Time limit for West Virginia Medicaid and MCO

Timely Filing Policy

To meet timely filing requirements for WV Medicaid, claims must be  received within one year from the date of service.

The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit.

(See exceptions below for Medicare primary claims and backdated medical card.) The original claim must have had the following valid information:

• Valid provider number

• Valid member number

• Valid date of service

• Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim.

If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing

Worker compensation - Some terms and definition - Part 1

1.0 Standardized Billing / Electronic Billing Definitions;

(a) “Assignee” means a person or entity that has purchased the right to payments for medical goods or services from the health care provider or health care facility and is authorized by law to collect payment from the responsible payer.

(b) “Authorized medical treatment” means medical treatment in accordance with Labor Code section 4600 that was authorized pursuant to Labor Code section 4610 and which has been provided or authorized by the treating physician.

(c) “Balance forward bill” is a bill that includes a balance carried over from a previous bill along with additional services or a summary of accumulated unpaid balances.

(d) “Bill” means:

(1) the uniform billing form found in Appendix A setting forth the itemization of services provided along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills; or

(2) the electronic billing transmission utilizing the standard formats found in Section Two – Transmission Standards 2.0 Electronic Standard Formats, 2.1 Billing, along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills.

(e) “Billing Agent” means a person or entity that has contracted with a health care provider or health care facility to process bills for services provided by the health care provider or health care facility.

(f) “California Electronic Medical Billing and Payment Companion Guide” is a separate document which gives detailed information for electronic billing and payment. The guide outlines the workers? compensation industry national standards and California jurisdictional procedures necessary for engaging in Electronic Data Interchange (EDI) and specifies clarifications where applicable. It will be referred to throughout this document as the “Companion Guide”.

Common Error that results Denial - Molina Healthcare

Errors That Result In Denied Claims;

This information is presented for you to review your internal procedures and identify areas where the number of denied claims could be reduced. Denied claims result in delay of payment. Please note HIPAA claim adjustment reason and remit remark codes as provided on the remittance advice.

Claim Errors (Remittance Advice Remarks)

• The rendering provider is not eligible to perform the service billed (185) or claim/service lacks information which is needed for adjudication. (16/MA30)

o Service code not covered to the provider type or specialty

Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:

• The request must submitted in writing

• The request must be supported with documentation

o documentation should include any claim examples or indicate why the code should be payable

• If there is no supporting documentation, the request will not be considered.

• Missing/incomplete/invalid HCPCS Code (A1/M20)

o Validate code keyed correctly

o Validate code is current for Date of Service (DOS)

• Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)

o For resolution to these denials, please refer to www.dhhr.wv.gov/bms

----Select Drug Code/NDC Drug Information.

o NDC, unit of measure and units should be submitted on Medicare primary claims (even though not required by Medicare) so the information will cross over to Medicaid, eliminating the need to submit Medicaid secondary -claims on paper.

Code Descriptor

POS 19 Off campusoutpatient hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22 On campusoutpatient  hospital

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons

who do not require hospitalization or institutionalization.

Additional information related to POS codes 19 and 22

**  Payments for services provided to outpatients who are later admitted as inpatients within three days (or, in the case of non-IPPS hospitals, one day) are bundled when the patient is seen in a wholly-owned or whollyoperated physician practice. The three-day payment window applies to diagnostic and nondiagnostic

services that are clinically related to the reason for the patient’s inpatient admission, regardless of whether the inpatient and outpatient diagnoses are the same.

The three-day payment rule will also apply to services billed with POS code 19.

**  Claims for covered services rendered in an off campus-outpatient hospital setting (or in an on campus-outpatient hospital setting, if payable by Medicare) will be paid at the facility rate. The payment  policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19

unless otherwise stated.

POS 19 - When should we use

New and revised place of service codes for outpatient hospitals

Note: This article was revised December 9, 2015, to clarify the effective date of place of service (POS) 19. POS 19 will be accepted for any claims processed on or after January 1, 2016. That is, POS code 19 is valid for any claim, regardless of the date of service, when it is processed on or after January 1, 2016. The title of the table was also changed for clarification. All other information is unchanged.

**  Revising the current place of service (POS) code set by adding new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient

hospital” to “on campus-outpatient hospital;” and

**  Making minor corrections to POS codes 17 (walk-in retail health clinic) and 26 (military treatment facility).

You should ensure that your billing staffs are aware of these POS code change

Therefore, in response to the discussion in the 2015 physician fee schedule (PFS) final rule with comment period published November 13, 2014 (79 FR 67572); in order to differentiate between on-campus and off-campus provider-based hospital departments, CMS is creating a new POS code (POS 19) and revising the current POS code description for outpatient hospital (POS 22).

CR 9231, from which this article is taken, provides this POS code update, effective January 1, 2016. Specifically, CR 9231 updates the current POS code set by adding

new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient hospital” to “on campus-outpatient hospital” as described in the   following table.

Can we appeal while using GA modifier -Medicare

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

Sacral Nerve Stimulation Coding Information CPT code 64561, 64581, A4290

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x    Hospital Inpatient (Medicare Part B only)

13x    Hospital Outpatient

83x    Ambulatory Surgery Center

85x    Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, for further guidance.

0360    Operating Room Services - General Classification

0361    Operating Room Services - Minor Surgery

0362    Operating Room Services - Organ Transplant - Other than Kidney

0367    Operating Room Services - Kidney Transplant

0369    Operating Room Services - Other OR Services

CPT/HCPCS Codes

Group 1 Paragraph

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

What we can do in IVR - What are information need to use IVR

Interactive voice response (IVR) system capabilities

The IVR system provides automated information on claims, benefits and more, 24 hours a day, seven days a week.

Call the number on the back of the member’s Humana identification card to reach the IVR system.

Information available through IVR system

You can obtain a variety of information by using the IVR system.

The system can:

Confirm member coverage and the date the coverage began.

Notify you if referrals are required by the member’s plan.

Give you the status of a referral request.

Provide the member’s deductible, copayment and coinsurance information.

Provide the member’s out-of-pocket and lifetime maximum information.

Retrieve claim status for specific members.

Retrieve claim status for all your claims on one or more days.

Initiate inpatient admission and non-HMO (health maintenance organization) outpatient preauthorization requests.

Provide preauthorization request status*, directing your call to a Humana customer care representative, if needed.

In addition, you can use the system to request that the following information be sent to you by fax:

Member eligibility information.

Claims status: 40 claims per page, organized in a remit format.

Referral documentation.

Preauthorization documentation.

*Available in most areas

The IVR system gives you the option of requesting help from a Humana customer care representative. Assistance is available Monday through Friday on the following topics:

Medical eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.

Dental eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.

Preauthorizations: 8 a.m. to 6 p.m. EST.

Financial recovery: 8 a.m. to 5 p.m. EST.