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September 22, 2022, 09:42 EDT

Chapter 5: Billing Procedures (Pharm)

Updated: 10/1/2017

 

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 for 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: Automated Crossover Claims Processing (DME)

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.

 

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 Virginia Medicaid 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 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: Billing for Pharmacy Services

To bill the Virginia Medicaid Program for pharmaceutical services provided to members, a provider may use the Daily Pharmacy Drug Claim Ledger (DMAS-173 R6/03).  For compounded prescriptions, use the Compound Prescription Pharmacy Claim Form (DMAS-174).  In the case of home I.V. services or Durable Medical Equipment (DME), which includes nutritional supplements, the CMS-1500 form must be used.  Virginia Medicaid encourages pharmacy providers to submit claims for electronic processing whenever possible.  Electronic claims must be submitted in NCPDP Version D.0 format.

 

Providers shall bill the Virginia Medicaid Program their usual and customary charges for all prescriptions dispensed.  The Medicaid claims processing system will calculate the reimbursement due according to the rules described in Chapter IV of this manual.

 

The National Drug Code (NDC) assigned by the manufacturer or distributor found on the package label must be used when billing the Virginia Medicaid Program.  Hyphens in an NDC are not recognized in the DMAS processing system.  

 

For a multiple-source drug (VMAC or CMS) with maximum cost reimbursement limits where the physician indicates "Brand Necessary," the NDC identifying the brand-name product dispensed is used, and the DMAS-173 R6/03 requires entry of the number "1" in field 9 DAW.  If "Brand Necessary" is not indicated on the prescription, the NDC must identify the less expensive generic product actually dispensed, not the brand-name product.

 

Co-payment amounts shall be as follows:

 

        One dollar ($1.00) co-pay for generic drug products; and

        Three dollars ($3.00) co-pay for single source or "Brand Necessary" products.

Billing Instructions: Third Party Liability (TPL) Collections for Point-of-Service (POS) Claims (Pharm)

In order to conserve Medicaid dollars, and as payer of last resort, DMAS is beginning a process of Coordination of Benefits (COB) for Third Party Liability (TPL) collection at the Point-of-Service.  For pharmacy claims having a service date on or after June 20, 2003, DMAS will send an online claim denial message to pharmacy providers submitting POS claims for which the patient has other insurance coverage.  The messages used in this project are shown in the table below.

 

VA

Code

Virginia Denial Message Text

NCPDP Code

NCPDP Reject Message Text

313

Bill Any Other Available Insurance

41

Submit Bill To Other Processor Or Primary Payer

387

Primary               Carrier Payment                Needs Explanation

13

Missing/Invalid Other Coverage Code

 

DMAS requests that providers receiving either of these messages verify whether the patient has additional coverage.  If the patient acknowledges such coverage, the pharmacist should submit the claim first to that third party.  Once the other insurer adjudicates the claim, the claim may be resubmitted to DMAS using appropriate messages in NCPDP data element fields, "OTHER COVERAGE CODE" and "OTHER PAYER AMOUNT."  These fields are included in existing payer specifications.  In order to submit an override to the denial, the pharmacist must use the appropriate response in each field as shown below.  In the case where a patient denies having additional coverage, the responses to be used in these fields are also noted below.

 

The pharmacy TPL editing is based on the NCPDP "Other Coverage Code" standard values (Version D.0).  These values and their definitions are as follows:

 

00  - Not specified

01  - No other coverage identified

02  - Other coverage exists - payment collected

03  - Other coverage exists - this claim not covered

04  - Other coverage exists - payment not collected

05  - Managed care plan denied

06  - Other coverage denied - not a participating provider

07  - Other coverage exists - not in effect on date of service (DOS) 

08  - Claim is being billed for co-pay

 

Below is a grid reflecting the combination of Other Coverage Codes, presence or absence of a third party payment amount, and whether or not the member's record indicates third party pharmacy coverage with the proposed corresponding claim disposition.

