Online Claim Entry UB-04 - New Mexico Medicaid Portal

Online Claim Entry
UB-04
Presented by:
Xerox State Healthcare, LLC
Provider Relations
Resources
When online use: Ask Service Representative
HIPAA.Desk.NM@xerox.com
NMPRSupport@xerox.com
Call Center 505-246-0710 or 800-299-7304
New Mexico Web Portal
• Provider Information section
• Links and FAQ section
• Provider Login section
Purpose of the Workshop
Provide complete explanation of how to fill out the UB-04 paper
claim form for:
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Claim Form Instructions
Timely Filing
NCCI – National Corrective Coding Initiative
New Hospital Outpatient Payment Method
Add/Manage Templates
Medicaid Primary Claims
Medicaid secondary to a Third Party Liability (TPL)
HMO co-payments
Medicare Replacement Plans
Medicare Primary Claims
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Important State Websites
STATE WEBSITES:
PROGRAM POLICY MANUAL
•
http://www.hsd.state.nm.us/mad/policymanual.html
BILLING INSTRUCTIONS
•
http://www.hsd.state.nm.us/mad/billinginstructions.html
REGISTERS AND SUPPLEMENTS:
•
http://www.hsd.state.nm.us/mad/registers/2012.html
Important Update
On October 1, 2014, the ICD-9 code sets used to report medical
diagnoses and inpatient procedures will be replaced by ICD-10 code
sets.
The transition to ICD-10 is required for everyone covered by the
Health Insurance Portability Accountability Act (HIPAA). Please note,
the change to ICD-10 does not affect CPT coding for outpatient
procedures and physician services.
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November 20, 2013
Claim Form Instructions
Where to get a copy of claim form instructions
Click Forms ,
Publications, and
Instructions under
Provider Information
Where to get a copy of claim form instructions
Scroll down
Open file
Timely Filing
What is a Transaction Control Number (TCN)?
91308700085000001
The first digit indicates
what the claim “media” is:
Batch number
The twelfth digit
in an adjustment/
void TCN will
either be:
1= Debit
2= Credit
2 = electronic crossover
3 = other electronic claim
4 = system generated
claim or adjustment
8 = paper claim
The last two
digits of the
year the
claim was
received
The numeric
day of the
year.
The claim number within
the batch.
9 = Web portal claim entry
This is the Julian Date - this represents the date the claim
was received by Xerox: this claim was received the 87th
day of 2013, or March 28, 2013
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Timely Filing Denials
Re-filing Claims and Submitting Adjustments
UB-04 form: Put the TCN in block 64 on the paper form.
0001
1
1
MEDICAID
082807
8,100 00
123456789
CONNIE CLIENT
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NCCI
National Corrective Coding
Initiative
NCCI (National Corrective Coding
Initiative)
Is a CMS program that consists of coding policies and edits. Medicaid
NCCI Edits consist of two types:
(1) NCCI procedure-to-procedure edits that define pairs of Healthcare
Common Procedure Coding System (HCPCS)/Current Procedural
Terminology (CPT) codes that should not be reported together for a
variety of reasons; and
(2) Medically Unlikely Edits (MUE), units-of-service edits, that define for
each HCPCS/CPT code the number of units of service beyond which
the reported number of units of service is unlikely to be correct (e.g.,
claims for excision of more than one gallbladder or more than one
pancreas).
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NCCI (National Corrective Coding
Initiative)
RA EOB Codes:
6501 or 6502 - Per the National Correct Coding Initiative, payment is
denied because the service is not payable with another service on the
same date of service.
6503 through 6505 - Per the National Correct Coding Initiative, payment is
denied because provider billed units of service exceeding limit.
Please visit the link below for any additional information:
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Data-and-Systems/National-Correct-Coding-Initiative.html
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New Hospital Outpatient Payment
Method
New Hospital Outpatient Payment
Method for New Mexico Medicaid
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All General Acute Hospitals and Rehabilitation Hospitals
must include a procedure code on every line item to receive
payment.
•
It is recommended that you bill all outpatient services for the
same date of service on the same claim form all inclusive.
New Hospital Outpatient Payment
Method for New Mexico Medicaid
The following resources are available on the HSD/MAD
website located at:
http://www.hsd.state.nm.us/mad/PFeeSchedules.html
• Hospital Outpatient Payment Method FAQ
• Hospital Outpatient Payment Method Revenue Codes
• Hospital Outpatient Payment Method Procedure Codes
• Notice of Hospital Outpatient Prospective payment System
Rates
• Explanation of Simulation Spreadsheet for Outpatient services
Add/Manage Templates
UB-04 - Add Claim Template
Please note template are limited
to 25 per user.
HINT: think about use procedure
code, or dates (billing range
dates)
The best time to directly enter your claim is Sunday through Friday
between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by
Friday 6 pm could be adjudicated and reflect as early as Monday
on your Remittance Advice.
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UB-04 - Add Claim Template
Fill out any information you would like included in your
template
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UB-04 - Add Claim Template
Fill out any information you would like included in your template
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UB-04 - Add Claim Template
Fill out any information you would like included in your template
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UB-04 - Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
View next slide for additional fields.
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UB-04 - Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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UB-04 - Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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UB-04 - Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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UB-04 - Add Claim Template
Fill out any information you would like included in your template.
