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1. 27 6 3 UB 04 Claim Form with NPI 34 6 4 Completion of UB 04 Claim Form with NPI 35 6 4 1 Detailed tions i sirina iiaiai ii ie iaiia iei iaiia i i iaeia 35 6 5 Duplicate or Inappropriate 42 MAP 24 Memorandum to Local Community Based 43 Medicare Deductibles and 45 Appendix A z T 46 9 1 Revenue GCOdes t etes tite e ese tere er eese een e dena 46 07 07 2015 Pagei 10 11 12 13 14 Buy 49 10 1 Internal Control Number ICN n 49 INP DOING ED 50 11 1 R mittance Advice cia a tian ania teure tae ee 50 11 1 1 Examples of Pages in Remittance 50 s s kau net ote en tt e cubat ertet e HU cte OT 52 T1 S9 Banner Pages en ain a co b 52 T1 4 Paid Claims Page eem oett de ee bett ede fo eese te EE ad 55 11 5 Denied Claims Page ie rete Eme Getae ee Gee et redde 57 11 6 Claims in Process sinn snnt nnns 59 11 7 Ret
2. 11 5 2 Retroactive Eligibility Back Dated 11 5 3 Unacceptable 11 5 4 Third Party Coverage 12 5 4 1 Commercial Insurance Coverage this does NOT include Medicare 12 5 4 2 Documentation That May Prevent a Claim from Being Denied for Other Coverage 12 5 4 3 When there is no response within 120 days from the insurance carrier 13 5 4 4 For Accident and Work Related Claims sse 13 55 Provider Inquiry Form suite eer aee deer erede p cer pe e 15 5 6 Prior Authorization Information sse enne 17 5 7 Adjustments and Claim Credit 18 5 8 Cash Refund Documentation 00 enn nnns innen 20 5 9 Return to Provider better niae tee ele ede ee eee ned re Peur da ded toner c aedi 22 5 10 Provider Representative 4 24 5 10 1 Phone Numbers and Assigned Counties a 24 6 Completion of UB 04 Claim Form with 4 24 04422 25 6 1 UB 04 Claim Form with NPI and 26 6 2 Completion of UB 04 Claim Form with NPI and 27 6 2 1 Detailed Instr ctlOns
3. 07 07 2015 Page 50 This section details all categories contained the Remittance Advice for the current cycle month to date and year to date Explanation of Benefit EOB codes listed throughout the Remittance Advice is defined in this section Summary EOB Code Descriptions Any Explanation of Benefit Codes EOB which appears in the RA is defined in this section NOTE For the purposes of reconciliation of claims payments and claims resubmission of denied claims it is highly recommended that all remittance advices be kept for at least one year 07 07 2015 Page 51 11 2 Title The header information that follows is contained on every page of the Remittance Advice REPORT CRA XBPD R COMMONWEALTH OF KENTUCKY 1 DATE 01 25 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE CLAIM TYPE The type of claims listed on the Remittance Advice PROVIDER NAME The name of the provider that billed The type of provider is listed directly below the name of provider PAYEE ID The eight digit Medicaid assigned provider ID of the billing provider The NPI number of the billing provider The category type of page begins each section and is centered for example PAID CLAIMS All claims contained in each Remittance Advice are listed in numerical order of the prescription number 11 3 Banner Page All Remittance Advices have a banner page as the first page The banner
4. Other TLP Rsn 10 Prov Refund Duplicate Payment 41 Acct Recv Patient Assessment 11 Prov Refund Cost Settlement 42 Acct Recv Orthodontic Fee 12 Prov Refund Other Unknown 43 Acct Receivable KENPAC 13 Acct Receivable Fraud 44 Acct Recv Other DMS Branch 14 Acct Receivable Abuse 45 Acct Receivable Other 15 Acct Receivable TPL 46 Acct Receivable CDR HOSP Audit 16 Acct Recv Cost Settlement 47 Act Rec Demand Paymt Upat 1099 17 Receivable HP Enterprise Services 48 Act Rec Demand Paymt No 1099 Request 49 PCG 18 Recoupment Warrant Refund 50 Recoupment Cold Check 19 Act Receivable SURS Other 51 Recoupment Program Integrity Post 20 Acct Receivable Dup Payt Payment Review Contractor A 21 Recoupment Fraud 52 Recoupment Program Integrity Post Payment Review Contractor B 22 Civil Money Penalty 53 Claim Credit Balance 23 Recoupment Health Insur TPL 54 Recoupment Other St Branch 24 Recoupment Casualty Insur TPL 55 Recoupment Other 25 Recoupment Member Paid TPL 56 Recoupment TPL Contractor 26 Recoupment Processing Error 57 Acct Recv Advance Payment 27 Recoupment Billing Error 58 Recoupment Advance Payment 28 Recoupment Cost Settlement 59 Non Claim Related Overage 29 Recoupment Duplicate Payment 60 Provider Initiated Adjustment 30 Recoupment Paid Wrong Vendor 61 Provider Initiated CLM Credit 31 Recoupment SURS 07 07
5. The usual and customary charge for services provided for the Member The amount allowed for this service Amount paid if any by private insurance excluding Medicaid and Medicare Copay amount to be collected from member The amount to be collected from the member The total dollar amount reimbursed by Medicaid for the claim listed Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice Note The ORIGINAL claim information appears first followed by the NEW adjusted claim information 07 07 2015 Page 63 11 Appendix C REPORT CRA TRAN R COMMONWEALTH OF KENTUCKY DATE 12 26 2006 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE FINANCIAL TRANSACTIONS PROVIDER J PAYEE ID 99999999 PO BOX 5555 NPI ID 99999999 CITY 55555 5555 TRANSACTION PAYOUT REASON RENDERING SVC DATE NUMBER CCN AMOUNT CODE PROVIDER FROM THRU MEMBER NO MEMBER NAME NO NON CLAIM SPECIFIC PAYOUTS TO PROVIDERS REFUND REASON CCN AMOUNT CODE MEMBER NO MEMBER NAME NO NON CLAIM SPECIFIC REFUNDS FROM PROVIDERS A R SETUP RECOUPED ORIGINAL TOTAL REASON NUMBER ICN DATE THIS CYCLE AMOUNT RECOUPED BALANCE CODE 1106 011306 0 00 22 41 0 00 22 41 92 TOTAL BALANCE 22 41 07 07 2015 Page 64 11 Appendix C 11 9 Financial Transaction Page 11 9 1 Non Claim Specific Payouts to Provid
