institutional format billingmanuals.medicaidalaska.com/docs/dnld/tr_institutional...authorization...

Institutional Format Billing January 2019

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Disclaimer

The information contained in this presentation was current at the time it was written. It was prepared as a tool to assist providers and is not intended to be all inclusive, grant rights, impose obligations, or function as a stand-alone document. Although every reasonable effort has been made to assure the accuracy of the information within the presentation, the ultimate responsibility for understanding Medicaid program regulations lies with the provider of services. The State of Alaska – Department of Health and Social Services – and Conduent, Incorporated employees and staff make no representation, warranty or guarantee that this compilation of information is error-free and/or comprehensive and will bear no responsibility or liability for the results or consequences of the use of this guide.

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Overview

• Institutional Format Billing • Electronic Claim

– Practice Management Software – Health Enterprise – Payerpath – Attachments

• Paper Claim • National Drug Codes • Medicare/Medicaid Crossover • Additional Resources

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Institutional Format Billing

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National Uniform Billing Committee (NUBC)

• National Uniform Billing Committee (NUBC) Data Element Specifications Manual – http://www.nubc.org – 312.422.3390

• Use the NUBC manual in conjunction with Provider Billing Manual – Complete all required fields – Include all attachments as required

• Alaska Medicaid provides claim form instructions with supplemental information specific to claims filed with Alaska Medicaid – http://manuals.medicaidalaska.com/docs/dnld/Billing_UB04_Instructions.pdf

http://www.nubc.org/http://manuals.medicaidalaska.com/docs/dnld/Billing_UB04_Instructions.pdf

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Institutional Format Billing Providers • Administrative wait bed • Ambulatory Surgery Center • End-Stage Renal Disease (ESRD) Center • Federally Qualified Health Center • Free-Standing Birth Center • Home Health Agency • Hospice • Inpatient Hospital • Inpatient Psychiatric Hospital • Intermediate Care Facility • Outpatient Hospital • Residential Psychiatric Treatment Center

• Rural Health Clinic • Skilled Nursing Facility • Swing Bed • Tribal Clinic • Tribal Hospital

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Electronic Claims

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Claims Submission Methods

There are several billing options for Alaska Medical Assistance providers. • 837I Transaction (electronic claim using billing software)

– Companion Guide: http://medicaidalaska.com – Implementation Guide (referred to as TR3): http://www.wpc-edi.com

• Alaska Medicaid Health Enterprise • Payerpath (electronic claim)

http://medicaidalaska.com/http://www.wpc-edi.com/

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Electronic Billing Requirements Providers electing to submit claims electronically using practice management software must complete a HIPAA certification process. Documentation Requirements • Available at https://medicaidalaska.com Documentation Documents & Forms

Forms – Provider or Billing Agent Information Submission Agreement, commonly referred to as a

PISA or BAISA, Enrollment Forms – Electronic Remittance (835) Authorization election where provider designates who

receives the 835 transaction, which is the weekly claim transaction/processing summary Transaction Testing Requirements • Review applicable companion guide(s) for complete testing procedures

http://manuals.medicaidalaska.com/docs/companionguides.htm • For further assistance, the accompanying Technical Report Type 3 (TR3) is available for

purchase through the Washington Publishing Company at http://www.wpc-edi.com

Contact Conduent Electronic Commerce Customer Support (ECCS) coordinator at 907.644.6800 option 3 or 800.770.5650 option 1, 4

https://medicaidalaska.com/http://www.wpc-edi.com/

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Attachments • Some claims will need supporting documentation included with the claim, such as:

– Explanation of Benefits from other insurance – Medical records or clinical documentation – Consent forms

• When billing using paper claim forms, attachments must be sent in with the claim • When billing electronically, attachments must be faxed on the same day the claim is

submitted • For electronic billing, an attachment control number must be:

– Entered into the electronic claim – Written on the attachment(s) – Documented on the fax attachment cover sheet

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Electronic Transaction Attachment • Fax attachments the same day the claim information is transmitted • Attachment indicators must be included in the transaction using the appropriate Loop ID

(refer to the TR3 for further guidance)

Loop ID Reference Use Name Codes Alaska Medicaid Notes

2300 or 2400

PWK01 S Claim Supplemental Information

B2 Prescription Required when the provider will be submitting paper documentation B3 Physician Order

B4 Referral Form

CK Consent Form

EB Explanation of Benefits

M1 Medical Record Attachment

OZ Support Data for Claim

2300 or 2400

PWK02 R Report Transmission Code

BM By Mail Enter method of documentation transmission

FX

2300 or 2400

PWK05 R Identification Code Qualifier

AC By Fax Qualifier for PWK06 segment

2300 or 2400

PWK06 S Attachment Control Number

Enter unique attachment control number to include on faxed documents to match attachment to claim.