 

Other Coverage Code

TPL Amt

TPL

Indicated on

Member's Record

Initial Claim Disposition

Override Process

 

Other Coverage Code

TPL Amt

TPL

Indicated on

Member's Record

Initial Claim Disposition

Override Process

0 = Not Specified

0

Yes

Deny, Bill Other Carrier VA code 313/NCPDP

code 41

Provider can resubmit with an Other Coverage Code of 3 or 4 as appropriate.

0 = Not Specified

0

No

Pay

 

0 = Not specified

>0

Yes or No

Deny, TPL Indicators

Conflict

VA code 387/NCPDP

code 13

Provider can resubmit with corrected Other Coverage Code or zeros in TPL Amount.

1 = No other coverage identified

0

Yes

Deny, Bill Other Carrier VA code 313/NCPDP

code 41

Provider can resubmit with an Other Coverage Code of 3 or 4 as appropriate.

1 = No other coverage identified

0

No

Pay

 

1 = No other coverage identified

>0

Yes or No

Deny, TPL Indicators

Conflict

VA code 387/NCPDP

code 13

Provider can resubmit with corrected Other Coverage Code or zeros in TPL Amount.

2 = Other coverage exists, payment collected

0

Yes or No

Deny, TPL Indicators

Conflict

VA code 387/NCPDP

code 13

Provider can resubmit with corrected Other Coverage Code and TPL Amount.

2 = Other coverage exists, payment collected

>0

Yes or No

Pay

Payment = Calculated

Amount minus Other

Payer Amount  

3 = Other coverage exists, this claim not covered

0

Yes or No

Pay

This code should be used when the drug is not covered by the other carrier 

3 = Other coverage exists, this claim not covered

>0

Yes or No

Deny, TPL Indicators

Conflict

VA code 387/NCPDP

code 13

Provider must resubmit with corrected Other Coverage Code if wrong code entered or enter zeros in TPL Amount if Other Coverage Code was entered correctly.

4 = Other coverage exists, payment not collected

>0

Yes or No

Deny, TPL Indicators

Conflict

VA code 387/NCPDP

code 13

Provider can resubmit with corrected Other Coverage Code or zeros in TPL Amount.

Other Coverage Code

TPL Amt

TPL

Indicated on

Member's Record

Initial Claim Disposition

Override Process

4 = Other coverage exists, payment not collected

0

Yes or No

Pay

This code should be used when the drug is covered by the other carrier but the pharmacy has not been able to collect from the other resource.

5 = Managed Care

Plan Denial

0

Yes

Denial

This code should be used when the drug is not covered by other payer.

6 = Other coverage denied, not participating provider

0

 

 

 

7 = Other coverage exists - Not in effect on date of service

0

 

 

 

8 = Claim is being billed for co-pay

0

 

 

 

 

If a patient denies having other coverage, the pharmacist should use the appropriate override codes and fill the prescription as if it were a "Pay-and-Chase" claim.  Until future notice, such claims will be handled under the "Pay-and-Chase" Waiver.  Pharmacists are requested to make every effort to capture TPL payments where possible in order to maximize the potential cost savings to the Medicaid program.  

 

Virginia Medicaid, always the payer of last resort, will only pay claims to the maximum of the Virginia Medicaid Allowed Amount.  The coordinated benefit payment of the TPL amount and any additional Medicaid payment will be equivalent to the appropriate payment allowed under DMAS payment rules.  Therefore, the total payment may not appear to correspond to the submitted claim amount.  The final adjudication under Medicaid will show the appropriate co-pay to be collected from the patient.

 

For claims submitted using other media, pharmacy providers are requested to attempt to determine if such TPL coverage exists.  Using the proprietary format of the DMAS-173 (R6/03), use of fields 23 and 24 will capture the desired elements.  This information is mandatory for paper claims submission of TPL claims.  Immediate pharmacist participation in this effort will assist in the DMAS cost-savings initiatives. 