6. fon eo gl T me PRINCIPAL CODE DATE Marg Come 009213257 07 07 2015 Page 26 6 2 Completion of UB 04 Claim Form with and Taxonomy 6 2 1 Detailed Instructions Included is a representative sample of codes and or services that may be covered by KY Medicaid FORM LOCATOR FORM LOCATOR NAME AND DESCRIPTION Provider Name Address and Telephone Enter the complete name address and telephone number including area code of the facility Patient Control Number Enter the patient control number The first 14 digits aloha numeric will appear on the remittance advice as the invoice number Type of Bill Enter the appropriate code to indicate the type of bill 2nd Digit Type of Facility 1 2 Hospital 3rd Digit Bill Classification he Inpatient including Medicare Part A Inpatient Medicare Part B only Outpatient 4 Non patient 4th Digit Frequency 0 Non payment 1 Admit through discharge 2 Interim first claim 3 Interim continuing claim 4 Interim final claim Statement Covers Period FROM Enter the beginning date of the billing period covered by this invoice in numeric format MMDDYY THROUGH Enter the last date of the billing period covered by this invoice in numeric format MMDDY Y Do not include days prior to when the Member s KY Medicaid eligibility period began The FROM date is the date of the admission if the Member was
7. 13 PROVIDER REMITTANCE ADVICE UB CLAIMS IN PROCESS PROVIDER PAYEE ID 99999999 5555 ANY STREET NPI ID 99999999 SUITE 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 01 26 2007 ICN ATTENDING SERVICE DATES DAYS ADMIT BILLED TPL SPENDDOWN PATIENT ACCT NUM PROV FROM THRU DATE AMOUNT AMOUNT AMOUNT MEMBER NAME JOHN DOE MEMBER NO MBRID99999 ICN9999999999 NPI9999999 062206 062406 2 062206 4 010 60 0 00 0 00 PATACCT9999 REV CD HCPCS RATE SRV DATE LVL CARE UNITS BILLED AMT DETAIL EOBS 111 062206 DEF 2 00 1 203 60 250 062206 DEF 42 00 587 84 258 062206 DEF 22 00 455 82 212 062206 DEF 1 00 9 01 370 062206 DEF 1 00 714 12 410 062206 DEF 6 00 387 76 710 062206 DEF 1 00 592 45 TOTAL UB CLAIMS IN PROCESS 4010 60 0 00 0 00 07 07 2015 Page 58 11 Appendix C 11 6 Claims in Process Page DESCRIPTION The 14 digit alpha numeric Patient Control Number from Form Locator 3 The Member s last name and first initial The Member s ten digit Identification number as it appears on the Member s Identification card CN The 13 digit unique system generated identification number assigned to each claim by HP Enterprise Services ATTENDING PROVIDER The attending provider s NPI The date or dates the service was provided in month day FROM THRU and year numeric format DAYS The number of days billed ADMIT DATE The admit date of member BILLED AMOUNT The usual and customary charge for services provided for the Member
8. Show this card each time you receive any medical services Rules l Use this card only for the person listed on the front of this card Magnetic Strip 2 Do not let anyone else use this card to get services 3 Do not give false information or hide information to get medical coverage If vou break the rules vou can be prosecuted for fraud and have to money back If you need to replace this card call your local DCBS office If you have questions about your coverage call 800 635 2570 THIS CARD DOES NOT GUARANTEE ELIGIBILITY OR PAYMENT FOR SERVICES Provider You responsible for verifying the identity eligibility and co pay status of the cardholder Fligibility information may be obtained at i or by calling 800 807 1301 Pharmacy information may be obtained by calling 800 432 7005 To report fraud 800 372 2970 Commonwealth of Kentucky f z Department for Community Based Services If found please drop this card in U S mailbox 275 East Main Stroet 3W A sten Frankfort K Y 40621 0001 Through a vendor of your choice the magnetic strip can be swiped to obtain eligibility information Providers who wish to utilize the card s magnetic strip to access eligibility information may do so by contracting with one of several vendors 07 07 2015 Page 2 1 General 1 2 2 Member Eligibility Categories 1 2 2 1 and SLMB Qualified Medicare Beneficiaries Q
9. TABLE CONTENTS NUMBER DESCRIPTION PAGE 1 General DE 1 dto Introductions iet ette tret ore etna 1 1 2 Member 1 1 2 1 Plastic Swipe KY Medicaid Card 2 1 2 2 Member Eligibility Categories U n u 3 1 2 3 Verification of Member Eligibility 6 2 Electronic Data Interchange 444 8 2 1 CHOW lo Get Slarted ace etta etae ee et hace i Mv kane i EE Rare Enea 8 2 2 Formatand Testini iei ee erste tete iei evel co lE EE dit cer e d TNE 8 2 3 ECS Helps t eem e tte tutte n ein spa ass 8 3 7 J SGruBIeeeE HQ 9 SR EE Mow to Ger Stared ne uy au a k a a T k 9 3 2 KYHealth Net Companion Guides eene entere nnns nnne 9 4 General Billing Instructions for Paper Claim Forms 0 221211 10 44 General Instructions uoce aen eo age et deer edet en cea de aksa dero 10 422 IMAGING z E 10 4 3 Optical Character ennemi nennen nennen nnns 10 5 Additional Information and Forms 14 0004 4 4 u 11 5 1 Claims with Dates of Service More than One Year
10. rned Clalm nas lates reden Re Eee ied pete acce ad i 61 11 8 Adjusted Claims Page 63 11 9 Financial Transaction 65 11 9 4 Specific Payouts to Providers 22 65 11 9 2 Non Claim Specific Refunds from 65 11 9 3 Accounts 66 11 10 Summa Edere ute ette tea de uba 69 14104 Payiments z i uu u y u Qu kaa iare NR aii err 70 Appendix D aaa 73 12 1 Remittance Advice Location Codes LOC 73 2 22 deve Irene nep 74 13 1 Remittance Advice Reason Code ADJ RSN CD or RSN CD 74 Appendix FS uu ERE 77 14 1 Remittance Advice Status Code ST 77 07 07 2015 Page ii 1 General 1 General 1 1 Introduction These instructions are intended to assist persons filing claims for services provided to Kentucky Medicaid Members Guidelines outlined pertain to the correct filing of claims and do not constitute a declaration of coverage or guarantee of payment Policy questions should be directed to the Department for Medicaid Services DMS Policies