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Electronic Transaction Attachment, cont.

On the Attachment Fax Cover Sheet, include:

• From - name of sender – Fax # - sender’s fax number – Number of Pages - total number of pages included in attachment/fax – Attachment Control # - a unique attachment identifier designated by the sender – TCN (17 digit Transaction Control Number) - corresponding TCN for original claim

referred to in the attachment – Member Medicaid ID - corresponding member ID – Provider Medicaid ID - corresponding provider ID – Date of Service – corresponding dates of service from original claim

Access fax cover sheet form at http://manuals.medicaidalaska.com/docs/forms.htm

http://manuals.medicaidalaska.com/docs/forms.htm

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Payerpath

Payerpath is a web-based electronic transaction program provided by the State of Alaska free of charge. • Claims submission is via the internet • Processing is immediate • Pre-submission claim auditing allows error correction prior to claim submission • Allows providers to save member demographics for more efficient future billing

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Health Enterprise

Providers may submit claims through Health Enterprise. • Must be enrolled with AK Medicaid and have an account on the portal • Accessed through www.medicaidalaska.com • Detailed computer-based training modules are available on the Learning Portal at

https://learn.medicaidalaska.com/ – Select Providers Enterprise to see the full array of automated trainings available

http://www.medicaidalaska.com/https://learn.medicaidalaska.com/

Create New Claim

Starting on your Home page, hover over Claims, then over Create Claims and choose Create Institutional Claim

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UB-04-Entry View vs. 837-Entry View

There are two different views of the Health Enterprise claim form screens.

• The UB-04 form view is formatted to look like the UB-04 claim form and shows all fields in one continuous screen

• The 837-entry view is formatted more consistent with electronic claims and data fields are divided into multiple portlets

• The Switch View link in the upper right corner of the screen allows providers to change between the views as desired

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Void or Replacement Claim

Health Enterprise may be used to process a void or adjustment of an original claim that was submitted through Health Enterprise. • Under New Institutional Claim, select Yes when asked if the new claim is a void or

replacement claim • Select the Resubmission Type Code from the drop down box, either Replacement or Void • Enter the TCN you are replacing or voiding • Once a TCN is entered, all previously submitted information will appear on the screen

Enter the required billing provider information as indicated by a red asterisk * .

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Billing Provider

Enter the required claim information as indicated by a red asterisk * . • Patient Account # • Type of Bill • Claim Frequency Code from drop-down • Statement from and to dates

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Claim Information

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Enter the patient’s information as indicated by a red asterisk * .

Patient Information

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Enter the admission and discharge information as indicated by a red asterisk * .

Admission and Discharge

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To add condition, occurrence, or value information, click on Add and enter the appropriate information. Be sure to save within the portlet before exiting.

Condition, Occurrence, and Value Codes

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Service Line Items Enter required service line items as indicated by a red asterisk * and any other fields as they apply to services rendered. Click save within the portlet before moving on.

Enter the total claim charge amount (all lines totaled), the patient’s estimated amount due, and the service authorization number if one was required for the services rendered.

If the user selects Yes for other insurance, a portlet will open to enter the other insurance information:

• The Other Insured’s Last and First Name, Middle Initial and Suffix • The Subscriber ID • Group or Policy # • Insurance Plan or Group Name • Benefits Assignment Certification

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Payment

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Enter the diagnosis code(s) that best describe the patient’s condition. A principal diagnosis is required as indicated by a red asterisk *.

Diagnosis Codes

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Surgical procedure codes are reserved for inpatient claims. Enter the procedure code(s) that best describe the procedure completed.

Surgical Procedure Codes

If the claim has attachments, such as medical records or a consent form, indicate Yes to open the attachment portlet. • Click on the Add Attachment button • Select the attachment type and submission method from the options in the drop down boxes • Attachments must be sent the same day the claim is submitted • Save each attachment line before moving on • Add any necessary remarks in the field provided

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Attachment Indication

Enter other provider information applicable to the services rendered for an attending, operating and/or other provider by entering the required information.

