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September 22, 2022, 09:42 EDT

Chapter : Billing Procedures (RD)

Updated: 7/31/2015

 

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 (Podiatry)

The Medical Assistance Program regulations require the prompt submission of all claims. Virginia Medicaid is mandated by federal regulations [42 CFR § 447.45(d)] to require the initial submission of all claims (including accident cases) within 12 months from the date of service. Providers are encouraged to submit billings within 30 days from the last date of service or discharge. Federal financial participation is not available for claims, which are not submitted within 12 months from the date of the service. Submission is defined as actual, physical receipt by DMAS. In cases where the actual receipt of a claim by DMAS is undocumented, it is the provider’s responsibility to confirm actual receipt of a claim by DMAS within 12 months from the date of the service reflected on a claim. If billing electronically and timely filing must be waived, submit the DMAS-3 form with the appropriate attachments. The DMAS-3 form is to be used by electronic billers for attachments. (See Exhibits) Medicaid is not authorized to make payment on these late claims, 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 of application for benefits. All eligibility requirements must be met within that time period. Unpaid bills for that period can be billed to Medicaid the same as for any other service. If the enrollment is not accomplished in a timely way, billing will be handled in the same manner as for delayed eligibility.

 

Delayed Eligibility - Medicaid may make payment for services billed more than 12 months from the date of service in certain circumstances. Medicaid denials may be overturned or other actions may cause eligibility to be established for a prior period. Medicaid may make payment for dates of service more than 12 months in the past when the claims are for an enrollee whose eligibility has been delayed. It is the provider’s obligation to verify the patient’s Medicaid eligibility. Providers who have rendered care for a period of delayed eligibility will be notified by a copy of a letter from the local department of social services which specifies the delay has occurred, the Medicaid claim number, and the time span for which eligibility has been granted. The provider must submit a claim on the appropriate Medicaid claim form 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 thirteen months from date of the initial denied claim where the initial claim was filed within the 12 months limit to be considered for payment by Medicaid. The procedures for resubmission are:

  • Complete invoice as explained in this billing chapter.
  • Attach written documentation to justify/verify the explanation. This documentation may be continuous denials by Medicaid or any dated follow-up correspondence from Medicaid showing that the provider has actively been submitting or contacting Medicaid on getting the claim processed for payment. Actively pursuing claim payment is defined as documentation of contacting DMAS at least every six months. Where the provider has failed to contact DMAS for six months or more, DMAS shall consider the resubmission to be untimely and no further action shall be taken. 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 Medicaid 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 Medicaid within 12 months from the date of the service. If the provider waits for the settlement before billing Medicaid and the wait extends beyond 12 months from the date of the service, Medicaid shall make no reimbursement.

 

Other Primary Insurance - The provider should bill other insurance as primary. However, all claims for services must be billed to Medicaid within 12 months from the date of the service. If the provider waits for payment before billing Medicaid and the wait extends beyond 12 months from the date of the service, Medicaid shall make no reimbursements. If payment is made from the primary insurance carrier after a payment from Medicaid 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 or FAMIS Plus. The other insurance plan pays first. Having other health insurance does not change the co-payment amount that providers can 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 members must notify the insurance company. The member must notify the insurance company within 90 days of the end of Medicaid coverage to reinstate the supplemental insurance.

 

Submit the claim in the usual manner by mailing the claim to billing address noted in this chapter.

Billing Instructions: Billing Invoices (DME)

The requirements for submission of physician 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)

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

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

Billing Instructions: Automated Crossover Claims Processing (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.

Requests for Billing Materials

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

The CMS-1500 (02-12) is a universally accepted claim form that is required when billing DMAS for covered services. The form is available from form printers and the U.S. Government Printing Office. Specific details on purchasing these forms can be obtained by writing to the following address:

U.S. Government Print Office Superintendent of Documents Washington, DC 20402

(202)512-1800 (Order and Inquiry Desk)

Note: The CMS-1500 (02-12) will not be provided by DMAS.