Billing Instructions: Billing Instructions (Pharm)

The Pharmacy Claim Form, DMAS-173 (R 6/03), will be used for adjustments and voids of pharmacy claims.  At the end of the chapter in the “Exhibits” section you will find an example of the Pharmacy Claim Form, DMAS-173 (R 6/03) and Compound Prescription Pharmacy Claim Form, DMAS-174 (R 6/03).  Directions for the DMAS-174 appear on the back of the claim form and may also be found in the "Exhibits" section.

 

The form is printed in "red drop-out" ink which allows it to be processed through a scanner, rather than having to be entered by operators into the system.  This format will speed up processing and should improve the timeliness of claims resolution.

 

Because the scanners operate only when the forms are printed in this special ink, it will not be possible for providers to make copies of the form to be used as substitutes for the supplied forms.  Please be sure to order forms from Commonwealth-Martin in adequate time for your needs.

Virginia Department of Medical Assistance Services Pharmacy Claim Form (DMAS-173  R6/03)

 

Required Fields 

 

Field

Number

Description

 

Required (*) 

1

Medicaid Pharmacy Provider Number (9digits)

*

2

2a

Patient's Last Name 

Patient’s First Name

*

3

12-digit Medicaid Patient ID

*

4

Patient's Sex  M=Male   F=Female

*

5

Patient's Birth Date  MMDDCCYY

 

6

Level of Service 

* - only if Emergency  (03)

7

Days Supply

*

8

New Prescription = 00; Refill =  01 to 99

*

9

DAW Codes = 1

*- only if brand dispensed (1)

10

Patient's location

* - only if Nursing Home (03)

11

Resubmit Code

 

12

Original Reference Number

 

13

Seven-digit Rx Number 

*

14

Date Dispensed (MMDDCCYY) (zero fill)

*

15

11-digit NDC of Product Dispensed 

*

16

Metric Decimal Quantity -    EG    (e.g., 000002.500)

*

17

Unit Dose Code

* - only if Unit Dose for

Nursing Home (4)

18

Service Authorization Medical Certification

 

Field

Number

Description

 

Required (*) 

 

Code  

 

19

11-digit Service Authorization Number

 

20

Valid Prescriber's Medicaid Provider ID #

*

21

ICD CM Diagnosis Code

 

22

Usual & Customary Charge  (e.g., 199/09 for $199.09)

*

23

Other Coverage Codes

 

24

Dollar Amount Paid by Primary Payer

 

25

Dispensing Status. To be used for partial fill prescriptions only. Partial fill = P or

Completion of a partial fill = C

*- if needed 

26

Intended Metric Quantity to be dispensed. 

The quantity positions are the same as field

16 (e.g., 000002.500)

 

*

27

Days' supply corresponding to in-tented metric quantity (#26)

*

28

Prescription number from initial partial fill.  Use for completion claim.  

 

29

Date dispensed from initial partial fill.  Use for completion claim.

 

30

Comments

 

31

Pharmacy name, address, and phone number   

*

31

Certification statement, signature, and date      

*

 

Special information for current pharmacy claims submission:

Billing Instructions: Pharmacy Claim Form, DMAS-173 (R06/03)

The Pharmacy Claim Form is designed to be completed for one patient only.  Each block on the form must be completed correctly with the required information to receive payment for services provided and to avoid delays in processing the claim. (See the "Exhibits" section at the end of this chapter for a sample of this form.)

 

The instructions for completing each block on this form are as follows:  

 

                

Block 1

Pharmacy ID Number - Enter the nine-digit provider identification number assigned by the Virginia Medicaid Program (remember to add two leading zeroes).

 

 

Block 2 and 2A 

Patient's Last Name

Patient's First Name

 

Block  3

Patient ID Number - Enter the 12-digit Virginia Medicaid identification number assigned to the member receiving the prescription.  This number must be entered exactly as it appears on the Medicaid ID card.

 

 

Block 4

Patient's sex - M = Male, F = Female.

