chapter four b - conduent · ub-92 march 1, 1999 4-1 chapter four
TRANSCRIPT
UB-92 March 1, 1999
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Chapter Four Billing Instructions
In this Chapter The following sections are covered in this chapter: Section Title
Page
Choosing the Correct Claim Form .............................................................................................. 4-2 Matrix for Choosing the Correct Claim Form............................................................... 4-3 How to Complete the UB-92 ........................................................................................................ 4-5 Prior Authorization.................................................................................................................... 4-23 Instruction for Completion of the Prior Authorization Form...................................... 4-27 How to Bill for Newborns .......................................................................................................... 4-29 Required Attachments and How to Complete ............................................................................ 4-29 Home Health Agencies and Hospital Based Home Health.......................................... 4-29 Home Health Billing Procedures................................................................................. 4-30 Sterilization Consent Form.......................................................................................... 4-31 Hysterectomy Acknowledgment of Consent .................................................................. 4-35 Abortion Certification................................................................................................... 4-37 Sample Claims and Forms ......................................................................................................... 4-39 Where to Send Your Claim......................................................................................................... 4-43 How to Resubmit a Denied Claim.............................................................................................. 4-43 Medicare Crossovers ................................................................................................................. 4-43 General Information ...................................................................................................... 4-43 How to File a Claim for a Dually Eligible Recipient .................................................... 4-44 The Remittance Advice............................................................................................................... 4-45 When Your Patient Has Other Insurance .................................................................................. 4-46 Sample Remittance Advice ............................................................................................. 4-47 How to Read Your Remittance Advice ........................................................................... 4-51 Adjustments and Refunds ........................................................................................................... 4-53 Refunding Money to Wyoming Medicaid ....................................................................... 4-53 Incorrectly Billed or Keyed Claims ............................................................................... 4-53 Third Party Recovery After Medicaid's Payment .......................................................... 4-54 How to File a Void or Adjustment Request.................................................................... 4-54 How to Complete the Adjustment Request Form ........................................................... 4-56 Where to Send the Adjustment Request.......................................................................... 4-58
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Choosing the Correct Claim Form You must use the Uniform Billing Claim Form (UB-92) when requesting payment for hospital and home health services authorized under the Wyoming Medicaid Program. An example of the claim form is depicted in this section. If you do not use the UB-92 form, your claim will be returned to you with a letter of explanation. This is a four-part form: • Submit the original copy to Consultec • Retain the carbon copies for your records Consultec does not supply the UB-92 claim form. The UB-92 may be ordered from an independent printer or from one of the following companies: • Standard Register Company • Moore Business Forms When your claim is received by Consultec's Document Control section, it is screened for missing information or necessary attachments. From time to time, there may be reasons why a claim is returned to you. The "Return to Provider Letter" will clearly state the reason the claim was rejected. Once the problem is corrected, return the claim to Consultec for processing. Claims are processed weekly. Checks are printed twice monthly. Under normal conditions, a claim can be processed from receipt to payment within 10 to 20 days. A check is mailed in the same envelope with the Remittance Advice if the claims were approved for payment.
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Matrix for Choosing the Correct Claim Form
CLAIM FORM
Service
UB-92
HCFA-1500
Required
Attachments
Bill Type
Specific Rev Codes
Home Health
*
HCFA 485, 486, & 487. Invoice required when billing rev code 27X (supplies)
33X
270*, 420, 430, 440, 550, 560, 570
Hospital Services
*
Dependent on services provided. (see Chapter 9)
11X
(inpatient) 13X, 14X
(outpatient)
Hospice Services
*
Election Statement and Physician's Cert. Statement.
81X or
82X
651, 652, 655, 656, 659
Durable Medical
Equipment
*
Professional Component
*
Ambulance
*
Trip report required
Rural Health Clinic
*
End Stage Renal Disease
*
72X
Comprehensive
Outpatient Rehab Facility
*
75X
Swing Bed Facilities
*
Medicare EOB (18X) or the Medicaid exempt letter when denial from Medicare is unattainable (17X, 27X)
17X, 27X (Medicaid
only or Medicare denied)
18X
(Medicare/ Medicaid)
100
Swing Bed Heavy Care
*
17X, 27X
Revenue code assigned by HCF for the individual recipient
For HCFA-1500 services, refer to the Medical Services Manual.
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Exhibit 4.1 Sample UB-92 Claim Form
THIS SECTION INTENTIONALLY LEFT BLANK
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How to Complete the UB-92 Instructions for completing the UB-92 claim form are included on the following pages. There are some basic rules you must know before you complete the claim form.
RULES FOR COMPLETING UB-92 CLAIMS
1
Use one claim form for each recipient.
2
Be sure the information on the form is legible.
3
Enter all information with a typewriter or black ink.
Before you begin to fill out the claim form you should answer the following questions: • Is the recipient eligible for Medicaid on the date of service? • Do you have a copy of the recipient's proof of eligibility? • Is the service covered by Medicaid? • Have the service limitations been exceeded? • Did you obtain prior authorization, if applicable? • Have you checked to make sure the recipient does not have other insurance? If your response to all of the above questions is favorable, you can begin to fill out the claim form following the instructions in this chapter. A separate notation is made when inpatient billing instructions differ from outpatient billing instructions. Use the instructions applicable to the type of claim you are completing. The number appearing with each instruction corresponds to the form locators on the UB-92.
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(Field #)
Item
Item Description
Req
Action
1
Provider Name, Address and Telephone Number
X
Enter the name of the provider submitting the bill and the complete mailing address and telephone number.
2 Unlabeled Field
Not required
3 Patient Control Number
X
(Optional) Enter your account number for the recipient. Any alpha/numeric character will be accepted and referenced on the Remittance Advice. No special characters are allowed, e.g., *@-#, etc.
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(Field #)
Item
Item Description
Req
Action
4
Type of Bill
X
Enter the three-digit code indicating the specific type of bill. The code sequence is as follows:
First Digit 1 Hospital (Inpatient/Outpatient) 2 Skilled Nursing (SNF Medicare/Medicaid Crossover
Only) 3 Home Health 7 Clinic (ESRD or CORF) 8 Special Facility (Hospice)
Second Digit 1 Inpatient 2 ESRD 3 Outpatient 5 CORF 7 Swingbed
Medicaid 8 Swingbed
Medicare/Medicaid
Third Digit 0 Non-payment/zero
claim 1 Admit through
discharge claim 2 Interim - 1st claim 3 Interim - continuing
claim 4 Interim - last claim
(thru date is discharge date)
5
Federal Tax Number
(Not Required)
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(Field #)
Item
Item Description
Req
Action
6
Statement Covers Period From/Through Dates
X
Enter the inpatient dates from date of admission through date of discharge or outpatient date of service. For services rendered on a single day, enter that date (MMDDYY) in both the "FROM" and "THROUGH" fields.
7 Covered Days
I
(Required for inpatient billing) Enter the number of days covered. Count date of admission but not date of discharge.
8 Non-Covered Days
X
(Required for inpatient billing when applicable) Enter the days of care not covered by Medicaid.
9 Co-Insurance Days
X
(When applicable) Enter the number of co-insurance days paid by Medicare.
10 Lifetime Reserve Days
Not required
11 Unlabeled Field
Not required
12 Patient's Name
Enter the recipient's last name, first name and middle initial exactly as shown on the front of the Medicaid Recipient ID Coupon.
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(Field #)
Item
Item Description
Req
Action
13
Patient's Address
X
Enter the full mailing address of recipient. (Street name and number, or box or RFD; city, state and zip code).