11. DATES DAYS ADMIT BILLED TPL SPENDDOWN PATIENT ACCT NUM FROM THRU DATE AMOUNT AMOUNT AMOUNT MEMBER NAME JANE DOE MEMBER NO MBRID99999 ICN9999999999 NPI9999999 021706 022106 4 021706 10 212 66 0 00 0 00 PATACCT9999 HEADER EOBS 2660 0092 REV CD HCPCS RATE SRV DATE LVL CARE UNITS BILLED AMT DETAIL EOBS 174 021706 DEF 4 00 9 382 04 2527 0062 250 021706 DEF 3 00 15 96 9953 0062 0883 001 300 021706 DEF 5 00 355 28 9953 0018 301 021706 DEF 11 00 361 54 9953 0018 302 021706 DEF 3 00 81 42 9953 0018 306 021706 DEF 1 00 16 42 9953 0018 MEMBER NAME JANE DOE MEMBER NO 9999999999 9999999999999 MCD 9999 021706 022106 4 021706 10 802 46 0 00 0 00 99999999 HEADER EOBS 2198 0016 REV CD HCPCS RATE SRV DATE LVL CARE UNITS BILLED AMT DETAIL EOBS 111 021706 DEF 3 00 1 805 40 112 021706 DEF 1 00 601 80 250 021706 DEF 232 00 608 33 258 021706 DEF 27 00 122 17 212 021706 DEF 1 00 206 78 300 021706 DEF 6 00 374 96 301 021706 DEF 29 00 909 72 307 021706 DEF 2 00 50 45 312 021706 DEF 3 00 582 99 370 021706 DEF 1 00 663 54 460 021706 DEF 1 00 15 06 720 021706 DEF 3 00 4 549 14 732 021706 DEF 1 00 312 12 TOTAL UB CLAIMS DENIED 21 015 12 200 00 0 00 07 07 2015 Page 56 11 Appendix C 11 5 Denied Claims Page FIELD DESCRIPTION PATIENT ACCOUNT The 14 digit alpha numeric Patient Control Number from Form Locator 3 MEMBER NAME The Member s last name and first initial MEMBER NUMBER The Member s ten digit Identification num
12. Number 4 Provider Name and Address 5 Provider 6 From Date of 7 To Date of Service Service 8 Original Billed 9 Original Paid 10 Remittance Amount Amount Advice Date 11 Please specify WHAT is to be adjusted on the claim You must explain in detail in order for an adjustment specialist to understand what needs to be accomplished by adjusting the claim 12 Please specify the REASON for the adjustment or claim credit request 13 Signature 14 Date DMS Approved January 10 2011 07 07 2015 Page 19 5 Additional Information and Forms 5 8 Cash Refund Documentation Form The Cash Refund Documentation Form is used when refunding money to Medicaid The mailing address for the Cash Refund Form is HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 Attn Financial Services Please keep the following points in mind when refunding Attach the Cash Refund Documentation Form to a check made payable to the KY State Treasurer e Attach applicable documentation such as a copy of the remittance advice showing the claim for which a refund is being issued e f refunding all claims on an RA the check amount must match the total payment amount on the RA If refunding multiple RAs a separate check must be issued for each RA 07 07 2015 Page 20 5 Additional Information and Forms HP Enterprise Services Mail To HP Enterprise Services Box 2108 Frankfort KY 40602 2108 ATTN Financial
13. TPL AMOUNT Amount paid if any by private insurance excluding Medicaid and Medicare The amount owed from the member 07 07 2015 Page 59 11 Appendix REPORT CRA IPPD R COMMONWEALTH OF KENTUCKY 1 DATE 01 30 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE UB CLAIMS RETURNED PROVIDER PAYEE ID 99999999 5555 ANY STREET NPI ID CITY KY 55555 5555 CHECK EFT NUMBER 999999999 ISSUE DATE 02 02 2007 ICN REASON CODE 9999999999999 01 CLAIMS RETURNED 01 07 07 2015 Page 60 11 Appendix 11 7 Returned Claim FIELD DESCRIPTION ICN The 13 digit unique system generated identification number assigned to each claim by HP Enterprise Services REASON CODE A code denoting the reason for returning the claim CLAIMS RETURNED ON THIS The total number of returned claims on the Remittance Advice Note Claims appearing on the returned claim page are forthcoming in the mail The actual claim is returned with a return to provider sheet attached indicating the reason for the claim being returned 07 07 2015 Page 61 11 Appendix C REPORT CRA HHAD R COMMONWEALTH OF KENTUCKY M1 DATE 01 23 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 33 PROVIDER REMITTANCE ADVICE UB CLAIM ADJUSTMENTS PROVIDER PAYEE ID 99999999 55555 ANY STREET NPI ID CITY KY 55555 0000 ICN ATTEND PROV SERVICE DATES BILLED ALLOWED TPL CO PAY SPENDDO
14. The Member s last name and first initial The Member s ten digit Identification number as it appears on the Member s Identification card The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services and year numeric format The usual and customary charge for services provided for the Member The allowed amount for Medicaid The amount collected from the member Amount paid if any by private insurance excluding Medicaid and Medicare The total dollar amount reimbursed by Medicaid for the claim listed Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice The total number of paid claims on the Remittance Advice The total dollar amount billed by the provider for all claims listed on the PAID CLAIMS page of the Remittance Advice only on final page of section The total dollar amount paid by Medicaid for all claims listed on the PAID CLAIMS page of the Remittance Advice only on final page of section 07 07 2015 Page 55 11 Appendix C REPORT CRA IPDN R COMMONWEALTH OF KENTUCKY M1 DATE 01 25 2007 RA 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 11 PROVIDER REMITTANCE ADVICE UB CLAIMS DENIED PROVIDER PAYEE ID 99999999 5555 ANY STREET NPI ID 99999999 SUITE 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 01 26 2007 ICN ATTENDING PROV SERVICE
15. become a business to business EDI Trading Partner or to obtain a list of Trading Partner vendors contact the HP Enterprise Services Electronic Data Interchange Technical Support Help Desk at HP Enterprise Services P O Box 2016 Frankfort KY 40602 2016 1 800 205 4696 Help Desk hours are between 7 00 a m and 6 00 p m Monday through Friday except holidays 2 2 Format and Testing EDI Trading Partners must test successfully with HP Enterprise Services and have Department for Medicaid Services DMS approved agreements to bill electronically before submitting production transactions Contact the EDI Technical Support Help Desk at the phone number listed above for specific testing instructions and requirements 2 3 ECS Help Providers with questions regarding electronic claims submission may contact the EDI Help desk 07 07 2015 Page 8 3 KYHealth Net 3 KYHealth Net The KYHealth Net website allows providers to submit claims online via a secure direct data entry function Providers with internet access may utilize the user friendly claims wizard to submit claims in addition to checking eligibility and other helpful functions 3 4 How to Get Started All Providers are encouraged to utilize KYHealth Net rather than paper claims submission become a KYHealth Net user contact our EDI helpdesk at 1 800 205 4696 or click the link below http www chfs ky gov dms kyhealth htm 3 2 KYHealth Net Companion Guides Fi