 

 

Block 5

Date of Birth - MMDDCCYY (zero fill as necessary, e.g., 06012003)

 

 

Block 6

Level of Service - Enter level of service if appropriate 01 = Patient Consultation, 02 = Home Delivery, 03 = Emergency, 04 = 24- hour supply, 05 = Patient consultation regarding generic product selection, 06 = In-home Service.  At the present time only 03 = emergency is functional.  It is to be used in an emergency when a Client Medical Management (CMM) member's designated CMM pharmacy is closed or does not stock the drug.

 

                

Block 7

Days Supply - Maximum allowable days supply is 34 

 

Block 8

Refill - If original enter 00. Refill values 01 to 99.

 

Block 9

DAW - Enter 1 for prescriptions for Brand Medically Necessary as indicated in the prescribing physician's own handwriting in accordance with Virginia law and Medicaid policy.  Fraudulent use of the DAW 1 indicator is an auditable offense. 

 

 

Block 10

Patient's Location - NCPDP approved codes include 00 = not specified, 01 = Home, 02 = Inter-Care, 03 = Nursing Home, 04 = Long Term/Extended Care, 05 = Rest Home, 06 = Boarding Home, 07 = Skilled Care Facility, 08 = Sub Acute Care Facility, 09 = Acute Care Facility, 10 = Outpatient, 11 = Hospice.

 

Currently the only functioning location code is 04 = Nursing Home.

 

 

Block 11

 

Resubmission Code - use if an adjustment or void is being requested. Codes are 1033 = correcting prescriber ID, 1034 = correcting metric quantity, 1035 = correcting drug code, 1036 = allowance for Rx less than pharmacy cost, (wholesale invoice attached), 1053 = Other, 1052 = Void.  This is the only form that will be accepted for adjustments and replaces DMAS 228.                 

 

 

 

 

Block 12

Original Reference Number - Enter the 16-digit original reference number (ICN) of the claim that is to be adjusted or voided. This field must be completed if field 11 is submitted. 

 

 

 

 

Block 13

Prescription Number – Enter nine-digit prescription number.  If the claim is a void or adjustment, the prescription number must be the original prescription number.

 

 

 

 

Block 14

Date Dispensed - Enter date as MMDDCCYY (zero fill as necessary - e.g., 10012003)

 

 

 

 

Block 15

NDC Code - Enter the 11-digit National Drug Code (NDC) for the dispensed product.  

 

 

 

 

Block 16

Metric Quantity - Enter the metric decimal quantity. The line serves as the decimal point.  The areas allows up to six digits before the decimal point (the line on the claim form) and three digits after the decimal point  (e.g., 000002.500).

 

 

 

 

Block 17

Unit Dose Code - Values are 0 = Not specified,   1 =  Not unit dose, 2 = Manufacturer's unit dose, 3 = Pharmacy Unit Dose, 4 = Unit Dose for Nursing Homes. 

 

 

 

 

Block 18

Service Authorization Medical Certification Code - Valid codes are 0 = Not specified, 1 = Service Authorization, 2 = Medical Certification, 3 = EPSDT, 4 = Exemption from Co-pay, 5 = Exemption from prescription limits, 6 = Family planning indicator, 7 = AFDC, 8 = Payer-defined exemption.

 

 

Block 19

Service Authorization Number - Enter 11-digit service  authorization number.

 

 

Block 20

Prescriber’s Medicaid ID Number - Enter the nine-digit Medicaid provider number.  A valid number must be entered for payment to be approved.  Use of the unknown prescriber numbers will be audited, and payment will be revoked when an unknown number is entered for a valid prescriber.   

 

 

 

Block 21

Diagnosis - Enter ICDCM diagnosis code if applicable.  Do not enter decimal point.

 

       

 

 

Block 22

Amount Billed - Enter usual and customary charge for prescription, including dispensing fee.  Line serves as decimal point 

(eg., 199/09 for $199.09).

 

 

Block 23

Other Coverage Code - Coordination of benefits can be billed online with the appropriate NCPDP coding information.  Valid codes include: 00 = Not specified, 01 = No other coverage exists, 02 = Other coverage exists and payments have been collected, 03 = Other coverage exists - claim not covered, 04 = Other coverage exists - payment not collected, 05 = Managed Care plan denied, 06 = other coverage denied - not a participating provider, 07 = Other coverage exists - not in effect on date of service, 08 = Claim being billed for co-pay.