14 Birth Date
X
Enter month, day and year of recipient's birthdate. (MMDDYY)
15 Sex
X
(Optional) Enter appropriate code. (M=Male, F=Female, or U=Unknown)
16 MS (Patient Marital Status)
Not required
17 Admission Date
X
Enter the date the recipient was admitted as an inpatient or the date of outpatient care. (MMDDYY)
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(Field #)
Item
Item Description
Req
Action
18
Admission Hr
X
Enter the code corresponding to the hour of admission as shown in the table
Code Time AM Code Time PM 00 12:00-12:59 midnight 12 12:00-12:59 noon 01 01:00-01:59 13 01:00-01:59 02 02:00-02:59 14 02:00-02:59 03 03:00-03:59 15 03:00-03:59 04 04:00-04:59 16 04:00-04:59 05 05:00-05:59 17 05:00-05:59 06 06:00-06:59 18 06:00-06:59 07 07:00-07:59 19 07:00-07:59 08 08:00-08:59 20 08:00-08:59 09 09:00-09:59 21 09:00-09:59 10 10:00-10:59 22 10:00-10:59 11 11:00-11:59 23 11:00-11:59
99 Hour Unknown -----------------------------------------------------------------------------------------------------------------
Outpatient: No entry required
Home Health:
No entry required
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(Field #)
Item
Item Description
Req
Action
Enter appropriate code.
19
Admission Type
X
Inpatient: 1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn Outpatient: No entry required Home Health: Codes same as Inpatient
20 SRC (Source of Admission)
X
Enter the Source of Admission Code.
21
Discharge Hour
X
(When applicable) Enter the hour the recipient was discharged.
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(Field #)
Item
Item Description
Req
Action
22
Patient Status
X
Enter the two-digit code indicating the status of the patient as noted below:
Code
01 02 03 04 05 06 07 20 30
Description discharged - home or self care discharged - other hospital discharged - SNF discharged - ICF discharged - other type of institution discharged - home health organization left against medical advice expired still a patient
23 MED Record
Not required
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(Field #)
Item
Item Description
Req
Action
24,25,262
7,28 29,30
Condition Codes
X
(Required) Enter codes used to identify conditions relating to this claim that may affect payer processing as noted below:
Code
01 02 03
04 06
08
17 38 39 77 80
81 82
Description Military Service related Condition is employment related Patient is covered by insurance not reflected here HMO Enrollee ESRD patient in first year of entitlement covered by employer group health insurance Patient would not provide information concerning other insurance coverage Patient is over 100 years old Semiprivate room not available Private room medically necessary Provider accepts assignment Patient is eligible for Medicare Part A only Patient is eligible for Medicare Part B only Patient is eligible for both Medicare Parts A and B
If any information is coded here, complete the appropriate form locator(s) 50, 58-62, or 63-66.
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(Field #)
Item
Item Description
Req
Action
31
Unlabeled
Not required
32,33,343
5
Occurrence Codes and Dates
X
(Required when applicable) Enter the appropriate occurrence code(s) and the date of occurrence for reporting information on the type of accident, crime victim, benefits, other insurance, or date of termination or third party coverage.
Code
01 02 03 04 05 06 11 23 24 25
Description Auto accident Auto accident/no fault insurance Accident/tort liability Accident/employment related Other accident Crime victim Date of onset Benefits exhausted (Medicare) Date insurance denied Date benefits terminated by primary payor
If there is any information coded in these form locator(s) then give full details in the appropriate fields 50, 58-62, 63-69.
36 Occurrence Span Code and Dates
X
Enter the occurrence span codes and the corresponding dates.
37 ICN
Not required
38 Responsible Party Name and Address
Not required
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(Field #)
Item
Item Description
Req
Action
39,40,41
Value Codes and Amounts
X
Enter the value codes and amounts when related to other insurance.
42 R Code (Revenue Code)
X
Enter the appropriate three-digit revenue code necessary to identify the specific accommodation or ancillary services.
43 Revenue Description
Enter a narrative description of the related revenue categories included on this bill.
44 HCPCS / Rates
X
For outpatient billing only - place the appropriate HCPCS code for all laboratory and radiology related services when billing. Note: HCPCS Laboratory procedure codes and
Radiology procedure codes can be obtained from the current CPT-4 book. Some laboratory procedures are considered panels consisting of several laboratory tests. List the panel procedure code and the price. DO NOT SEPARATE THESE.
45 Services Date
X
(Required for outpatient services) Enter the dates of service for each Revenue code.
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(Field #)
Item
Item Description
Req
Action
46
S. Units (Units of Services)
X
Enter a quantitative measure of service rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints of blood, or renal dialysis treatments, etc.
47 Total Charges
X
List the total charges for each revenue code line item. This includes any non-covered charges. Total the column at the bottom.
Outpatient When billing outpatient laboratory and radiology procedures, list the charge for each procedure.
48 Non-Covered
X
(When applicable) Enter detailed breakdown of non-covered charges on applicable codes. Total the column.
49 Unlabeled Charge Columns
Not required
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(Field #)
Item
Item Description
Req
Action
50
Payer (Identification)
X
Medicaid is payer of last resort. All other forms of third party resources should be listed first. Use the A-C spaces to list all insurance resources available. If other insurance is listed, give complete details in fields 58-62. List any prior payments in field 54 and attach documentation of payment or denial.
51 Provider No.
X
Medicaid Enter the nine-digit Medicaid Provider Number assigned to the provider by the Wyoming Medicaid program through Consultec's provider re-enrollment.
52 Rel (Release of information certification indicator)
Not required
53
Asg Ben (Assignment of benefits certification indicator)
Not required
54
Prior Payments
X
(Required when applicable) If there is an entry in 50, enter the amount received toward payment of this bill prior to the billing date by the indicated payer.
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(Field #)
Item
Item Description
Req
Action
55
Estimated Amount Due
Not required
56 Unlabeled
Not required
57 Due From Patient
X
Required for swing bed and swing bed - heavy care. Enter the expected patient contribution as determined by DFS.
58 Insured's Name
X
(Required when applicable) Refer to field 50. If any other insurance information is listed, enter the policyholder name.
59 P. Rel (Patient's Relationship to Insured)
X
(Required when applicable) Enter the patient's relationship corresponding to the other policyholder as listed in field 58.
60 Cert./ SSN/HIC/ID No. (Patient's Medicaid Recipient ID Number)
X
If Medicaid is the only payer, list the recipient's ten-digit Medicaid Recipient ID Number on the first line. If other insurance is listed, list agreement number or HIC number which corresponds to the type of coverage identified on each line of field 58.
61 Insured's Group Name
X
(Required when applicable) Enter the name of the group or plan through which the insurance is provided if the recipient is covered by insurance other than Medicaid.
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(Field #)
Item
Item Description
Req
Action
62
Insurance Group Number
X
(Required when applicable) Enter the group identification number assigned by the carrier or fund administrator to identify the group under which the recipient is covered.
63 (PA) Treatment Authorization
X
(Required when applicable) Inpatient and Outpatient: If the procedure/services require prior authorization, enter the number from the PA form here. Refer to PA form sample in this chapter for more detailed prior authorization instructions.
X (Required when applicable) Enter a code from the table below to define the employment status of the insured. Inpatient and Outpatient:
64
ESC (Employment Status Code)
CODE
1 2 3 4 5 6 9
DESCRIPTION Employed full-time Employed part-time Not employed Self-employed Retired Active Military Unknown
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(Field #)
Item
Item Description
Req
Action
65
Employer Name
X
(Required when applicable) Inpatient and Outpatient: Enter the name of the employer that might or does provide health care coverage for the individual identified in field 58.
66 Employer Location
X
(Required when applicable) Inpatient and Outpatient: Enter the specific location of the employer of the individual.
67 Principal Diagnosis Code
X
Inpatient and Outpatient: Enter the ICD-9-CM code (exactly as in book) describing the principal diagnosis. Use the most specific 3, 4 or 5-digit code for the diagnosis (use all 5 digits if applicable). Enter the codes for diagnosis other than the principal diagnosis in fields 68-75.
68-78 Other Diagnosis Codes
X
(Required when applicable) Inpatient and Outpatient: Enter the ICD-9-CM diagnosis codes corresponding to additional conditions that co-exist at the time of admission (or time of service), or develop subsequently, that had an effect on the treatment received during the length of stay or time of service.
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(Field #)
Item
Item Description
Req
Action
79
Procedure Coding Method Used
Not required.