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Other Providers

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Paper Claim Form

Paper Claim Form Font and Alignment • A large percentage of paper claims are processed through a scanner that extracts the information from the claim.

It is very important that providers ensure printed paper claim forms are legible and correctly aligned to prevent processing errors. Also, do not use red ink because the scanner is designed to overlook anything in red.

• Use font that clearly distinguishes between all characters, such as “O” vs “0”, “I” vs “1”, and “2” vs “Z”

Can you immediately tell the difference between “O” and “0” or “2” and “Z”?

• The scanner can interpret information only if it directly resides within each field. If the alignment is off, data may be lost or misinterpreted.

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O24429 Z370

What was submitted

What the scanner reads

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UB-04 Field Key (M): Mandatory

(C): Conditional

(O): Optional

(B): Leave Blank

The Alaska Medicaid UB-04 Claim Form Instructions can be reviewed on

http://manuals.medicaidalaska.com/docs/ProviderReference.html

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Fields 1 – 4 Field 1, (M), Billing Provider Name, Address and Telephone Number

Field 2, (O), Billing Provider’s Designated Pay-to Address • Alaska Medicaid directs all payments to the pay-to address on the provider enrollment file,

regardless of the address input in this file

Fields 3a – 3b, (O), Patient Control Number & Medical/Health Record Number • If 3a is used, the provider’s patient control number will appear on the remittance advice

Field 4, (M), Type of Bill • Frequency codes (position 4 value)7 and 8

will not be processed as an adjustment or void. Instead, submit an Adjustment Void Request Form (AK-05)

Services Valid Alaska Medicaid Codes Ambulatory Surgery

0831

ESRD 0721 RSBC 084x Home Health 032x, 033x, 034x Hospice 081x, 082x

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Fields 5 – 7 Field 5, (O), Federal Tax Number

Field 6, (M), Statement Covers Period • Enter the beginning and ending service dates being billed in the MM/DD/YY format, even

when “from” and “through” are the same date • The from date is the start date of the bill, not necessarily the admission date, which is

entered in field 12 • Billed period cannot cross the state fiscal year (July 1 through June 30), the calendar year

for tribal hospitals, or the facility’s established fiscal year • Include all covered and non-covered days

– Exception: do not include days when the patient was ineligible for Alaska Medicaid • If the patient status you are recording in field 17 indicates discharge, transfer or death,

make sure the date of that event is listed as the through date • ESRD claims – bill single dates of service only; spanned dates and/or multiple units will be

denied

Field 7, (B), Reserved – Leave Blank

M = Mandatory C = Conditional O = Optional B = Leave Blank

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Fields 8 – 14 Field 8a, (M), Patient Name • Enter the member’s name as it appears on their eligibility card Field 8b, (B), Patient Identifier • The member’s Medicaid ID is entered in field 60 Field 9, (O), Patient Address Field 10, (O), Patient Birth Date Field 11, (O), Patient Sex Field 12, (M), Admission/Start of Care Date • Long-term care facilities – use the date of admission to the facility or to new level of care Field 13, (C), Admission Hour • This field is required for inpatient claims Field 14, (C), Priority (Type) of Admission or Visit • This field is required for inpatient claims and outpatient hospitals


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Fields 15 – 34 Field 15, (C), Point of Origin for Admission or Visit • This field is required for inpatient claims Field 16, (C), Discharge Hour • This field is required for inpatient claims involving a discharged patient Field 17, (C), Patient Discharge Status • This field is required for inpatient claims Fields 18 – 28, (C), Condition Codes Field 29, (C), Accident State Field 30, (B), Reserved – Leave Blank Field 31 – 34, (C), Occurrence Codes and Dates • Medicare crossover claims – enter occurrence code 50 and the Medicare paid date • ESRD claims – on every dialysis claim, enter occurrence code 50 and the date of the

patient’s initial dialysis treatment


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Fields 35 – 41 Fields 35 – 36, (C), Occurrence Span Codes and Dates Field 37, (B), Reserved – Leave Blank Field 38, (O), Responsible Party Name and Address Fields 39 – 41, (C), Value Codes and Amounts • Required for inpatient claims • Annotate covered and non-covered days; the sum of covered and non-covered days must equal

the number of days reported in field 6, Statement Covers Period, and/or the number of service units for accommodations reported in field 46 – Consider the patient’s discharge status (field 17) to determine if the through date is covered or

non-covered • A continuing patient’s through date is billed as a covered day using value code 80 • A discharged patient’s through date is billed as a non-covered day using value code 81

• Do not bill the following as a covered day: – The date of discharge, transfer, or death – Unauthorized inpatient days (including days beyond the third consecutive inpatient day)


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Fields 39 – 41 (cont.)