 

 

Block 24

Payment by Primary Carrier - Enter payment by other carrier.  Line serves as decimal point (e.g., 299/09 = $299.09).

 

 

Block 25

Dispense Status - Partial and Complete fills.  This field is only required for partial prescription fills. Enter P for partial or C for complete.  This field should not be used when dispensing full prescriptions for the intended quantity.

 

 

Block 26

Quantity intended to be dispensed - Enter prescription quantity as  Prescribed by physician.  Line serves as decimal point.

 

 

Block 27

Intended Days' Supply - Enter days supply as prescribed by  Physician.

 

 

Block 28

Prescription Number from the Initial Partial Fill Claim - When submitting a completion 'C' claim, enter in field 28 the prescription number from the initial partial fill claim.

 

 

Block 29

Date Dispensed from the Initial Partial Fill Claim - When submitting the completion 'C' claim, enter in field 29 the date dispensed from the initial partial fill claim.

 

 

Block 30

Comments - Enter comments, if any (e.g., claim #3 used for high cholesterol).

 

 

Block 31

Pharmacy Contact Information - Enter the Pharmacy's name, address, and telephone number.

 

 

Block 32

Certification Statement - Note the certification statement on the claim form, then sign and date the claim form.

 

Billing Instructions: Pharmacy Claim Form, DMAS-174 (R06/03)

The Compound Prescription Pharmacy Claim Form is designed to be completed for one patient only.  Each block on the form must be completed correctly with the required information to receive payment for services provided and to avoid delays in processing the claim. (See the "Exhibits" section at the end of this chapter for a sample of this form.)

 

The instructions for completing each block on this form are as follows:

 

 

                

Block 1

The Resubmission Code is only used if an adjustment or void is being requested.  Enter the appropriate code if requesting the adjustment or void.  Valid values are 1033 = Correcting prescriber ID, 1034 = Correcting metric quantity, 1035 = correcting drug code, 1036 = Allowance for Rx less than pharmacy cost, (wholesale invoice attached), 1053 = Other, 1052 = Void.

 

 

Block 2 

The Original Reference Number is only used if an adjustment or void is being requested.  Enter the 16 digits of the original claim reference number (ICN) of the claim that is to be adjusted or voided.  This field must be filled if a code is in field 1.

 

Block 3

Leave blank.

 

 

Block 4

Enter your nine-digit Medicaid provider ID number.  Do not use zeros with slashes.

 

 

Block 5

Enter the level of service code if appropriate.  01 = Patient consultation, 02 = Home delivery, 03 = Emergency, 04 = 24-hour service, 05 = Patient consultation regarding generic product selection, 06 = In-home service.

 

 

Block 6

Enter the ICD-CM diagnosis code if appropriate.  If using a four- or five-digit code number, do not enter the decimal point.

 

                

Block 7

Service Authorization Medical Certification code, (PAMC).  Valid codes are: 0 = Not specified, 1 = Service Authorization, 2 = Medical certification, 3 = EPSDT, 4 = Exemption from Co-pay, 5 =

Exemption from prescription limits, 6 = Family planning indicator, 7 = AFDC, 8 = Payer-defined exemption.

 

Block 8

Enter the 11-digit service authorization number.

 

Block 9

Enter the 12-digit Medicaid Patient ID number. 

 

 

Block 10

Enter the patient's last name and first name in the appropriate boxes.

 

Block 11

 

Enter the patient's sex - M = Male, F = Female

 

 

 

 

Block 12

Enter the patient's birth date.  Use MMDDCCYY format.  Zero fill as appropriate (e.g., 06012003).

 

 

 

 

Block 13

Enter the prescriber's Medicaid provider ID number.  Do not use zeros with slashes.