80 Principal Procedure Code and Date
X
(Required when applicable) Inpatient and Outpatient: Enter the ICD-9-CM procedure code only for the primary procedure with date of service following.
81 Other Procedure Codes and Dates
X
(Required when applicable) Inpatient and Outpatient: Enter the ICD-9-CM codes identifying the procedures, other than the principal procedure, performed during the billing period covered by this bill and the dates on which the procedures (identified by the codes) were performed.
82 Attending Physician ID
X
Inpatient and Outpatient: Enter the attending physician's UPIN number. If a UPIN number is not available, enter the physician's nine-digit Wyoming Medicaid Provider number and name.
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(Field #)
Item
Item Description
Req
Action
83
Other Physician ID
X
(Required when applicable) Enter the UPIN number of the physician performing the principal procedure. If a UPIN number is not available, enter the physician's nine-digit Wyoming Medicaid Provider number and name.
84 Remarks
Not required
85 Provider Representative Signature
X
Inpatient and Outpatient: A personal signature, a facsimile signature, typed signature, computer generated name, or an authorized signature must appear in this field. Providers are responsible for all claims billed using their Wyoming Medicaid provider number whether the claim is submitted by the provider, the provider�s employee, sub-contractor, vendor, or business agent.
86 Date Bill Submitted
X
Inpatient and Outpatient: Enter the date in MMDDYY format on which the bill was signed, or submitted to the payer for payment.
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Prior Authorization Some procedures require Wyoming Medicaid's approval (prior authorization) before you provide the service. The prior authorization form must be submitted to Consultec before performing the services in question. The request will be approved or denied and you will receive a letter informing you of the decision. If the request is approved, a prior authorization number will be listed on the approval letter. This number must be in field 63 on the UB-92 claim form. To order this form, refer to Chapter 6. A copy of the PA form and instructions on completing the form follow this section. Reimbursement will not be made when you fail to obtain prior authorization for specified services. Telephone authorization may be granted in cases of medical emergency where the health of the patient would be endangered. To obtain emergency authorization, please call 1-800-251-1268 or (307) 777-5501 locally. Telephone prior authorization is not a guarantee of coverage. You must complete the prior authorization form noting the verbal approval and submit to Consultec. See Chapter 9 for additional information on Prior Authorization.
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SERVICES REQUIRING PRIOR AUTHORIZATION
• DME/MEDICAL SUPPLIES and PROSTHETICS/ORTHOTICS - Medical Supplies Provider Manual
• For extremely high cost items price negotiation may be necessary in consultation with HCF • EXPANDED HEALTH CHECK SERVICES - Refer to HCFA 1500 Provider Manual • VISION THERAPY • RECONSTRUCTIVE SURGERY PROCEDURES • LTC WAIVER SERVICES
The plan of care will come to the Division on Aging and will be entered into the system as approved by the Division on Aging.
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Exhibit 4.2 Sample Prior Authorization Form WYOMING MEDICAID PRIOR AUTHORIZATION FORM
I. PATIENT INFORMATION
II. PROVIDER INFORMATION
1. DOB
2. SEX
3. AGE
4. MEDICAID ID#
9. PROVIDER NUMBER
10. TELEPHONE
5. PATIENT NAME (LAST, FIRST, MI)
11. PROVIDER NAME
6. STREET ADDRESS
STREET ADDRESS
7. CITY, STATE, ZIP CODE
MAILING ADDRESS
8. PHONE NUMBER ( ) -
CITY, STATE, ZIP CODE
III. SERVICE INFORMATION
12. DATES OF SERVICE MM/DD/YY FROM TO
13. PROPOSED MEDICAL SUPPLIES, PHARMACY, SURGICAL PROCEDURES OR OTHER SERVICES, (LIST PRIMARY PROCEDURE FIRST)
14. PROCEDURE, NDC OR REVENUE CODE(S)
15. UNITS
16. ESTIMATED COST
17. STATE USE ONLY-APPROVED UNITS AMOUNTS
A.
B.
C.
D.
18. SUMMARY OF HISTORY (DIAGNOSIS, DATE OF ONSET, PROGNOSIS, PHYSICAL EXAMINATION, LABORATORY, X-RAY STUDIES, PHARMACY, AND APPLICABLE DOCUMENTATION MUST BE SUPPLIED IN SUFFICIENT DETAIL TO SATISFY THE MEDICAL NECESSITY FOR THE PRESCRIBED SERVICE. ADDITIONAL DOCUMENTATION MAY BE ATTACHED WHEN NECESSARY.) 19. REFFERRING WYOMING PHYSICIAN: TELEPHONE NUMBER: (IF THIS AUTHORIZATION REQUEST IS FOR SERVICE TO BE RENDERED OUT-OF-STATE, A BRIEF JUSTIFICATION STATEMENT IS REQUIRED) 20. VERBAL AUTHORIZATION GIVEN BY: DATE: PA NUMBER: 21. TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. SIGNATURE OF PROVIDER: DATE:
IV. AUTHORIZATION (FOR STATE USE ONLY) AUTHORIZATION IS VALID FOR SERVICES 22. FROM DATE: 23. TO DATE: 24. PRIOR AUTHORIZATION NUMBER 25. COMMENTS/EXPLANATION:
NOTE:AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO THE PATIENT'S ELIGIBILITY AND WYOMING BENEFIT LIMITATIONS. BE SURE THE MEDICAID IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICES. CONSULTEC, INC. * P.O BOX 667 * CHEYENNE, WY 82003 1-800-251-1268 * (307) 777-5501 (In Cheyenne) * FAX: (307) 777-5519 HCF/UMU1056/93
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Instructions for Completion of the Prior Authorization Form
I. PATIENT INFORMATION
1. Date of birth, sex, age, Medicaid Identification No. are required (items 1-4). 2. Name (recipient), city and state are required items (items 5 & 7). 3. Street address, zip code and phone # are optional but helpful (items 6 & 8).
II. PROVIDER INFORMATION
1. Provider identification number (nine-digit unique Wyoming Medicaid provider number), provider name, phone number and address are required (items 9-11).
III. SERVICE INFORMATION
1. Date(s) of services (item 12) is required. 2. Proposed services (written description), procedure codes, number of units (number of each service), and estimated cost
are required (items 13-16). The estimated cost is the cost (or rental) times the number of units. (Units can be days, months, or services, etc.)
*NOTE: RENTAL EQUIPMENT REQUIRES THE MODIFIER -RR* 3. Item 17 (number of units) reflects the number of units and is completed by the state evaluation when prior
authorizing the services. 4. Summary of History is required (item 18); please give as much information as possible supporting the need for the
service(s) requested including but not limited to documentation of medical necessity and prescriptions. You may attach additional sheets if necessary.
*Surgical requests require an attached history and physical. 5. Out of State Services (item 19);
Under Referring Wyoming Physician, enter the name or the provider number of the Wyoming physician referring the recipient for out-of-state services; enter the phone number of the referring Wyoming physician. The justification can be brief and can relate to item # 18.
6. Verbal authorization (item 20); Put the name of the person from Consultec who gave the verbal authorization, the date you spoke with them, and the PA number. Remember that this authorization is only a tentative authorization. Until a written request is received, the claim cannot be paid. The written request must be submitted to Consultec prior to submitting the claim.
7. Signature of provider (item 21) is required. IV. AUTHORIZATION
1. Items 22-25 will be completed by Wyoming Medicaid when prior authorization is approved or denied **NOTE: THERE MAY BE ADDITIONAL INSTRUCTIONS IN THE COMMENT SECTION IMPORTANT NOTE: The assigned PA # MUST appear on the claim form for proper reimbursement. On the HCFA-1500 it is required in field 23. On the UB-92 the PA number is required in field 63. REMINDERS Effective November 1, 1993, all Prior Authorization (PA) requests should be sent directly to the Consultec office.
- Prior authorization of services and supplies MUST be obtained before services are rendered - If verbal prior authorization is granted in an emergency, a written request MUST be submitted before the claim can be paid. - PA requests may also be faxed to Consultec (307-777-5519).