• Long-term care facilities – use value code 34 to indicate the amount of patient liability for the month of service billed

• Medicare crossover claims – Report the Medicare deductible in field 40

• Use value code A1 if Medicare is primary • Use value code B1 if Medicare is secondary

– Report Medicare coinsurance in field 41 • Use value code A2 if Medicare is primary • Use value code B2 if Medicare is secondary


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Fields 42 – 45 Field 42, (M), Revenue Codes • Refer to provider-specific billing manuals for covered revenue codes Field 43, (C), Revenue Description/IDE Number/Medicaid Drug Rebate/Line Level Rendering Provider NPI • Outpatient claims – report all NDC information for pharmacy charges (rev codes 025x and

063x) as outlined in the NUBC manual Field 44, (C), HCPCS/Accommodation Rates/HIPPS Rate Codes • Required for outpatient claims • Outpatient Hospitals and ESRD claims – use the appropriate HCPCS code to bill

outpatient lab or pharmacy charges • Ambulatory Surgery Centers – bill bilateral surgery by entering 2 units in field 46 or using

modifier 50 and entering 1 unit • ESRD claims – list all labs performed by the facility with modifiers, as applicable Field 45, (O), Service/Assessment Date


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Field 46 – 48 Field 46, (M), Service Units • Use the applicable coding reference to identify correct service unit measurements (days,

hours, etc.) • Inpatient claims – submitted units for room and board (multiple LOCs permissible) must be

equal to the number of covered and non-covered days reported in fields 39 – 41 • Outpatient claims:

– Enter the total number of HCPCS units for multiple services on the same day – Include service units for all lab services

• Long-term Care claims: – Bill authorized oxygen charges on a separate line, per month – Service units must equal the number of liters/bottles used – Attach documentation to the claim that demonstrates (or identifies) the metered amount

of oxygen administered Field 47, (M), Total Charges Field 48, (O), Non-Covered Charges


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Fields 49 – 53

Field 49, (B), Reserved – Leave Blank Field 50, (M), Payer Name • Alaska Medicaid is the payer of last resort – other payers are always listed before Alaska

Medicaid • When billing Alaska Medicaid, enter “Medicaid” • Do not enter any alternate names for Medicaid, including but not limited to: Alaska

Medicaid, Alaska Medicaid, Denali Care, Denali KidCare, Conduent, First Health, or ACS • Medicare crossover claims, enter Medicare on line A if Medicare is primary, or on line B if

Medicare is secondary Field 51, (C), Payer ID/Health Plan ID • List the appropriate identifier of any insurance other than Medicaid Field 52, (M), Release of Information Certification Indicator • Enter “Y” Field 53, (B), Reserved – Leave Blank


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Fields 54 – 58 Field 54, (C), Prior Payment - Payer • If other insurance (including Medicare) was billed, attach the explanation of benefits

showing the paid amount, even if the paid amount is $0.00 • Medicare crossover claims – enter the Medicare Paid Amount on the appropriate line (A for

primary, B for secondary) Field 55, (C), Estimated Amount Due - Payer • Medicare crossover claims

– The estimated amount due is the sum of the Medicare deductible and coinsurance (see field 40 – 41)

– Enter on the appropriate line (A for primary, B for secondary) Field 56, (M), National Provider Identifier – Billing Provider Field 57, (O), Other (Billing) Provider Number Field 58, (M), Insured’s Name • Enter the Medicaid member’s name as it appears on the eligibility card


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Fields 59 – 65 Field 59, (M), Patient’s Relationship to Insured Field 60, (M), Insured’s Unique Identifier • Enter the Medicaid member’s 10-digit Alaska Medicaid identification number Field 61, (O), Insured’s Group Name Field 62, (C), Insured’s Group Number • List the group number(s) of any other insurance, if a group number appears on the

insurance ID card Field 63, (C), Authorization Code/Referral Number • If an SA is required, enter the 10-character alphanumeric Alaska Medicaid SA number or