 

 

 

 

Block 14

Enter the prescription's seven-digit Rx number.  If this claim is for an adjustment or void, the Rx number must be the original Rx number on the claim being adjusted or voided.

 

 

 

 

Block 15

Enter the date dispensed in MMDDCCYY format.  Zero fill as appropriate (e.g., 10012003).

 

 

 

 

Block 16

Enter the days' supply.

 

 

 

 

Block 17

If this is an original prescription, enter 00.  Refill values are 01 to 99.

 

 

 

 

Block 18

Enter the patient's location.  Valid values are 00 = Not specified, 01

= Home, 02 = Inter-Care, 03 = Nursing Home, 04 = Long Term/Extended Care, 05 = Rest Home, 06 = Boarding Home, 07 = Skilled Care Facility, 08 = Sub Acute Care Facility, 09 = Acute Care Facility, 10 = Outpatient, 11 = Hospice.

 

 

Block 19

Enter the 11-digit National Drug Code (NDC).  Be certain all NDC's entered are current.

 

 

Block 20

Enter the Dispense as Written, (DAW) override code of "1" for prescriptions for which "Brand Necessary" is indicated in accordance with the law and Medicaid policy.  The value should be used only when the prescribing physician certifies "Brand Necessary" in his or her own handwriting for a prescribed brand- name drug that is generically available.

 

 

Block 21

Description or Drug Name of ingredient.

 

 

Block 22

Indicate the metric decimal quantity (e.g., 000002.500) of product using the appropriate unit of measure (each, gram, or milliliter). 

 

 

 

 

Block 23

Other Coverage Code (OCC).  Valid values are: 00 = Not specified, 01 = No other coverage, 02 = Other coverage exists - payment collected, 03 = Other coverage exists - claim not covered, 04 = Other coverage exists - payment not collected, 05 = Managed Care plan denial, 06 = other coverage denied - not a participating provider, 07 = Other coverage exists - not in effect on date of service (DOS), 08 = Claim is being billed for co-pay.

 

 

 

 

 

 

Block 24

Enter the dollar amount paid by the primary payer if other coverage applies (e.g., 2199/09 = $2,199.09).

 

 

 

 

Block 25

Enter the usual and customary charge for the prescription.  This field should include the dispensing fee.  The last two positions of the field are for cents only (e.g., 199/09 = $199.99).

 

 

 

 

Block 26

Enter comments, if any (i.e., "For high cholesterol").

 

 

 

 

Block 27

Enter the pharmacy's name, address, and telephone number.

 

 

 

 

Block 28

Note the certification statement on the claim form, then sign and date the claim form.

         

 

Billing Instructions: Instructions for the Completion of the Health Insurance Claim Form CMS-1500 (02-12), as a Void Invoice

The Void Invoice is used to void a paid claim.  Follow the instructions for the completion of the Health Insurance Claim Form, CMS-1500 (02-12), except for the locator indicated below.

 

Locator 22             Medicaid Resubmission

   Code -  Enter the 4-digit code identifying the reason for the submission of the void

                 invoice.

 

                                 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/ICN - Enter the claim reference number/ICN of the paid claim.  This number may be obtained from the remittance voucher and is required to identify the claim to be voided.  Only one claim can be voided on each CMS-1500 (02-12) submitted as a Void Invoice.  (Each line under Locator 24 is one claim).

 

NOTE:  ICNs can only be 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 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 

Billing Instructions: Group Practice Billing Functionality

Providers defined in this manual are not eligible to submit claims as a Group Practice with the Virginia Medicaid Program.  Group Practice claim submissions are reserved for independently enrolled fee-for-service healthcare practitioners (physicians, podiatrists, psychologists, etc.) that share the same Federal Employer Identification Number.  Facility based organizations (NPI Type 2) and providers assigned an Atypical Provider Identifier (API) may not utilize group billing functionality.  

 

Medicare Crossover:  If Medicare requires you to submit claims identifying an individual Rendering Provider, DMAS will use the Billing Provider NPI to adjudicate the Medicare Crossover Claim.  You will not enroll your organization as a Group Practice with Virginia Medicaid.