Failure to request the prior authorization prior to the rendering of services will result in denial of the service. Submit the prior authorization form to: Consultec, Inc. P. O. Box 667 Cheyenne, WY. 82003-0667 307-777-5501 Verbal authorization may be obtained by phoning Consultec at 1-800-251-1268.
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Instruction for Completion of the Prior Authorization Form
Item Number
Title
Action
1
Date of Birth
Enter MMDDYY of recipient's date of birth.
2
Sex
Enter recipient's sex.
3
Age
Enter recipient's age.
4
Medicaid Identification Number
Enter the recipient's ten-digit Wyoming Medicaid ID number.
5
Patient's Name
Enter last name, first name, and middle initial exactly as it appears on the Wyoming Medicaid ID Card.
6
Patient's Address
Enter the street address, including P.O. Box and apartment number, where recipient resides.
7
City, State, Zip Code
Enter the city, state, and zip code at which the recipient resides.
8
Phone Number
Enter the telephone number of the recipient.
9
Provider Number
Enter nine-digit unique Wyoming Medicaid provider number.
10
Provider Telephone Number
Enter area code and telephone number of provider, including extension, if appropriate.
11
Provider Name and Address
Enter provider name as it appears on the provider enrollment form, with either street address or P.O. box, city, state, and full zip code.
12
Date(s) of Service
Enter the date(s) of service this prior authorization will cover.
13
Proposed Services
Enter narrative description of service(s) being prior authorized.
14
Procedure/NDC/Revenue Codes
Codes for the service(s) being prior authorized should reflect narrative description.
15
Units
Enter number of each service being prior authorized.
16
Estimated Cost
Enter dollar amount times the units for each service being prior authorized.
17
State Use Only
To be completed by the State evaluator.
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Item
Number
Title
Action
18 Summary of History
Please give as much information as possible supporting the need for the service(s) requested. You may attach additional sheets if necessary.
19
Out-of-State Justification
Under "Wyoming Referring Physician," enter the name or the provider number of the Wyoming physician referring the recipient for out-of-state services. Under "Phone Number," enter the phone number of the referring Wyoming physician. The justification of out-of-state services can be brief and can relate to #19.
20
Verbal Authorization
Enter the name verbal authorization was given by, the date authorization was given, and the PA number.
21
Signature/Date
The form should be signed by the entity requesting prior authorization of services, with the date of the signature.
22-25
State Use Only
These items will be completed by Wyoming Medicaid when prior authorization is approved.
Send Prior Authorization Form to: Consultec P.O. Box 667 Cheyenne, WY 82003
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How to Bill for Newborns If the newborn's number is not available, submit a UB-92 claim for the newborn recipient using the mother's Recipient ID number. Enter the mother's number in field 60 on the UB-92 Claim Form. Consultec will verify the newborn's number by referencing the mother's Recipient ID number and insert the newborn's number in this field on the claim form. Write "Newborn Claim" on the face of the claim form to alert Consultec to process these claims differently. Send your newborn claims to:
Consultec Newborn Claims P.O. Box 547 Cheyenne, WY 82003
Required Attachments and How to Complete When providing Medicaid services, certain procedures or conditions require that other forms be used in addition to the claim form when billing for reimbursement. This section describes each required form and tells you how to prepare it for submission. Attachments When billing for services which require attachments, the attachments must be submitted with the UB-92 claim form. Examples of attachments include: • Consent Forms • Statement of Medical Necessity Home Health Agencies and Hospital Based Home Health The Home Health Agency must submit the UB-92 claim form with a type of bill (Field 4) of "33X." The acceptable revenue codes are:
• 270 Medical Supplies • 420 Physical Therapy • 430 Occupational Therapy • 440 Speech Therapy • 550 Skilled Nursing • 560 Medical Social Services • 570 Home Health Aide Services
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Home Health Billing Procedures • Home Health billing must be submitted on the UB-92, HCFA 1450 claim form. • Prior authorization will only be required for out-of-state providers. All services, regardless of dollar amount, provided by an out-of-state provider will require PA and the PA number must be entered on the UB-92 claim form in box 63. • Home Health agencies billing for rental or sale of durable medical equipment must be additionally enrolled as a medical equipment supplier. These charges must be billed on a HCFA-1500 claim form. • POTs and other HCFA forms must be signed and kept on file and be submitted upon request by Medicaid. The forms must accompany PAs when submitted. • Billing for services may be accomplished monthly or by certification period. Any claims with a revenue code of "27X" must have an invoice for the medical supplies attached. Refer to Chapter Nine for more information concerning requirements for attachments.
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Sterilization Consent Form Federal regulations require that recipients give written consent prior to sterilization for Medicaid to reimburse you for these procedures. The Sterilization Consent Form is obtained from Consultec. (See "Ordering Claim Forms" in Chapter Six.) The Sterilization Consent Form must be attached to all claims for Medicaid reimbursement of sterilization related procedures as mandated by the Federal Government. All sterilization claims must be processed according to the following Federal guidelines:
GUIDELINES The waiting period between consent and sterilization must not exceed 180 days and must be at least 30 days, except in cases of premature delivery and emergency abdominal surgery. The day the recipient signs the consent form and the surgical date are not included in the 30-day requirement. A recipient signs the consent form on July 1. To determine when the waiting period is completed, count 30 days beginning on July 2. The last day of the waiting period would be July 31; therefore, surgery may be performed on August 1. In the event of premature delivery, the consent form must be completed and signed by the recipient at least 72 hours prior to the sterilization, and at least 30 days prior to the expected date of delivery. In the event of emergency abdominal surgery, the recipient must complete and sign the consent form at least 72 hours prior to sterilization. The consent form SUPPLIED BY THE SURGEON must be attached to every claim for sterilization-related procedures; i.e., ambulatory surgical center clinic, physician, anesthesiologist, inpatient or outpatient hospital. Any claim for a sterilization-related procedure which does not have a signed and dated, valid consent form will be denied. All blanks on the consent form must be completed with the requested information. The consent form must be signed and dated by the recipient, the interpreter (if one is necessary), the person who obtained the consent, and the physician who will perform the sterilization. The physician statement on the consent form must be signed and dated by the physician who will perform the sterilization on the date of the sterilization or after the sterilization procedure was performed. The date on the sterilization claim form must be identical to the date and type of operation given in the physician's statement.
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Exhibit 4.7 Sterilization Consent Form STERILIZATION CONSENT FORM
HCF-01
NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
CONSENT TO STERILIZATION I have asked for and received information about sterilization from _________________. When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a ___________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years or age and was born on ______________________.
Month Day Year I, ________________________________, hereby consent of my own free will to be sterilized by ____________________________(doctor) by a method called _______________________________. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. _________________________________ Date:___________________________
Signature Month Day Year You are requested to supply the following information, but it is not required: Race and ethnicity designation (please check) __American Indian or Alaska Native __Black (not of Hispanic origin) __Asian or Pacific Islander __Hispanic __White (not of Hispanic origin)
INTERPRETER'S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in ______________________ language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation.
_____________________________ ________________________________ Signature of Interpreter Date
STATEMENT OF PERSON OBTAINING CONSENT
Before ___________________________________ signed the consent form, I name of individual
explained to him/her the nature of the sterilization operation ______________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure. ____________________________________ ___________________________
Signature of person obtaining consent Date ____________________________________________________________________
Facility ____________________________________________________________________ Address
PHYSICIAN'S STATEMENT Shortly before I performed a sterilization operation upon ________________________________ on _______________________________,
Name of individual to be sterilized Date of sterilization operation I explained to him/her the nature of the sterilization operation ________________,
specify type of operation the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested): � Premature delivery � Individual's expected date of delivery: ________________(Date) � Emergency abdominal surgery: (describe circumstances):
_________________________________________ __________________ Physician Date
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Use the following instructions to complete the Sterilization Consent Form. PART 1 CONSENT TO STERILIZATION 1 Enter the name of the physician or the name of the clinic from which the recipient received
sterilization information. 2 Enter the type of operation (no abbreviations). 3 Enter the recipient's date of birth (MM/DD/YY). 4 Enter the recipient's name. 5 Enter the name of the physician performing the surgery. 6 Enter the name of the type of operation (no abbreviations). 7 The recipient to be sterilized signs name here. 8 The same recipient in #7 dates signature here. 9 Check one box appropriate for recipient. This item is requested but NOT required. PART 2 INTERPRETER'S STATEMENT 10 Enter the name of the language the information was translated to. 11 Interpreter signs name here. 12 Interpreter dates signature here. PART 3 STATEMENT OF PERSON OBTAINING CONSENT 13 Enter recipient's name. 14 Enter the name of the operation. (No abbreviations.) 15 The person obtaining consent from the recipient signs here. 16 The person obtaining consent from the recipient dates signature here. 17 The person obtaining consent from the recipient enters the name of the facility where the person
obtaining consent is employed. The facility name must be completely spelled out. 18 The person obtaining consent from the recipient enters the complete address of facility in #17
above. Address must be complete, including state and zip code.