16. claim submission can reduce your processing time significantly You can also check claim status verify Post Office Box 2100 eligibility download remittance advices and many other functions Go to www kymmis com or contact Billing Inquiry at 1 800 807 1232 for more information You may also send an inquiry via e mail at Frankfort KY 40602 2100 ky_provider_inquiry hp com 1 Provider Number 3 Member Name first last 4 Medical Assistance Number 2 Provider Name and Address 5 Billed Amount 6 Claim Service Date 8 ICN if applicable Provider s Message 10 Signature Date HP Enterprise Services Response OFFICE USE ONLY This claim has been resubmitted for possible payment This claim paid on in the amount of This claim was denied on with code Aged claim Please see attached documentation concerning services submitted past the 12 month filing limit Other Signature Date HIPAA Privacy Notification This message and accompanying documents are covered by the Communications Privacy Act 18 U S C 2510 2521 and contain information intended for the specified individual s only This information is confidential If you are not the intended recipient or an agent responsible for delivering it to the intended recipient you are hereby notified that you have received this document in error and that any review dissemination copying or the taking of any action based on the conte
17. if applicable 07 07 2015 Page 38 80 Covered Days Enter the total number of covered days from Form Locator 6 Data entered in Form Locator 39 must agree with accommodation units in Form Locator 46 Covered days are not required for Medicare crossover claims for coinsurance days or life reserve days 82 Coinsurance Days Enter the number of coinsurance days billed to KY Medicaid during this billing period 83 Life Time Reserve Days Enter the Lifetime Reserve days the patient has elected to use for this billing period A1 Deductible Payer Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due A2 Coinsurance Payer Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due B1 Deductible Payer B Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due B2 Coinsurance Payer B Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due Enter the three digit revenue code identifying specific accommodation and ancillary services A list of revenue codes covered by KY Medicaid is located in Appendix B of this manual It is extremely important that the ancillary services reported on the UB 04 billing form be submitted by using the correct Revenue Codes All approved Revenue Codes are listed in Appendix B of this manual Incorrect billing of ancillary services or fa
18. or letters detailing filing dates are not acceptable documentation of timely billing Attachments must prove the claim was received in a timely manner by HP Enterprise Services 07 07 2015 Page 11 5 Additional Information and Forms 5 4 Third Party Coverage Information 5 4 1 Commercial Insurance Coverage this does NOT include Medicare When a claim is received for a Member whose eligibility file indicates other health insurance is active and applicable for the dates of services and no payment from other sources is entered on the Medicaid claim form the claim is automatically denied unless documentation is attached 5 4 2 Documentation That May Prevent a Claim from Being Denied for Other Coverage The following forms of documentation prevent claims from being denied for other health insurance when attached to the claim 1 Remittance statement from the insurance carrier that includes Member name Date s of service e Billed information that matches the billed information on the claim submitted to Medicaid and e Anindication of denial or that the billed amount was applied to the deductible NOTE Rejections from insurance carriers stating additional information necessary to process claim is not acceptable 2 Letter from the insurance carrier that includes e Member name Date s of service s e Termination or effective date of coverage if applicable e Statement of benefits available if applicable an
19. setup Please keep all Accounts Receivable Summary pages until all monies have been satisfied 07 07 2015 Page 66 11 Appendix C REPORT CRA SUMM R COMMONWEALTH OF KENTUCKY M1 DATE 02 01 2007 RA 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 13 PROVIDER REMITTANCE ADVICE SUMMARY PROVIDER PAYEE ID 99999999 NPI ID P O 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 02 02 2007 CURRENT CURRENT MONTH TD MONTH TD YEAR TD YEAR TD NUMBER AMOUNT NUMBER AMOUNT NUMBER AMOUNT CLAIMS PAID 43 130 784 46 43 130 784 46 1 988 4 143 010 13 CLAIM ADJUSTMENTS 0 0 00 0 0 00 18 0 00 MASS ADJUSTMENTS 0 0 00 0 0 00 0 0 00 TOTAL CLAIMS PAYMENTS 43 130 784 46 43 130 784 46 2 006 4 143 010 13 CLAIMS DENIED 1 1 917 CLAIMS IN PROCESS 2 PAYMENTS CLAIMS PAYMENTS 130 784 46 130 784 46 4 143 010 13 SYSTEM PAYOUTS NON CLAIM SPECIFIC 0 00 0 00 0 00 ACCOUNTS RECEIVABLE OFFSETS CLAIM SPECIFIC CURRENT CYCLE 0 00 0 00 0 00 OUTSTANDING FROM PREVIOUS CYCLES 0 00 0 00 44 474 35 NON CLAIM SPECIFIC OFFSETS 0 00 0 00 0 00 NET PAYMENT 130 784 46 130 784 46 4 098 535 78 REFUNDS CLAIM SPECIFIC ADJUSTMENT REFUNDS 0 00 0 00 0 00 NON CLAIM SPECIFIC REFUNDS 0 00 0 00 0 00 OTHER FINANCIAL MANUAL PAYOUTS NON CLAIM SPECIFIC 0 00 0 00 0 00 VOIDS 0 00 0 00 0 00 NET EARNINGS 130 784 46 130 784 46 4 098 535 78 07 07 2015 Page 67 11 Appendix C REPORT CRA EOBM R COMMONWEALTH OF