 

For more information on Group Practice enrollment and claim submissions using the CMS1500 (02-12), please refer to the appropriate practitioner Provider Manual found at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.

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: Special Billing Instructions -- Client Medical Management Program

The primary care provider (PCP) and any other provider who is part of the PCP’S CMM Affiliation Group bills for services in the usual manner, but other physicians must follow special billing instructions to receive payment.  (Affiliation Groups are explained in Chapter 1 under CMM.)  Other physicians must indicate a PCP referral or an emergency unless the service is excluded from the requirement for a referral.  Excluded services are listed in Chapter I.

 

All services should be coordinated with the primary health care provider whose name is provided at the time of verification of eligibility.  The CMM PCP referral does not override Medicaid service limitations.  All DMAS requirements for reimbursement, such as preauthorization, still apply as indicated in each provider manual.

 

When treating a restricted enrollee, a physician covering for the primary care provider or on referral from the primary care provider must place the primary care provider’s NPI in locator 17b or the API in Locator 17a with the qualifier ‘1D’and attach a copy of the Practitioner Referral Form (DMAS-70) to the invoice. The name of the referring PCP must be entered in locator 17.

 

In a medical emergency situation, if the practitioner rendering treatment is not the primary care physician, he or she must certify that a medical emergency exists for payment to be made.  The provider must enter a “Y” in Locator 24C and attach an explanation of the nature of the emergency.

 

LOCATOR SPECIAL INSTRUCTIONS

 

10d   Write “ATTACHMENT” for the Practitioner Referral Form, DMAS-70.

 

17   Enter the name of the referring primary care provider.

 

17a When a restricted enrollee is treated on referral from the primary physician, red shaded enter the qualifier ‘1D’ and the appropriate provider number (current Medicaid or an API) (as indicated on the DMAS-70 referral form) and attach a copy of the Practitioner Referral Form to the invoice.  Write “ATTACHMENT” in Locator 10d.

 

        Note:  Please refer to the time line for the appropriate provider number as indicated in main instruction above.

 

17b When a restricted enrollee is treated on referral from the primary physician, open enter the NPI number (as indicated on the DMAS-70 referral form) and attach a copy of the Practitioner Referral Form to the invoice.  Write “ATTACHMENT” in Locator 10d.

 

Note:  This locator can only be used for claims received on or after March 26, 2007.

 

24C When a restricted enrollee is treated in an emergency situation by a provider other than the primary physician, the non-designated physician enters a “Y” in this Locator and explains the nature of the emergency in an attachment.  Write “ATTACHMENT” in Locator 10d. 

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: Health Departments (Drugs, Family Planning and Nutritional Supplements)

Tuberculosis Oral Drugs

Health Department clinics should bill for all drugs using the unlisted HCPCS code J8499.  Modifier U2 must be used in Block 24-D of the CMS-1500 (02-12) claim form.  Clinics bill Medicaid with their actual cost for the drugs.  If no modifier is billed, the claim may be denied. The qualifier ‘N4’ should be in locator 24 red shaded line followed by the NDC of the J code listed in 24D.

 

Family Planning Drugs and Devices

Birth control pills must be billed using code J8499 along with modifiers FP and U2 in Block 24-D of the CMS-1500 (02-12) claim form.  The qualifier ‘N4’ should be in locator 24 red shaded line followed by the NDC of the J code listed in 24D. 

 

Family planning supplies (such as condoms, Intrauterine Devices, etc.) should be billed using unlisted supply code 99070 with the FP and U2 modifiers.  Actual costs for the drugs and supplies should be reflected in the charges.  Claims submitted without the modifiers may be denied. 

 

Nutritional Supplements

Nutritional Supplements should be billed using the national HCPCS codes for Enteral and Parenteral Therapy (B4000-B9999) with the U2 modifier in Block 24-D of the CMS-1500 (02-12) claim form.  Actual cost for the supplements should be billed. If no modifier is billed, the claim may be denied. 

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