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PART 4 PHYSICIAN'S STATEMENT 19 Enter the recipient's name. 20 Enter the date of sterilization operation. 21 Enter type of operation. (No abbreviations.) 22 Check applicable box: o If premature delivery is checked, you must write in the
expected date of delivery here.
o If emergency abdominal surgery is checked, describe circumstances here.
23 Physician who performs the sterilization signs here. 24 The physician's signature must be dated.
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Exhibit 4.8 Sample Hysterectomy Consent Form HYSTERECTOMY ACKNOWLEDGMENT OF CONSENT COMPLETE PART A IF CONSENT IS OBTAINED PRIOR TO SURGERY It is anticipated that ________________________________ will perform a hysterectomy on me. I understand that there are medical indications for this surgery. It has been explained to me and I understand that this hysterectomy will render me permanently incapable of bearing children. Diagnosis:_________________________________________________________________________________________ Signature of Patient:____________________________________________Date:___________________________________________ Signature of Person Explaining Hysterectomy:________________________________________Date:_________________________________________ _________________________________________________________________________________________________ COMPLETE PART B IF CONSENT IS OBTAINED AFTER SURGERY On_______________________________ ____________________________________________________________________________________ (Date) (Physician) performed a hysterectomy on me. I understand that there were medical indications for this surgery. Prior to the procedure the doctor again explained to me that this surgery would render me permanently incapable of bearing children. Diagnosis:________________________________________________________________________________________ Signature of Patient:______________________________________________ Date:_________________________________________________ Signature of Person Explaining Hysterectomy:__________________________________________Date:_______________________________________ _________________________________________________________________________________________________ COMPLETE PART C IF NO CONSENT IS OBTAINED Diagnosis:_________________________________________________________________________________________ Check which is applicable: [ ] Other reason for
sterility____________________________________________________________________________________ __________________________________________________________________________________________
[ ] Previous tubal Date:_________________________________________ [ ] Emergency situation (describe) ___________________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________ _____________________________ Physician Signature Date _____________________________________________________________________________________________________ HCF-03
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Hysterectomy Acknowledgment of Consent A copy of the completed Hysterectomy Acknowledgment of Consent form must be attached to each UB-92 claim form when billing for hysterectomy related services before Wyoming Medicaid will consider the claim for payment. The originating physician is required to supply other billing providers (e.g., hospital, surgeon, anesthesiologist, etc.) with a copy of the completed Hysterectomy Acknowledgment of Consent form. Use the following instructions to complete the Hysterectomy Consent Form. PART A CONSENT OBTAINED PRIOR TO SURGERY 1 Enter the name of the physician performing the surgery. 2 Enter the narrative diagnosis for the recipient's condition. 3 The recipient receiving the surgery signs here and dates. 4 The person explaining the surgery signs here and dates. PART B CONSENT OBTAINED AFTER SURGERY 5 Enter the date and the physicians name who performed the hysterectomy. 6 Enter the narrative diagnosis for the recipient's condition. 7 The recipient receiving the surgery signs here and dates. 8 The person explaining the surgery signs here and dates. PART C NO CONSENT IS OBTAINED 9 Enter the narrative diagnosis for the recipient's condition. 10 Check applicable box:
• If other reason for sterility is checked, you must write what was done. • If previous tubal is checked, you must enter the date of the tubal.
• If emergency situation is checked, you must enter the description.
11 The physician who performed the hysterectomy signs here and dates.
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Abortion Certification The Wyoming Medicaid Abortion Certification form must accompany all claims for abortion related services. This requirement includes, but is not limited to, claims from the attending physician, assistant surgeon, anesthesiologist, pathologist, and hospital. Refer to a sample of the form and instructions for completing the form on subsequent pages in this chapter. Use the following instructions to complete the Abortion Certification Form. 1 Enter the name of the attending physician or surgeon. 2 Check the option (1, 2, or 3) that is appropriate for the recipient. 3 You must enter the name of the recipient receiving the surgery and their address. 4 The attending physician or surgeon signs here. 5 Enter the performing physician's address.
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Exhibit 4.9 Sample Abortion Certification Form ABORTION CERTIFICATION FORM I, Doctor____________________________________________, certify that:
________ (1) my patient suffers from a physical disorder, physical injury, or physical
illness including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place her in danger unless an abortion is performed; or
________ (2) this pregnancy is a result of sexual assault as defined in W.S. 6-2-301 which
was reported to a law enforcement agency within 5 days after the assault or within 5 days after the time the victim was capable of reporting the assault; or
________ (3) the pregnancy is the result of incest. Patient Name: _____________________________________ Address: _____________________________________
_____________________________________
Physician Signature: _________________________________
Address: _________________________________
_________________________________
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Sample Claims and Forms
Exhibit 4.10 Completed UB-92 Claim Form
THIS SECTION INTENTIONALLY LEFT BLANK
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Exhibit 4.11 Sample Sterilization Consent Form STERILIZATION CONSENT FORM
NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
CONSENT TO STERILIZATION I have asked for and received information about sterilization from _________________. When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a ___________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years or age and was born on ______________________.