20. 2015 Page 75 13 Appendix E 62 CLM CR Paid Medicaid VS Xover 95 Beginning Recoupment Balance 63 CLM CR Paid Xover VS Medicaid 96 Ending Recoupment Balance 64 CLM CR Paid Inpatient VS Outp 97 Begin Dummy Rec Bal 65 CLM CR Paid Outpatient VS Inp 98 End Dummy Recoup Balance 66 CLS Credit Prov Number Changed 99 Drug Unit Dose Adjustment 67 TPL CLM Not Found on History AA PCG 2 Part A Recoveries 68 FIN CLM Not Found on History BB PCG 2 Part B Recoveries 69 Payout Withhold Release CB PCG 2 AR CDR Hosp 71 Withhold Encounter Data Unacceptable DG DRG Retro Review 72 Overage 99 or Less DR Deceased Member Recoupment 73 No Medicaid Partnership Enrollment IP Impact Plus 74 Withhold Provider Data Unacceptable IR Interest Payment 75 Withhold PCP Data Unacceptable CC Converted Claim Credit Balance 76 Withhold Other MS Prog Intre Post Pay Rev Cont C 77 A R Member IPV OR On Demand Recoupment Refund 78 CAP Adjustment Other RP Recoupment Payout 79 Member Not Eligible for DOS RR Recoupment Refund 80 Adhoc Adjustment Request SC SURS Contract 81 Adj Due to System Corrections SS State Share Only 82 Converted Adjustment UA HP Enterprise Services Medicare Part A 83 Mass Adj Warr Refund f f f Y DMS Mass Adj Request UB ES Tn Services Medicare Part B 85 Mass Adj SURS Request XO Psych Crossover Refund 86 Third Party Paid TPL 87 Claim Adjustment TPL 88 Beginning Dummy Recoupment Bal 89 Ending Dummy Recoupment Bal 90 Retro Rate M
21. 7e Attending Physician ID Enter the Attending Physician NPI number 07 07 2015 Page 33 6 3 UB 04 Claim Form with Alone NOTE KY Medicaid advises providers to use this method when a single NPI corresponds to a single KY Medicaid provider ID I emer scones o 42 DATE ADM RR M TYPE 16 RG 16 oHa 18 19 20 21 oz To M m oe WE CE IIT YC 46 SERV UNITS 47 TOTAL CHARGES 48 NON4 e RON COVED GHA OMARGES 49 CREATION DATE ogee 4 a Se C n CO 27217 63 TREATMENT AUTHORIZATION CODES 86 EMPLOYER NUBC zz Marg Comme 009213267 07 07 2015 Page 34 6 4 Completion of UB 04 Claim Form with Alone 6 4 1 Detailed Instructions Included is a representative sample of codes and or services that may be covered by KY Medicaid NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the NPI number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim FORM LOCATOR FORM LOCATOR NAME AND DESCRIPTION Provider Name Address and Telephone Enter the complete name address and telephone number including area code of the facility Patient Control Number Enter the patient control
22. Enter the appropriate indicator which describes the determination of the PRO Utilization Review Committee Approved as Billed C2 Automatic Approval as Billed Based on Focus Review C3 Partial Approval If the PRO authorized a portion of the Member s hospital stay the approved date s must be shown in Form Locator 36 Occurrence Span These dates should be the same as the dates of service in Form Locator 6 The condition codes are also included in the UB 04 Training Manual Information regarding the Peer Review Organization is located in the Reference Index 31 34 Occurrence Codes and Dates Enter the appropriate code s and date s defining a significant event relating to this bill Reference the UB 04 Training Manual for additional codes Discharge Code and Date Enter 42 and the actual discharge date when the THROUGH date Form Locator 6 is not the actual discharge date and Form Locator 4 indicates Final Bill Accident Related Codes 01 Auto Accident 02 No Fault Insurance Involved Including Accident or Other 03 Accident Tort Liability 04 Accident Employment Related 05 Other Accident Not described by the other codes 35 36 Occurrence Span Code and Dates Enter occurrence span code and the first and last days approved by the PRO UR when condition code C3 partial approval has been entered in Form Locators 18 28 37 Medicare EOMB Date Enter the EOMB date from Medicare
23. George Added Discharge Status 21 per CO 13326 4 2 11 29 2011 Brenda Orberson Updated 5010 changes Ann Murray DMS approved 12 27 2011 Renee Thomas 4 3 02 08 2012 Stayce Towles Updated provider rep listing Ann Murray DMS Approved 02 14 2012 John Hoffman 4 4 02 22 2012 Brenda Orberson Global updates made to remove all references to Ann Murray KenPAC and Lockin DMS Approved 03 09 2012 John Hoffman 4 5 04 05 2012 Stayce Towles Updated provider rep listing Ann Murray DMS Approved 04 11 2012 John Hoffman 4 6 06 04 2012 Stayce Towles Updated sections 6 1 6 2 1 6 3 and 6 4 1 based Ann Murray upon HP recommendation with DMS approval from Alisha Clark DMS Approved 06 28 2012 Alisha Clark 4 7 08 30 2012 Stayce Towles Replace Provider Inquiry form with new form Patti George approved by John Hoffman on 08 30 2012 4 8 01 16 2013 Vicky Hicks Update section 1 2 2 2 to reflect former Passport i Members having a choice of MCOs as of 1 1 2013 DMS Approved 2 27 2013 John Hoffman 4 9 06 04 2013 Vicky Hicks Updates to NET PAYMENT and NET EARNINGS i descriptions in Section 11 10 1 DMS Approved 07 09 2013 John Hoffman 4 10 07 29 2013 Stayce Towles Updates to section 5 10 Provider Rep listing Patti George 5 0 03 19 2014 Stayce Towles Updates sections 1 5 per DMS Approved 4 7 14 by Lee Guice 5 1 07 07 2015 Stayce Towles Add field 66 to the detailed billing instructions for ICD indicator Approved by John Hoffmann OATS 7 6 15
24. HART MCLEAN BATH GRANT MERCER BALLARD HARLAN METCALFE BOONE GRAYSON MONTGOMERY BARREN HENDERSON MONROE BOURBON GREENUP MORGAN BELL HICKMAN MUHLENBERG BOYD HANCOCK NELSON BOYLE HOPKINS OWSLEY BRACKEN HARDIN NICHOLAS BREATHITT JACKSON PERRY BRECKINRIDGE HARRISON OHIO CALDWELL KNOX PIKE BULLITT HENRY OLDHAM CALLOWAY KNOTT PULASKI BUTLER JEFFERSON OWEN CARLISLE LARUE ROCKCASTLE CAMPBELL JESSAMINE PENDLETON CASEY LAUREL RUSSELL CARROLL JOHNSON POWELL CHRISTIAN LESLIE SIMPSON CARTER KENTON ROBERTSON CLAY LETCHER TAYLOR CLARK LAWRENCE ROWAN CLINTON LINCOLN TODD DAVIESS LEE SCOTT CRITTENDEN LIVINGSTON TRIGG ELLIOTT LEWIS SHELBY CUMBERLAND LOGAN UNION ESTILL MADISON SPENCER EDMONSON LYON WARREN FAYETTE MAGOFFIN TRIMBLE FLOYD MARION WAYNE FLEMING MARTIN WASHINGTON FULTON MARSHALL WEBSTER FRANKLIN MASON WOLFE GRAVES MCCRACKEN WHITLEY GALLATIN MEADE WOODFORD bordering their state unless noted above e Provider Relations contact number 1 800 807 1232 NOTE Out of state providers contact the Representative who has the county closest 07 07 2015 6 Completion of UB 04 Claim Form with NPI Following are instructions for billing psychiatric inpatient hospital services on the UB 04 Billing Form Only instructions for form locators required for HP Enterprise Services processing or Medicaid Program information are included Instructions for form locators not used by HP Enterprise Services or Medicaid Program processing may be found in the UB 04 Tr
