for NEMT service CPT/HCPCS codes listed below.

A0426                        Non-Emergency Advanced Life Support Ambulance – These transports need to be preauthorized and billed to the Non-Emergency Medicaid Transportation

Broker (866) 386-8331. Call Broker before transport.

 

A0428                         Non-Emergency Basic Life Support Ambulance – These transports need to be preauthorized and billed to

the Non-Emergency Medicaid Transportation Broker (866) 386-8331. Call Broker before transport.

 

A0434                         Specialty Care Transport (SCT) – These transports need to be preauthorized and billed to the Non-Emergency Medicaid Transportation

Broker (866) 386-8331. Call Broker before transport.

 

NOTE: DMAS is responsible for calculating and paying all Fee For Service Medicaid/Medicare Crossover payments for Emergency and Non-Emergency Ambulance Services. 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

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