Month Day Year I, ________________________________, hereby consent of my own free will to be sterilized by ____________________________(doctor) by a method called _______________________________. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. _________________________________ Date:___________________________ Signature Month Day Year You are requested to supply the following information, but it is not required: Race and ethnicity designation (please check) __American Indian or Alaska Native __Black (not of Hispanic origin) __Asian or Pacific Islander __Hispanic __White (not of Hispanic origin)
INTERPRETER'S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in ______________________ language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. _________________________________ _____________________________ Signature of Interpreter Date
STATEMENT OF PERSON OBTAINING CONSENT
Before ___________________________________ signed the consent form, I name of individual explained to him/her the nature of the sterilization operation ______________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure. ____________________________________________________________________ Signature of person obtaining consent Date ____________________________________________________________________
Facility ____________________________________________________________________ Address
PHYSICIAN'S STATEMENT Shortly before I performed a sterilization operation upon ________________________________ on _______________________________, Name of individual to be sterilized Date of sterilization operation I explained to him/her the nature of the sterilization operation ________________,
specify type of operation the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested): � Premature delivery � Individual's expected date of delivery: ________________(Date) � Emergency abdominal surgery: (describe circumstances): _________________________________________ __________________ Physician Date
HCF-01
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Exhibit 4.12 Sample Hysterectomy Acknowledgment of Consent Form HYSTERECTOMY ACKNOWLEDGMENT OF CONSENT COMPLETE PART A IF CONSENT IS OBTAINED PRIOR TO SURGERY It is anticipated that ________________________________ will perform a hysterectomy on me. I understand that there are medical indications for this surgery. It has been explained to me and I understand that this hysterectomy will render me permanently incapable of bearing children. Diagnosis:_________________________________________________________________________________________ Signature of Patient:____________________________________________Date:___________________________________________ Signature of Person Explaining Hysterectomy:________________________________________Date:_________________________________________ _________________________________________________________________________________________________ COMPLETE PART B IF CONSENT IS OBTAINED AFTER SURGERY On_______________________________ ____________________________________________________________________________________ (Date) (Physician) performed a hysterectomy on me. I understand that there were medical indications for this surgery. Prior to the procedure the doctor again explained to me that this surgery would render me permanently incapable of bearing children. Diagnosis:_________________________________________________________________________________________ Signature of Patient:______________________________________________ Date:_________________________________________________ Signature of Person Explaining Hysterectomy:__________________________________________Date:_______________________________________ _________________________________________________________________________________________________ COMPLETE PART C IF NO CONSENT IS OBTAINED Diagnosis:_________________________________________________________________________________________ Check which is applicable: [ ] Other reason for
sterility____________________________________________________________________________________ __________________________________________________________________________________________
[ ] Previous tubal Date:_________________________________________ [ ] Emergency situation (describe) ___________________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________ _____________________________ Physician Signature Date _____________________________________________________________________________________________________ HCF-03
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Exhibit 4.13 Sample Abortion Certification Form ABORTION CERTIFICATION FORM I, Doctor____________________________________________, certify that:
________ (1) my patient suffers from a physical disorder, physical injury, or physical
illness including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place her in danger unless an abortion is performed; or
________ (2) this pregnancy is a result of sexual assault as defined in W.S. 6-2-301 which
was reported to a law enforcement agency within 5 days after the assault or within 5 days after the time the victim was capable of reporting the assault; or
________ (3) the pregnancy is the result of incest. Patient Name: _____________________________________ Address: _____________________________________
_____________________________________
Physician Signature: _________________________________
Address: _________________________________
_________________________________
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Where to Send Your Claim Send your UB-92 claim forms to:
Consultec/Claims P.O. Box 547 Cheyenne, WY 82003-0547
How to Resubmit a Denied Claim Please check your Remittance Advice before submitting a second request for payment. Claims can be resubmitted for one of the following reasons: • The claim has not appeared on a Remittance Advice as paid, denied, or pended for thirty days since you submitted it, or • The claim was denied due to incorrect or missing information. You can resubmit a claim on a new claim form or a legible photocopy after correcting any error or attaching requested documentation. Claims and attachments which cannot be clearly microfilmed or photocopied will be returned. Medicare Crossovers Wyoming Medicaid reimburses for Medicare/Medicaid services when provided to an eligible recipient. These services must be billed on a UB-92 claim form. General Information • Dually eligible recipients are recipients who are eligible for Medicare and Medicaid. • Medicare coverage is identified on the recipient card. Questions regarding Medicare benefits can also be directed to AVR. • Providers must accept assignment of claims for dually eligible recipients. • The State of Wyoming reimburses providers for 100% of deductible amounts and 100% of coinsurance amounts due on Medicare covered services for dually eligible recipients.
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How to File a Claim for a Dually Eligible Recipient
• Medicare is primary and must be billed first. Direct your questions related to Medicare claims processing to the Medicare carrier. • A paper claim with the Medicare EOMB attached must be filed. • The claims must: ! Be a legible photocopy of the UB-92 submitted to Medicare or completed according to
Medicare billing instructions.
! Have your nine-digit Consultec Medicaid number in field 51.
! Have attached a copy of the Medicare EOB. The time limit for filing Medicare crossover claims to Wyoming Medicaid is twelve months from the date of service or six months from the date of the Medicare payment, whichever is later.
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The Remittance Advice The Remittance Advice (RA) plays an important communication role between you and Wyoming Medicaid. It tells you what happened to the claims submitted for payment - whether they were paid, pended, or denied. Aside from providing a record of transactions, the RA assists you in resolving possible errors so that you CAN resubmit denied claims (See Exhibit 4.14 for sample RA and instructions on how to read the RA). • Claims are grouped by disposition category. For example, paid, denied, and pended claims and claim adjustments are listed in separate sections. ! Claim Status PAID group contains all the paid claims. If you have been paid for a claim
that you later decide should not have been billed to Medicaid, refer to How to File a Void or Adjustment Request in this chapter for instructions. You can only void or adjust a paid claim.
! Claim Status DENIED group reports denied claims. If you have new or additional information that might make a denied claim payable, you may rebill it (see How to Resubmit a Denied Claim in this chapter).
! Claim Status PENDED group reports claims pended for review. Do not rebill these claims. You cannot adjust or void pended claims. All claims in pended status are reported each payment cycle until paid or denied.
• All paid, denied, and pended claims and claim adjustments are itemized within each group in alphabetic order by recipient last name. • Transaction Control Numbers (TCNs) are assigned to all of the claims in the batch as they are microfilmed. The TCN assigned to each claim allows the claim to be tracked throughout the Wyoming Medicaid system. The digits and groups of digits in the TCN have special meanings, as explained in this example:
0 93180 00 001 0001 00 | | || | | | | | | || | | | Line number (00 except for drug, administrative | | || | | | transportation) | | || | | Claim Number | | || | Type of document (0=new claim, 1=credit, 2=adjustment) | | || Batch number | | |Microfilm reel number | | Microfilm machine number | Year/Julian date Claim input medium indicator......................................................................... 0=Exam entered
2=Tape-to-tape 3=ASAP 4=Computer generated (Adjustment)
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The RA Summary Section reports the number of claim transactions, and total payment, or check amount. If your account with Consultec shows a prior negative balance, it will be carried forward from week to week until eliminated. When Your Patient Has Other Insurance If the recipient has other insurance coverage reflected on Wyoming Medicaid records, payment will be denied unless you report the coverage on your claim. Medicaid is always the payer of last resort except for prenatal, absent parent policies, and HEALTH CHECK claims. To help you file with the other carrier, the following information is provided on the RA directly below the denied claim: • Insurance carrier name, • Name of insured, • Policy number, • Insurance carrier address, • Group number, if applicable and • Group employer name and address, if applicable. Record other insurance coverage information reported on the RA on your recipient's file for future use. The information below the denied claim regarding third party liability is specific to the individual recipient. To report other insurance carried on a recipient, see Chapter 6, Exhibit 6.3. The Third Party Resources Information Sheet is for reporting new insurance coverage or changes in insurance coverage on a recipient's policy. Complete the form and send to Consultec for processing.