25. KENTUCKY M1 DATE 02 01 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 14 PROVIDER REMITTANCE ADVICE EOB CODE DESCRIPTIONS PROVIDER PAYEE ID 99999999 NPI ID P O BOX 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 02 02 2007 EOB CODE EOB CODE DESCRIPTION 0022 COVERED DAYS ARE NOT EQUAL TO ACCOMMODATION UNITS 0271 CLAIM DENIED MEMBER AVAILABLE INCOME INFORMATION NOT ON FILE FOR THE MONTH OF SERVICE PLEASE CONTACT DMS AT 502 564 6885 0409 INVALID PROVIDER TYPE BILLED ON CLAIM FORM 0883 CLAIM DENIED DEPLICATE PROCEDURE HAS BEEN PAID 9999 PROCESSED PER MEDICAID POLICY HIPAA REASON CODE HIPAA ADJ REASON CODE DESCRIPTION 0016 Claim service lacks information which is needed for adjudication Additional information is supplied using remittance advice remarks codes whenever appropriate 0018 Duplicate claim service 0052 The referring prescribing rendering provider is not eligible to refer prescribe order perform the service billed 0092 Claim Paid in full 00A1 Claim denied charges 07 07 2015 Page 68 11 Appendix C 11 10 Summary Page FIELD DESCRIPTION CLAIMS PAID The number of paid claims processed current month and year to date CLAIM ADJUSTMENTS The number of adjusted credited claims processed adjusted credited amount billed and adjusted credited amount paid or recouped by Medicaid If money is recouped the dollar amount is followed by a negative sign These figures
26. Kentucky UNBRIDLED SPIRIT Commonwealth of Kentucky KY Medicaid Provider Billing Instructions For Psychiatric Inpatient Hospital Services Provider Type 02 Version 5 1 July 7 2015 Document Change Log Document Comments Version 10 21 2005 HP Enterprise Initial creation of DRAFT Billing Instructions for Psychiatric Inpatient Hospital Services Provider 12 14 2005 HP Enterprise Update revisions made by DMS Services 01 18 2006 HP Enterprise Replaced Provider Rep list with most current list Services Carolyn Stearman with revisions requested by DMS 4 04 14 2006 Lize Deane aded with revisions requested by Commonwealth 1 5 04 24 2006 Tammy Delk Updated with revisions requested by Commonwealth Commonwealth i a a d UB 04 with NPI 12 22 2006 Ron Chandler 22 UB04 with NPI form amp UB92 form with data rom Stayce Towles EE uud with revisions requested by Stayce Towles 2 01 30 2007 Murray o with revisions requested during alkthrough A 5 2007 VID MEL Appendix C KY Medicaid card and ICN pane Provider Rep table 02 23 2007 Murray Revised according comment log Walkthrough 1 8 2 6 are actually the same as revisions were made back to back and no publication would have been made nn GIL MEE DIGNAS os and added claim forms and descriptors gia Hill Inserted revised list presum
27. MB and Specified Low Income Medicare Beneficiaries SLMB are Members who qualify for both Medicare and Medicaid In some cases Medicaid may be limited QMB Members have Medicare and full Medicaid coverage as well QMB only Members have Medicare and Medicaid serves as a Medicare supplement only A Member with SLMB does not have Medicaid coverage Kentucky Medicaid pays a buy in premium for SLMB Members to have Medicare but offers no claims coverage 1 2 2 2 Managed Care Partnership Medical benefits for persons whose care is overseen by a Managed Care Organization MCO are similar to those of Kentucky Medicaid but billing procedures and coverage of some services may differ Providers with MCO questions should contact the respective MCO provider services Passport Health Plan at 1 800 578 0775 WellCare of Kentucky at 1 877 389 9457 Humana Caresource at 1 855 852 7005 Anthem Blue Cross Blue Shield at 1 800 880 2583 or Aetna Better Health of KY at 1 855 300 5528 1 2 2 3 The Kentucky Children s Health Insurance Program KCHIP provides coverage to children through age 18 who have no insurance and whose household income meets program guidelines Children with KCHIP III are eligible for all Medicaid covered services except Non Emergency Transportation and EPSDT Special Services Regular KCHIP children are eligible for all Medicaid covered services For more information access the KCHIP website at http kidshealth ky gov en kch
28. RU DATE MEMBER NO MBRID99999 030806 031006 2 030806 6 307 35 UNITS BILLED AMT ALLOWED AMT DETAI 2 00 1 700 00 0 00 2527 48 00 653 90 0 00 9932 7 00 275 30 0 00 9932 67 00 386 15 0 00 9932 12 00 292 00 0 00 9932 3 00 177 00 0 00 9932 1 00 2 148 00 0 00 9932 1 00 299 00 0 00 9932 1 00 376 00 0 00 9932 MEMBER NO 9999999999 030806 031006 2 030806 6 307 35 UNITS BILLED AMT ALLOWED AMT DETAI 2 00 1 700 00 0 00 9932 48 00 653 90 0 00 9932 7 00 275 30 0 00 9932 67 00 386 15 0 00 9932 12 00 292 00 0 00 9932 3 00 177 00 0 00 9932 1 00 2 148 00 0 00 9932 1 00 299 00 0 00 9932 1 00 376 00 0 00 9932 12 614 70 ALLOWED AMT L EOBS 0062 0883 0018 0018 0018 0018 0018 0018 0018 0018 0018 0 00 L EOBS 0018 0275 0015 0015 0883 00 0018 0018 0018 0018 0018 0018 0018 0 00 11 Appendix C DATE 01 30 2007 PAGE 2 PAYEE ID 99999999 NPI ID CHECK EFT NUMBER 999999999 ISSUE DATE 02 02 2007 SPENDDOWN TPL AMT PAID AMT COPAY AMT 0 00 0 00 3 488 25 0 00 0 00 0 00 3 488 25 0 00 0 00 0 00 6 976 50 07 07 2015 Page 54 11 4 Paid Claims Page PATIENT ACCOUNT MEMBER NAME MEMBER NUMBER CN ATTENDING PROVIDER FROM THRU DAYS ADMIT DATE BILLED AMOUNT ALLOWED AMOUNT SPENDDOWN COPAY AMOUNT TPL AMOUNT PAID AMOUNT CLAIMS PAID ON THIS RA TOTAL BILLED TOTAL PAID 11 Appendix C DESCRIPTION The 14 digit alpha numeric Patient Account Number from Form Locator 3