8-digit Qualis SA number Field 64, (B), Document Control Number – Leave Blank Field 65, (O), Employer Name


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Fields 66 – 67 Field 66, (M), Diagnosis and Procedure Code Qualifier • Enter the ICD indicator appropriate for the date of service

– Enter 9 for ICD-9 diagnosis codes; required for dates of service prior to 10/1/2015 – Enter 0 for ICD-10 diagnosis codes; required for dates of service on and after 10/1/2015

Field 67, (M), Principal Diagnosis Code and Present on Admission Indicator • Submit a principal diagnosis and any other diagnoses in fields A-Q when other condition(s)

coexist or subsequently develop during treatment – For dates of service prior to 10/1/2015, only ICD-9 diagnosis codes will be accepted and

for dates of service on and after 10/1/2015, only ICD-10 diagnosis codes will be accepted

• ESRD claims – enter the comorbidity diagnosis code


Inpatient Claims – If the dates of service overlap the ICD-10 implementation date of 10/1/2015, the entire claim must be coded with ICD-10.

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Fields 68 – 74e Field 68, (B), Reserved – Leave Blank Field 69, (M), Admitting Diagnosis Code Fields 70a – c, (O), Patient’s Reason for Visit Field 71, (B), Prospective Payment System Code – Leave Blank Fields 72a – c, (O), External Cause of Injury Code and Present on Admission Indicator Field 73, (B), Reserved – Leave Blank Field 74, (C), Principal Procedure Code and Date • Required for inpatient claims when a procedure was performed Fields 74a – e, (C), Other Procedure Codes and Dates • Required for inpatient claims when additional procedures were performed


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Fields 75 – 81 Field 75, (B), Reserved – Leave Blank Field 76, (M), Attending Provider Name and Identifiers • Enter the NPI and name of the licensed physician who certified the medical necessity of

services rendered and has primary responsibility for the member’s care and treatment Field 77, (O), Operating Physician Name and Identifiers Fields 78 – 79, (C), Other Provider Names and Identifiers • If using, record the ID numbers and names of the licensed physicians who referred the

patient • If the member is in the Care Management Program, and the rendering provider is not their

primary care provider, the primary care provider’s referral must be attached to the claim for Alaska Medicaid to cover the service

Field 80, (O), Remarks Field Field 81, (O), Code-Code Field


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National Drug Codes

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Billing for Drugs

• The Deficit Reduction Act of 2005 (DRA) included specific data submission requirements necessary to collect Medicaid drug rebates from drug manufacturers for physician-administered drugs. Additionally, Social Security Act Section 1927 requires state drug rebate participation. State Medicaid programs must gather and submit drug utilization information in order to secure drug rebates and receive Federal Financial Participation (FFP) for these drugs.

• For more information on the Medicaid Drug Rebate program, visit https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html

• Alaska Medicaid outpatient drug coverage regulations can be found at 7 AAC 120.110 Covered Outpatient Drugs and Home Infusion Therapy

• Alaska Medicaid drug payment regulations can be found at 7 AAC 145.400 – 7 AAC 145.410

https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.htmlhttps://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.htmlhttp://www.akleg.gov/basis/aac.asp7.120.100http://www.akleg.gov/basis/aac.asp7.120.100http://www.legis.state.ak.us/basis/aac.asp7.145.400http://www.legis.state.ak.us/basis/aac.asp7.145.400

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Drug Rebate Applicability Drug rebates are applicable to: • Claims for medications administered in physician’s offices, clinics, and other outpatient settings, including

Medicare part B and C crossover claims • National Drug Code (NDC) information used in conjunction with appropriate HCPCS/CPT codes for

rendered services – NDC codes should be used with “A”, “C”, “J”, "P", “Q”, and "S" codes – Though not all-inclusive, providers may refer to the NDC/HCPCS Crosswalk at

https://www.dmepdac.com/palmetto/PDAC.nsf/DID/B723CU33 to determine the appropriate HCPCS code for the NDC being used