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Sample Remittance Advice Exhibit 4.14 (Outpatient) See the subsequent pages for a description of the RA item numbers. ******************************************************************************************************************************
TO: CODY HOSPITAL OUTPATIENT R.A. NO.: 123460 DATE PAID: 03/18/93 PROVIDER NUMBER: 444444400 PAGE: 2 **************PATIENT NAME********* RECIPIENT TRANS-CONTROL-NUMBER / BILLED OTHER PAID BY MEDICAL LAST FIRST MI IDENT NUM LINE-ITEM SVC-DATE PROC REV UNITS AMT. INS MCAID RECORD NO S EOB EOB
CLAIM TYPE: OUTPATIENT CLAIM STATUS PAID
ORIGINAL CLAIMS: CLIENT NAME A M CLIENT ID # 0-93060-11-001-0001-01 200.00 0.00 200.00 8805099991
01 01/30/93 121 11 100.00 0.00 100.00 C 02 01/30/93 55555 300 11 100.00 0.00 100.00 C
CLIENT NAME B M CLIENT ID # 0-93060-12-001-0001-01 200.00 0.00 200.00 8805099991 01 01/30/93 121 11 100.00 0.00 100.00 C 02 01/30/93 55555 300 11 100.00 0.00 100.00 C
ADJUSTMENT CLAIMS: CLIENT NAME B M CLIENT ID # 0-93061-11-002-1002-01 200.00- 0.00 200.00- 8805099991
01 01/30/93 121 11 100.00- 0.00 100.00- C 02 01/30/93 55555 301 11 100.00- 0.00 100.00- C
CLIENT NAME B M CLIENT ID # 0-93061-11-002-2002-01 300.00 0.00 250.00 8805099991 01 01/30/93 121 11 150.00 0.00 150.00 C 02 01/30/93 55555 301 11 150.00 0.00 100.00 C
PAID CLAIM LINE CUTBACK REASONS NET 100.00 0.00 50.00 A B C ADJ-R: 77 TCN-TO-CREDIT: 2-92150-11-001-0001-00
CLAIM TYPE: OUTPATIENT CLAIM STATUS DENIED
ORIGINAL CLAIMS: CLIENT NAME C M CLIENT ID # 0-93060-23-001-0001-00 200.00 0.00 0.00 88050999991 111 111
01 01/30/93 121 11 100.00 0.00 0.00 K 111 111 02 01/30/93 55555 301 11 100.00 0.00 0.00 K 101 111
PREVIOUS-DATE-PAID: 01/30/93 CONFLICTING-TCN: 2-92150-11-001-0001-00 CLIENT NAME C M CLIENT ID # 0-93060-23-001-0001-00 100.00 0.00 0.00 88050999991 111 111
01 01/30/93 55555 121 11 100.00 0.00 0.00 K 201 111
THIS MEDICAID RECIPIENT HAS OTHER COVERAGE BY: NATIONWIDE INSURANCE POLICY HOLDER: RECIPIENT C CLIENT NAME C M CLIENT ID # 1000 NATIONWIDE PLAZA POLICY NUMBER: RCP02020202020220
CHEYENNE, WY 82001 GROUP NUMBER: GR010101010
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TO: CODY HOSPITAL OUTPATIENT R.A. NO.: 123460 DATE PAID: 03/18/93 PROVIDER NUMBER: 444444400 PAGE: 3 **************PATIENT NAME********* RECIPIENT TRANS-CONTROL-NUMBER / BILLED OTHER PAID BY MEDICAL LAST FIRST MI IDENT NUM LINE-ITEM SVC-DATE PROC REV UNITS AMT. INS MCAID RECORD NO S EOB EOB
• • •CLAIM TYPE: OUTPATIENT • • • CLAIM STATUS • • PENDED
ORIGINAL CLAIMS: CLIENT NAME D M CLIENT ID # 0-93061-11-002-2002-00 200.00 8805099991 900
01 01/30/93 55555 121 11 100.00 900 02 01/30/93 55555 121 11 100.00 900
CLIENT NAME D M CLIENT ID # 0-93061-11-002-2002-00 200.00 8805099991 900 01 01/30/93 55555 121 11 100.00 900 02 01/30/93 55555 121 11 100.00 900
ADJUSTMENT CLAIMS: CLIENT NAME D M CLIENT ID # 0-93061-11-002-2002-00 200.00 8805099991 900
01 01/30/93 55555 121 11 100.00 900 02 01/30/93 55555 121 11 100.00 900
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Sample Remittance Advice Exhibit 4.14 (Inpatient) See the subsequent pages for a description of the RA item numbers. ******************************************************************************************************************************
TO: CODY HOSPITAL INPATIENT R.A. NO.: 123460 DATE PAID: 03/18/93 PROVIDER NUMBER: 444444400 PAGE: 4 **************PATIENT NAME********* RECIPIENT TRANS-CONTROL-NUMBER COVERED PERIOD COVER BILLED OTHER PAID BY MEDICAL
LAST FIRST MI IDENT FROM TO DAYS LOC AMT. INS MCAID RECORD NO. S EOB EOB CLAIM TYPE: INPATIENT CLAIM STATUS PAID
ORIGINAL CLAIMS:
CLIENT NAME A M CLIENT ID # 0-93060-11-001-0001-01 01/20/93 01/30/93 10 06 300.00 0.00 100.00 8805099991 C CLIENT NAME B M CLIENT ID # 0-93060-12-001-0001-01 01/20/93 01/30/93 10 06 200.00 0.00 90.00 8805099991 C
PAID CLAIM LINE CUTBACK REASONS ABC
ORIGINAL CLAIMS:
CLIENT NAME C M CLIENT ID # 0-93060-23-001-0001-00 01/20/93 01/30/93 10 06 200.00 0.00 0.00 88050999991 101 111 PREVIOUS-DATE-PAID: 01/30/93 CONFLICTING-TCN: 2-92150-11-001-0001-00
CLIENT NAME C M CLIENT ID # 0-93060-23-001-0001-00 01/20/93 01/30/93 10 03 100.00 0.00 0.00 88050999991 201 111
THIS MEDICAID RECIPIENT HAS OTHER COVERAGE BY: NATIONWIDE INSURANCE POLICY HOLDER: RECIPIENT C RECIPIENT C M 1000 NATIONWIDE PLAZA POLICY NUMBER: RCP02020202020220
CHEYENNE, WY 82001 GROUP NUMBER: GR010101010
CLAIM TYPE: INPATIENT CLAIM STATUS SUSPENDED
ORIGINAL CLAIMS:
CLIENT NAME D M CLIENT ID # 0-93061-11-002-2002-00 01/20/93 01/30/93 10 11 100.00 8805099991 900 CLIENT NAME D M CLIENT ID # 0-93061-11-002-2002-00 01/20/93 01/30/93 10 06 100.00 8805099991 900
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REMITTANCE TOTALS: PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 4 - - - - 900.00 590.00 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 2 - - - - 150.00 150.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 4 - - - - 600.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 - - - - 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 6 - - - - 900.00 AMOUNT OF CHECK: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 790.00
- - - - THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT: 101 CLAIM PREVIOUSLY PAID ON THE DATE INDICATED 2 111 RECIPIENT NOT ELIGIBLE ON DATES OF SERVICE 201 RECIPIENT IS COVERED BY OTHER INSURANCE 2 900 CLAIM IS CURRENTLY IN PROCESS 6
- - - - THE FOLLOWING IS A DESCRIPTION OF THE CUTBACK REASON CODES THAT APPEAR ABOVE: COUNT: A CUTBACK HAS OCCURRED DUE TO FACT THAT BENEFIT CAPS HAVE BEEN EXCEEDED FOR THE TIME PERIOD APPLICABLE 2 B CUTBACK HAS OCCURRED DUE TO FACT THAT BENEFIT CAPS HAVE BEEN EXCEEDED FOR THIS TYPE OF SERVICE 2 C CUTBACK HAS OCCURRED DUE TO FACT THAT BENEFIT CAPS HAVE BEEN EXCEEDED FOR THIS RECIPIENT 2 - - - - THE FOLLOWING IS A DESCRIPTION OF THE LEVEL OF CARE CODES THAT APPEAR ABOVE.: COUNT: 03 PSYCHIATRIC 06 ROUTINE CARE 11 NEONATAL INTENSIVE CARE
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How to Read Your Remittance Advice Each claim processed during the weekly cycle is listed on the Remittance Advice with the following information:
RA
ITEM
TITLE
WHAT ITEM MEANS
1
Last, First, and MI
The recipient's name as found on the Wyoming Medicaid ID card.
2
Recipient Ident Num
The recipient's Wyoming Medicaid Identification Number.
3
Trans Control Number
Transaction Control Number: The unique identifying number assigned to each claim submitted.
4
Proc
The procedure code billed that applies to lab services.
5
Rev
The revenue code billed.
6
Units
The number of units submitted.
7
Covered (From/Thru)
The covered period of the claim from admit to the date of discharge or thru date.
8
LOC
The Level of Care
9
Billed Amt.
Your usual and customary charge for the number of units billed.
10
Other Ins.
Any amount paid by another insurance carrier.
11
Paid By Mcaid
The amount per unit allowed times the number of units billed plus the dispensing fee (as long as no service limitations have been exceeded).
12
S
(Pricing Source) How the system priced each claim. For example, claims priced manually by a peer review consultant have a distinct code. Claims paid according to the Medicaid fee schedule have another code. Below is a table which translates these "source codes": A =Anesthesia B =Billed Charge
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RA
ITEM
TITLE
WHAT ITEM MEANS
C =Percent-of-Charges D =Inpatient Per diem Rate E =EAC Priced Plus Dispensing Fee F =Fee Schedule G =FMAC Priced Plus Dispensing Fee H =Encounter Rate I =Institutional Care Rate K =Denied L =Maximum Suspend Ceiling M =Manually Priced N =Provider Charge O =Relative Value Units TC P =Prior Authorization Rate R =Relative Value Unit Rate S =Relative Value Unit PC T =Fee Schedule TC X =Medicare Coinsurance and Deductible Y =Fee Schedule PC Z =Fee Plus Injection
13
EOB
Explanation of Benefits: Codes which explain why a service was denied or why payment was reduced. A translation of these codes is included in the final Summary Section of the Remittance Advice.