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Sections can be expanded by checking all sections with Red Text.
UB-04 - Manage Claim Template
Edit or Delete
created
templates
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Medicaid Primary Claim
Forms
Online Claims Entry
To begin the claim submission, all field with a RED asterisk (*) must be completed
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Click on the Red Text for the UB-04
Claim form instructions
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November 20, 2013
Additional Information Option
Sections can be expanded by
selecting all sections with Red Text
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Sections can be expanded by
selecting all sections with Red Text
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Sections can be expanded by
selecting all sections with Red Text
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Click
upload
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Review the Uploading Attachments Restrictions.
You can attach files up to 10 MB
Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files.
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
All field with a Red Asterisk (*) are REQUIRED fields
Diagnosis codes do not require a period(.)
Only enter the numeric value
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November 20, 2013
Online Claims Entry Primary Claim (Cont.)
Indicate the Total charge
x
Verify Total charge is correct
If total change is missing or does not match up with the line item
provided on the claim, the claim will deny or post additional edits.
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November 20, 2013
Medicaid Third Party
Liability (TPL) Claim
Third Party Liability (TPL) Tips
• TPL is commercial insurance
• TPL must be billed primary to Medicaid
• Medicaid does not consider Medicare TPL
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Third Party Liability (TPL) Tips
• Always enter the amount paid in the “Paid Amount” field
provided in the “Other Insurance Info” section of claim.
• If Medicaid requires a PA for the service, then a PA issued by
Medicaid Utilization Review is always required when TPL is
involved, no matter if TPL paid or denied the service.
• Attach the TPL EOB showing the payment/denial with the claim.
• Always include the explanation page of the EOB along with the
page of the EOB that shows payment/denial.
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Medicaid TPL Claim Example
Indicate Paid Amount
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November 20, 2013
Medicaid TPL Claim Example
Indicate the Total charge
TPL Payment
Co-pay/Co-insurance/
Deductible
x
Verify Total charge is correct
If total change is missing or does not match up with the line item
provided on the claim, the claim will deny or post additional edits.
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November 20, 2013
Medicaid Co-payment
Claim Forms
PPO/HMO Co-Pay Tips
• Indicate PPO/HMO under “Other Insurance Info” section of
the claim.
• Indicate Co-pay amount in the Co-pay field provided in the
“Other Insurance Info” section of claim.
• Attach the EOB.
• In the “Prior Payment Amount” enter the difference between
the billed amount and the co-payment\Amount Due.
• Enter the co-payment amount in the “Amount Due” field.
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HMO Co-pay Claim Example
Indicate Copay amount
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November 20, 2013
HMO Co-pay Claim Example
Indicate the Total charge
Difference
Co-pay/Co-insurance/
Deductible
x
Verify Total charge is correct
If total change is missing or does not match up with the line item
provided on the claim, the claim will deny or post additional edits.
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Medicare Replacement
Plan Claim Forms
Medicare Replacement Plan
Indicate “Medicare Advantage” for Medicare Replacement Plan
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November 20, 2013
Medicare Replacement Plan
Attach
Copy of
EOB
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November 20, 2013
Medicare Replacement Plan
Total Charge
Difference between total charge
and the co-payment amount
Co-Payment Amount
X
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Medicare Primary Claim
Forms
Medicare Primary Claims
Indicate “Medicare” for Medicare Crossover submissions
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November 20, 2013
Medicare Primary Claims
Attach
Copy of
EOB
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November 20, 2013
Medicare Primary Claims
Only Indicate Total charge on Medicare Crossovers
Leave the Prior Payment Amount and Amount Due Blank
X
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Inpatient claims for
Medicare Part B-only
clients
Inpatient Claims for Medicare Part
B-only clients
• Certain Medicaid/Medicare clients only have Medicare Part B
coverage.
• Medicare may cross over the Part B claim with type of bill 121. This
claim does not have an accommodation revenue code on it.
• The claim will deny and the provider will need to resubmit and
include the following four things on the claim:
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Inpatient claims for Medicare Part
B-only clients
• Use type of bill “121”.
• Attach a copy of the EOMB indicate Medicare paid amount in
previous payment box (form locator 54).
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Inpatient Claims for Medicare Part Bonly clients
Indicate “Medicare” for Inpatient Claims for Medicare Part B-Only Recipients
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November 20, 2013
Inpatient Claims for Medicare Part Bonly clients
Attach
Copy of
EOB
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November 20, 2013
Inpatient Claims for Medicare Part Bonly clients
Total Charge
TPL Payment Amount
Difference between Total Charge and Prior Payment Amount
X
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UB-04 Tips
UB-04 Tips
Ensure the line item charges are correct and match the total charge.
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UB-04 Tips
• Include all appropriate EOB’s for TPL, HMO, etc.
• If you are a for profit organization, make sure gross receipts tax
is included in the line items, if required.
• Rev codes, diagnosis codes, etc., are entered correctly.
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Resources
When online use: Ask Service Representative
HIPAA.Desk.NM@xerox.com
NMPRSupport@xerox.com
Call Center 505-246-0710 or 800-299-7304
New Mexico Web Portal
• Provider Information section
• Links and FAQ section
• Provider Login section