Drug rebates are not applicable to: • IHS and tribally operated 638 facilities reimbursed at the federally published all-inclusive rate • ESRD bundled claims unless modifier "AY" is used to indicate an item or service rendered to an ESRD

patient is not for treatment of ESRD

https://www.dmepdac.com/palmetto/PDAC.nsf/DID/B723CU33

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Identifying Drugs on Claims

To correctly identify the drugs and manufacturers to invoice and collect rebates, the Centers for Medicare and Medicaid Services (CMS) deemed that the use of NDC numbers is critical because there often several NDCs linked to a single HCPCS code. • Alaska Medicaid will pay claims submitted for these drugs only if the manufacturer participates in the

Federal Drug Rebate program and federal matching funds are available – Quarterly Drug Rebate listings are available on the CMS website

https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.html

• Bill the National Drug Code (NDC) for the actual drug that is administered • Record the NDC into the patient record • Do not use a miscellaneous code if a specific HCPCS-NDC match is available

https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.htmlhttps://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.html

National Drug Codes • The NDC is found on the prescription drug label of the drug container (e.g. vial, bottle or tube). The NDC is a

universal number that identifies a drug or a related drug item • NDC consists of 11 digits in three sections.

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National Drug Codes (cont.)

Examples: • Product label indicates: 54225-1798-29 • Submit on claim as: 54225179829

• Product label indicates: 452-72-89 • Submit on claim as: 00452007289

• Product label indicates: 45-6-9

– How would you submit this on a claim? – The correct answer is 00045000609

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NDC Information

Acceptable units of measure for recording NDC quantities are as follows: Milligram (mg) is not an acceptable unit

qualifier when billing NDC quantities. Drugs administered using a mg dosage must be converted for billing to UN if in solid/powder form or ML if in a liquid/solution form. Only use the GR if the drug meets the description for the grams unit type. Refer to the CMS Drug Products in the Medicaid Drug Rebate Program database for assistance in determining the correct “Unit Type required for billing.

https://data.medicaid.gov/Drug-Pricing-and-Payment/Drug-Products-in-the-Medicaid-Drug-Rebate-Program/v48d-4e3e/data

Code Unit Type Description

UN Unit Powder for injection (needs to be reconstituted), pellet, kit, patch, tablet, device

ML Milliliter Liquid, solution, or suspension

F2 International Unit Products described as IU/vial or micrograms

GR Gram Ointments, creams, inhalers, or bulk powder in a jar

https://data.medicaid.gov/Drug-Pricing-and-Payment/Drug-Products-in-the-Medicaid-Drug-Rebate-Program/v48d-4e3e/data

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Converting NDC Units to HCPCS Units

• Providers are required to submit the NDC unit of measure and units administered as well as the HCPCS equivalent units on the claim form – The requirement is the same for Medicaid and Medicare crossover claims – Providers must identify the NDC, unit of measure, amount administered, the NDC

strength, HCPCS code and the HCPCS unit of measure • Billing Note: NDCs must be billed with the corresponding HCPCS based on the

description and quantity administered. Claims may be denied if a misc. HCPCS code is billed when an appropriate NDC to HCPCS match exists.

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Example • The NDC unit of measure for 60793070010 is mL and 1 mL was administered. The NDC strength equals

600,000 iU per mL. The corresponding HCPCS code, J0561, is measured at 100,000 iU per billed unit. • In this example, 1mL of this NDC equals 6 units of J0561.

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Example (cont.) The following information would be reported on the claim form for this NDC

Billing Note

Decimals must be used on all Medicaid and Medicare claims when billing a fraction of an NDC unit.

Partial units billed without a decimal may be denied for excessive units

Description Example Value N4 qualifier N4

11 digit NDC number from the drug label 60793070010

NDC unit of measure mL

NDC units administered (Note: insert a decimal when reporting a fraction of a unit up to 3 decimal places.) 1 or 1.000

Corresponding HCPCS codes J0561

HCPCS units 6

Drug revenue code (institutional claims only) 0636

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Medicare Crossover

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Medicare Crossover Claims

• Claims for members who have both Medicare and Medicaid must be submitted to Medicare first; if submitted electronically, these claims should automatically “crossover” from Medicare’s system into Medicaid’s

• If crossover claims do not appear on the Remittance Advice from Alaska Medicaid within one month of your receiving the EOMB from Medicare, contact Provider Inquiry at 907.644.6800, option 1, or 800.770.5650,toll-free option 1, 1

• Only one service per claim document is permitted • Attach the Explanation of Medicare Benefits (EOMB) and EOB from third-party payer, if

applicable, to each crossover claim • If you are billing for Medicare/Medicaid dual eligible members using a paper claim form,

document Medicare billing appropriately on your claim form and include the EOMB with your claim