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Adjustments and Refunds From time to time, you may receive payment for an amount other than billed. Sometimes, you may receive payment from a third party after Wyoming Medicaid has made payment. When this happens, submit an adjustment to correct that payment.
• An adjustment is required if an error or change would result in a partial refund. An adjustment is also required if an error or change resulted in an underpayment. • A cancellation of the entire remittance advice is required if an error would result in complete refund of the entire Wyoming Medicaid payment.
Refunding Money to Wyoming Medicaid If you receive a payment for claims that you did not submit, return the check issued by Wyoming Medicaid only when every claim payment listed on the Remittance Advice is not yours. Example: None of the recipients listed are your patients. In this situation, return the Remittance Advice and check with a Void/Adjustment Request to:
Consultec Adjustments P.O. Box 667 Cheyenne, WY 82003-0667
If you receive a Remittance Advice which lists some correct payments and some incorrect payments, do not return the Wyoming Medicaid check. Deposit the check and file an adjustment request for each individual claim payment which should be completely refunded. File an adjustment request for each individual claim partially paid incorrectly. Incorrectly Billed or Keyed Claims Since Consultec processes an adjustment or credit request as a replacement to the original, erroneously paid claim, it is vital that all claim items on the request are completed correctly. DO NOT JUST BILL FOR REMAINING UNPAID AMOUNTS OR UNITS.
For example, you submitted and received payment for 3 units of a procedure and you should have billed for 5 units. Do not bill for the remaining 2 units, submit an adjustment for the full 5 units. If a Consultec keying error caused the incorrect payment, submit an adjustment claim with no corrections. However, please be sure that it was a keying error that caused an unexpected payment. In some cases, claim payment is "cut back" due to service limitations. If you were not paid the maximum allowable amount, you are notified on the RA in the "EOB" column as to the reason. All EOB codes are translated at the end of the RA just prior to the Summary Section.
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Third Party Recovery After Medicaid's Payment If you discover the liability of another payer after Wyoming Medicaid paid you, you MUST submit an adjustment request.
• An adjustment is required if another carrier's payment was equal to or higher than Wyoming Medicaid's maximum allowable payment amount. • An adjustment is required if the other carrier's payment was less than the Wyoming Medicaid maximum allowable amount.
How to File a Void or Adjustment Request Adjustments will not be considered unless submitted on the Adjustment Request Form and all pertinent information is provided. Adjustment requests will not be accepted by telephone. You no longer need to send an adjustment request for each line item paid incorrectly. You can correct all errors which occurred on the original claim form with one adjustment request by making changes in red on the claim form and attaching the corrected claim to the adjustment request form. Adjustments and voids are processed as replacement claims. In processing, the original payment is completely deducted and the adjustment is processed as a regular claim. The net result is a transaction which will increase or decrease your check. Refer to Exhibit 4.15 for a sample Void/Adjustment Request form and instructions. Provider requested adjustments must be received by Consultec within six months of the date of payment.
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Exhibit 4.15
VOID/ADJUSTMENT REQUEST FORM
If your claim was DENIED, DO NOT use this form.
Please resubmit your claim. SECTION A: CHECK BOX 1) OR 2) � 1) CLAIM ADJUSTMENT: Attach claim copy with
corrections made in red ink. DO NOT USE HIGHLIGHTER.
Complete Section B and C.
If attaching a check, the check should be payable to Health Care Financing.
� 2) CANCELLATION OF THE ENTIRE
REMITTANCE ADVICE. Every claim on the Remittance Advice must be incorrect. This option should only be used in rare instances.
Attach RA and warrant.
Skip to Section C.
SECTION B TO FACILITATE CLAIM ADJUSTMENT PROCESSING, PLEASE COMPLETE THE FOLLOWING: 1. 17-DIGIT TCN: ┌┬┬┬┬┬┬┬┬┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┴┴┴┴┴┴┴┴┘ 2. 9-DIGIT PAY-TO-PROVIDER: 3. PROVIDER NAME ┌┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┘ ________________________________________________________ 4. 10-DIGIT RECIPIENT NUMBER: ┌┬┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┴┘ 5. REASON FOR ADJUSTMENT OR VOID: SECTION C: SIGNATURE AND DATE REQUIRED PROVIDER SIGNATURE: DATE: ___________________________________ __________________________
RETURN ALL REQUESTS TO: CONSULTEC P.O. BOX 667
CHEYENNE, WY 82003-0667
(FOR CONSULTEC USE ONLY) REMARKS/STATUS: ADJUSTED BY: _____________________ DATE: ____________________
C-VAR-5-93
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How to Complete the Adjustment Request Form
VOID/ADJUSTMENT REQUEST FORM
If your claim was DENIED, DO NOT use this form.
Please resubmit your claim. SECTION A: CHECK BOX 1) OR 2) � 1) CLAIM ADJUSTMENT: Attach claim copy with
corrections made in red ink. DO NOT USE HIGHLIGHTER.
Complete Section B and C.
If attaching a check, the check should be payable to Health Care Financing.
� 2) CANCELLATION OF THE ENTIRE
REMITTANCE ADVICE. Every claim on the Remittance Advice must be incorrect. This option should only be used in rare instances.
Attach RA and warrant.
Skip to Section C.
Section
Field #
Field Name
Action
A
1
Claim Adjustment
Mark this box if any adjustments need to be made to a claim. Attach a copy of the claim with corrections made in red ink. Sections B and C must be completed.
2
Void
Mark this box if an error or change would result in complete refund of the Wyoming Medicaid payment. Attach a copy of the Remittance Advice and the warrant. Every claim on the Remittance Advice must be incorrect. This option should only be used in rare instances. (Skip to Section C)
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SECTION B TO FACILITATE CLAIM ADJUSTMENT PROCESSING, PLEASE COMPLETE THE FOLLOWING: 1. 17-DIGIT TCN: ┌┬┬┬┬┬┬┬┬┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┴┴┴┴┴┴┴┴┘ 2. 9-DIGIT PAY-TO-PROVIDER: 3. PROVIDER NAME ┌┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┘ ________________________________________________________ 4. 10-DIGIT RECIPIENT NUMBER: ┌┬┬┬┬┬┬┬┬┬┐ └┴┴┴┴┴┴┴┴┴┘ 5. REASON FOR ADJUSTMENT OR VOID:
Section
Field #
Field Name
Action
B
1
17-digit TCN
Enter the 17-digit transaction control number assigned to each claim from the remittance advice (RA).
2
9-digit Pay-To-Provider Number
Enter your nine-digit Wyoming Medicaid provider number from the RA.
3
Provider Name
Enter the provider's name.
4
10-digit Recipient Number
Enter the ten-digit Medicaid Recipient ID number.
5
Reason for Adjustment
Enter the specific reason for this adjustment and any pertinent information to assist Consultec in processing this adjustment.
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SECTION C: SIGNATURE AND DATE REQUIRED PROVIDER SIGNATURE: DATE: ___________________________________ __________________________
RETURN ALL REQUESTS TO: CONSULTEC P.O. BOX 667
CHEYENNE, WY 82003-0667
(FOR CONSULTEC USE ONLY) REMARKS/STATUS: ADJUSTED BY: _____________________ DATE: ____________________
C-VAR-5-93
Section
Field #
Field Name
Action
C
Provider Signature and Date
Signature of the provider or the provider's authorized representative and the date.
Adjusted By:
Do not write in this section. To be completed by Consultec.
Where to Send the Adjustment Request
Mail the completed adjustment request to:
Consultec Adjustments P.O. Box 667
Cheyenne, WY 82003
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Sample Claim Adjustment
THIS SECTION INTENTIONALLY LEFT BLANK
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Sample Cancellation of the Remittance Advice
THIS SECTION INTENTIONALLY LEFT BLANK