29. Services CASH REFUND DOCUMENTATION 1 Check Number 2 Check Amount 3 Provider Name ID Address 4 Member Name 5 Member Number 6 From Date of Service 7 To Date of Service 8 RA Date 9 Internal Control Number If several ICNs attach RAs edle dues La b Eb ade Research for Refund Check appropriate blank a Payment from other source Check the category and list name attach copy of EOB Health Insurance Auto Insurance Medicare Paid Other b Billed in error c Duplicate payment attach a copy of both RAs If RAs are paid to two different providers specify to which provider ID the check is to be applied d Processing error OR overpayment explain why e Paid to wrong provider f Money has been requested date of the letter attach a copy of letter requesting money g Other Contact Name Phone DMS Approved January 10 2011 07 07 2015 Page 21 5 Additional Information and Forms 5 9 Return to Provider Letter Claims and attached documentation received by HP Enterprise Services are screened for required information listed below If the required information is not complete the claim is returned to the provider with a Return to Provider Letter attached explaining why the claim is being returned A claim is returned before processing if the following information is missing e Provider ID e Member Identification number e Member first and last names and EOMB for Medicare Medicaid cr
30. WN PAID PATIENT NUMBER FROM THRU AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT MEMBER NAME JOHN DOE MEMBER NO 9999999999 9999999999999 MCD 9999 030106 033106 3 886 47 0 00 0 00 0 00 0 00 3 592 90 99999999999999 9999999999999 MCD 9999 030106 033106 3 886 47 0 00 0 00 0 00 0 00 0 00 99999999999999 HEADER EOBS 0053 00A1 REV CD HCPCS RATE SRV DATE MODIFIERS UNITS BILLED AMT ALLOWED AMT DETAIL EOBS 651 030106 31 00 3 886 47 0 00 0686 0119 NET OVERPAYMENT AR 3 592 90 TOTAL NO OF ADJ 1 TOTAL UB ADJUSTMENT CLAIMS 0 00 0 00 0 00 0 00 0 00 3 592 90 Providers have an option of requesting an adjustment as indicated above or requesting a cash refund form and instructions for completion can be found in the Billing Instructions If a cash refund is submitted an adjustment CANNOT be filed If an adjustment is submitted a cash refund CANNOT be filed 07 07 2015 Page 62 11 Appendix C 11 8 Adjusted Claims Page The information on this page reads left to right and does not follow the general headings DESCRIPTION The 14 digit alpha numeric Patient Control Number from Form Locator 3 The Member s last name and first initial The Member s ten digit Identification number as it appears on the Member s Identification card The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services The date or dates the service was provided in month day and year numeric format
31. ained mechanically during the imaging stage does not have to be manually typed thus reducing claim processing time Information on the claim must be contained within the fields using font 10 as the recommended font size in order for the text to be properly read by the scanner 07 07 2015 Page 10 5 Additional Information and Forms 5 Additional Information and Forms 5 1 Claims with Dates of Service More than One Year Old In accordance with federal regulations claims must be received by Medicaid no more than 12 months from the date of service or six months from the Medicare or other insurance payment date whichever is later Received is defined in 42 CFR 447 45 d 5 as date the agency received the claim as indicated by its date stamp on the claim Kentucky Medicaid includes the date received in the Internal Control Number ICN The ION is a unique number assigned to each incoming claim and the claim s related documents during the data preparation process Refer to Appendix A for more information about the ICN For claims more than 12 months old to be considered for processing the provider must attach documentation showing timely receipt by DMS or HP Enterprise Services and documentation showing subsequent billing efforts if any To process claims beyond the 12 month limit you must attach to each claim form involved a copy of a Claims in Process Paid Claims or Denied Claims section from the appropriate Remit
32. aining Manual The UB 04 Training Manual and billing forms may be obtained from the address below Kentucky Hospital Association P O Box 24163 Louisville KY 40224 Telephone 1 502 426 6220 Claims for mental hospital services provided to eligible Members must be submitted monthly to the Medicaid Program A full calendar month s billing is required unless The Member is admitted to the facility during the month e The Member is discharged or expires and e The Member s authorization for benefit provisions is withdrawn by the PRO UR Committee on the basis that further stay is not medically necessary Providers may not split bill for a month s service that is submitting bills more frequently than a full calendar month 1st through 15th 16th through 31st All bills submitted must be calendar month pure A separate UB 04 billing form must be used for each Member The original UB 04 billing form must be submitted monthly to HP Enterprise Services P O Box 2106 Frankfort KY 40602 2106 Courier delivery HP Enterprise Services 656 Chamberlin Lane Frankfort KY 40601 07 07 2015 Page 25 6 1 UB 04 Claim Form with NPI and Taxonomy El PS n C po i Do SO BIRTHOATE a 9 li RR PARERE 2 42REV CD 43 DESCRIPTION 4 Ri RMACY PAGE OF CREATION DATE TOTALS 0 Seana
33. amount as shown on the EOMB to be applied toward Member s coinsurance amount due Enter the three digit revenue code identifying specific accommodation and ancillary services A list of revenue codes covered by KY Medicaid is located in Appendix B of this manual It is extremely important that the ancillary services reported on the UB 04 billing form be submitted by using the correct Revenue Codes All approved Revenue Codes are listed in Appendix B of this manual Incorrect billing of ancillary services or failure to correct any remarks may ultimately affect the instate provider s prospective payment rate NOTE Total charge Revenue code 0001 must be the final entry in column 42 line 23 Total charge amount must be shown in column 47 line 23 07 07 2015 Page 31 Enter the standard abbreviation assigned to each revenue code Creation Date Enter the invoice date or invoice creation date Enter the quantitative measure of services provided per revenue code Total Charges Enter the total charges relating to each revenue code for the billing period The detailed revenue code amounts must equal the entry total charges Claim total must be shown in field 47 line 23 Payer Identification Medicare Paid Amount Enter the paid amount from Medicare if applicable Enter the amount paid if any be a private insurance Enter the Pay To NPI number Enter the Pay To Taxonomy number Enter the facilities zip code Ente