The request for forms or Billing Supplies must be submitted by: Mail Your Request To:

Commonwealth Mailing 1700 Venable St.,

Richmond, VA 23223

Calling the DMAS order desk at Commonwealth Martin 804-780-0076 or, by faxing the DMAS order desk at Commonwealth Martin 804-780-0198

All orders must include the following information:

  • Provider Identification Number
  • Company Name and Contact Person
  • Street Mailing Address (No Post Office Numbers are accepted)
  • Telephone Number and Extension of the Contact Person
  • The form number and name of the form
  • The quantity needed for each form

Please DO NOT order excessive quantities.

Direct any requests for information or questions concerning the ordering of forms to the address above or call: (804) 780-0076.

Billing Procedures (RD)

Physicians 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. Completed claims should be mailed to:

 

Department of Medical Assistance Services Practitioner

P.O. Box 27444

Richmond, Virginia 23261-7444

Or

 

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Billing Instructions: Electronic Filing Requirements

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

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

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

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

277 - Unsolicited Response (5010)

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

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

835 - Health Care Claim Payment/ Remittance (5010)

837 - Dental Health Care Claim or Encounter (5010)

837 - Institutional Health Care Claim or Encounter (5010)

837 - Professional Health Care Claim or Encounter (5010)

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

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

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

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

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

Billing Instructions: ClaimCheck

 

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

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

 

        PTP Edits:

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

 

        MUE Edits:

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

 

        Exempt Provider Types:

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

 

        Service Authorizations:

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

 

        Modifiers:

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

 

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

  

Reconsideration

 

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

 

 

Payment Processing Unit, Claim Check

Division of Program Operations

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219

 

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

Billing Instructions: Reconsideration (DME)

 

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, Virginia23219

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: 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: Place of Service Codes

CMS - 1500 CODE

00-10 Unassigned
11 Office location
12 Patient's home
13-20 Unassigned
21 Inpatient hospital
22 Outpatient hospital
23 Emergency room
24 Ambulatory surgical center
25 Birthing center
26 Military treatment center
27-30 Unassigned
31 Skilled nursing facility
32 Nursing facility
33 Custodial care facility
34 Hospice
35-40 Unassigned
41 Ambulance - land
42 Ambulance - air or water
43-50 Unassigned
51 Inpatient psychiatric facility
52 Psychiatric facility - partial hospitalization
53 Community mental health center
54 Intermediate care facility/mentally retarded
55 Residential substance abuse treatment facility
56 Psychiatric residential treatment center
57-60 Unassigned
61 Comprehensive inpatient rehabilitation facility
62 Comprehensive outpatient rehabilitation facility
63-64 Unassigned
65 End stage renal disease treatment facility
66-70 Unassigned
71 State or local public health clinic
72 Rural health clinic
73-80 Unassigned
81 Independent laboratory
82-98 Unassigned
99 Other unlisted facility

 

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. 

Special Billing Instructions Freestanding Renal Dialysis Clinic Manual

Locator 24D

Procedures, Services or Supplies

 

 

CPT/HCPCS - Enter the procedure codes appropriate for the services rendered from the list given below. Dialysis codes M0916 and M0931 include the supplies used during treatment and the following routine laboratory tests: complete blood count (RBC, WBC, Hgb, Hct, WBC differential, platelet count), hepatitis profile (Anti-HAV, Anti HAV-IgM, HBsAg, H Be Ag, Anti-HBs, Anti-H Bc, Anti H Bc-IgM, and Anti-H Be), and blood chemistry tests (albumin, albumin/globulin ratio, alkaline phosphatase, bilirubin [total and direct], calcium, carbon dioxide content, chlorides, cholesterol, creatinine, globulin, glucose, lactic dehydrogenase, phosphorous, potassium, sodium, SGOT, SGPT, total protein, urea nitrogen, and uric acid). Use the appropriate Physicians' Current Procedural Terminology (CPT) or HCPCS codes for non-routine laboratory tests that are actually performed by the dialysis center.

 

Procedure and Modifier codes for billing services are:

 

90945, 90947

U1

 

 

90935, 90937

 

 

 

93005, 93010

 

 

 

P9010

 

 

 

36430

 

 

 

To bill for medications administered by injection during the course of treatment, use the appropriate HCPCS code for the substance(s) given.

 

Note: DMAS is requiring the NDC whenever a J-code is billed. Refer to locator 24A red shaded special note.

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

 

 

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