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Timely Filing

• All claims must be filed within 12 months of the date you provided services to the member • The 12-month timely filing limit applies to all claims, including those that must first be filed

with a third-party carrier

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Additional Resources

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HIPAA General Resources

• Centers for Medicare and Medicaid Services: HIPAA General Information – https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-

Simplification/HIPAAGenInfo/index.html?redirect=/HIPAAGenInfo/

• State of Alaska: Health Insurance Portability and Accountability Act (HIPAA) – http://dhss.alaska.gov/fms/its/Pages/Hipaa.aspx

• Alaska Medicaid Website: HIPAA News & Information – http://manuals.medicaidalaska.com/docs/hipaanews.htm

https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html?redirect=/HIPAAGenInfo/https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html?redirect=/HIPAAGenInfo/http://dhss.alaska.gov/fms/its/Pages/Hipaa.aspxhttp://manuals.medicaidalaska.com/docs/hipaanews.htm

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Recordkeeping

• Recordkeeping requirements are documented in the Individual Provider Agreement and Tax Certification and Group Provider Agreement and Tax Certification

• Although most recordkeeping requirements are consistent for all providers, some requirements are provider-type specific

• Providers must maintain complete and accurate clinical, financial, and other relevant records to support the care and services for which they bill Alaska Medicaid for a minimum of 7 years from the date of service

• Providers are subject to audits, reviews and investigations

http://manuals.medicaidalaska.com/docs/dnld/Form_Individual_Provider_Agreement.pdfhttp://manuals.medicaidalaska.com/docs/dnld/Form_Individual_Provider_Agreement.pdfhttp://manuals.medicaidalaska.com/docs/dnld/Form_Group_Provider_Agreement.pdf

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Overpayments & Repayment of Payment Errors

Providers should closely review each remittance advice (RA) to ensure it reflects accurate payment for all billed services, including correct member details and services provided. • In accordance with 7 AAC 105.220(e), Alaska Medicaid providers have 30 days from the

time of payment to notify the department in writing of a payment error. • Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department

within 60 days of identifying the overpayment. • Mail the written overpayment notification and a copy of the RA page detailing the

overpayment to the address below:

Conduent State Healthcare, LLC P.O. Box 240807 Anchorage, Alaska 99524-0807

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Additional Resources Alaska Medicaid Health Enterprise website at http://medicaidalaska.com. • Information necessary for successful billing • Includes provider-specific Medicaid billing manuals and fee schedules You may also call: • Provider Inquiry

– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2 – Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1 • EDI Coordinator

– Electronic transaction assistance – 907.644.6800, option 3 or 800.770.5650 (toll-free), option 1, 4

http://medicaidalaska.com/

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Institutional Format BillingDisclaimerOverview�Institutional Format BillingNational Uniform Billing Committee (NUBC)Institutional Format Billing Providers�Electronic Claims Claims Submission MethodsElectronic Billing RequirementsAttachmentsElectronic Transaction AttachmentElectronic Transaction Attachment, cont.PayerpathHealth EnterpriseCreate New ClaimUB-04-Entry View vs. 837-Entry ViewVoid or Replacement ClaimBilling Provider Claim InformationPatient InformationAdmission and DischargeCondition, Occurrence, and Value CodesService Line ItemsPaymentDiagnosis CodesSurgical Procedure CodesAttachment IndicationOther Providers�Paper Claim FormPaper Claim Form Font and AlignmentUB-04Fields 1 – 4 Fields 5 – 7 Fields 8 – 14 Fields 15 – 34 Fields 35 – 41 Fields 39 – 41 (cont.)Fields 42 – 45 Field 46 – 48 Fields 49 – 53 Fields 54 – 58 Fields 59 – 65 Fields 66 – 67 Fields 68 – 74e Fields 75 – 81 �National Drug CodesBilling for DrugsDrug Rebate ApplicabilityIdentifying Drugs on ClaimsNational Drug CodesNational Drug Codes (cont.)NDC InformationConverting NDC Units to HCPCS UnitsExampleExample (cont.) �Medicare CrossoverMedicare Crossover ClaimsTimely Filing�Additional ResourcesHIPAA General ResourcesRecordkeepingOverpayments & Repayment of Payment Errors Additional ResourcesSlide Number 65