34. and regulations are outlined on the DMS website at http chfs ky gov dms Regs htm Fee and rate schedules are available on the DMS website at http chfs ky gov dms fee htm 1 2 Member Eligibility Members should apply for Medicaid eligibility through kynect kyenroll ky gov by phone at 1 855 4kynect 1 855 459 6328 or in person at their local Department for Community Based Services DCBS office Members with questions or concerns can contact Member Services at 1 800 635 2570 Monday through Friday This office is closed on holidays The primary identification for Medicaid eligible members is the Kentucky Medicaid card This is a permanent plastic card issued when the Member becomes eligible for Medicaid coverage The name of the member and the member s Medicaid identification ID number are displayed on the card The provider is responsible for checking identification and verifying eligibility before providing services NOTE Payment cannot be made for services provided to ineligible members Possession of a Member Identification card does not guarantee payment for all medical services 07 07 2015 Page 1 1 General 1 2 1 Plastic Swipe KY Medicaid Card _ KyHealth Choices Member Name entuck 5 First Middle Initial if available Last yY UNBRIDLED SPIRIT 10 DIGIT Member Identification Number CHILD CLAYTON 1234567890 DO NOT THROW AWAY This is your permanent medical card Card Holder
35. ass Adj 91 Beginning Credit Balance 92 Ending Credit Balance 93 Beginning Dummy Credit Balance 94 Ending Dummy Credit Balance 07 07 2015 Page 76 14 Appendix F 14 Appendix F 14 1 Remittance Advice Status Code ST CD The following is a one character code indicating the status of the accounts receivable transaction A Tm oo N lt x lt Active Hold Recoup Payment Plan Under Consideration Hold Recoup Other Other Inactive FFP Not Reclaimed Other Inactive FFP Paid in Full Payout on Hold Involves Interest Cannot Recouped Hold Recoup Refund Inactive Charge off FFP Not Reclaimed Payout Complete Payout Set Up In Error Active Prov End Dated Active Provider A R Transfer HP Enterprise Services On Hold Hold Recoup Further Review Hold Recoup Bankruptcy Hold Recoup Appeal Hold Recoup Resolution Hearing 07 07 2015 Page 77
36. be used only for hospital based PRO FEE physicians other than psychiatrists Psychiatric Pro Fee PRO FEE PSTAY Total Charges 07 07 2015 Page 48 10 Appendix 10 1 Internal Control Number ICN An Internal Control Number ICN is assigned by HP Enterprise Services to each claim During the imaging process a unique control number is assigned to each individual claim for identification efficient retrieval and tracking The ICN consists of 13 digits and contains the following information 11 10 032 123456 1 2 3 4 E pem 3 D mU 7 Ss O E sincera 7 p ewm u erase O s 5 eee 7 E EM O O T n _ O VOID CHECK RELATED 2 Year of Receipt 3 Julian Date of Receipt The Julian calendar numbers the days of the year 1 365 For example 001 is January 1 and 032 shown above is February 1 4 Batch Sequence Used Internally 07 07 2015 Page 49 11 11 1 Remittance Advice This section is a step by step guide to reading a Kentucky Medicaid Remittance Advice RA The following sections describe major categories related to processing adjudicating claims To enhance this document s usability detailed descriptions of the fields on each page are included reading the data from left to right top to bottom 11 1 1 Examples of Pages in Remittance Advice There are several types of pages in a Remittance A
37. ber as it appears on the Member s Identification card ICN The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services ATTENDING PROVIDER The member s attending provider CLAIM SERVICE DATE The date or dates the service was provided in month day FROM THRU and year numeric format DAYS The number of days billed ADMIT DATE The admit date of the member BILLED AMOUNT The usual and customary charge for services provided for the Member TPL AMOUNT Amount paid if any by private insurance excluding Medicaid and Medicare SPENDDOWN AMOUNT The amount owed from the member CLAIM PMT AMT The total dollar amount reimbursed by Medicaid for the claim listed Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice CLAIMS DENIED ON THIS RA The total number of denied claims on the Remittance Advice TOTAL BILLED The total dollar amount billed by the Home Health Services for all claims listed on the DENIED CLAIMS page of the Remittance Advice only on final page of section TOTAL PAID The total dollar amount paid by Medicaid for all claims listed on the DENIED CLAIMS page of the Remittance Advice only on final page of section 07 07 2015 Page 57 11 Appendix REPORT CRA IPSU R COMMONWEALTH OF KENTUCKY M1 DATE 01 25 2007 9899899 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE
38. correspond with the summary of the last page of the ADJUSTED CLAIMS section PAID MASS ADJ CLAIMS The number of mass adjusted credited claims mass adjusted credited amount billed and mass adjusted credited amount paid or recouped by Medicaid These figures correspond with the summary line of the last page of the MASS ADJUSTED CLAIMS section Mass Adjustments are initiated by Medicaid and HP Enterprise Services for issues that affect a large number of claims or providers These adjustments have their own section MASS ADJUSTED CLAIMS page but are formatted the same as the ADJUSTED CLAIMS page CLAIMS DENIED These figures correspond with the summary line of the last page of the DENIED CLAIMS section CLAIMS IN PROCESS The number of claims processed that suspended along with the amount billed of the suspended claims These figures correspond with the summary line of the last page of the CLAIMS IN PROCESS section 07 07 2015 Page 69 11 Appendix DESCRIPTION The number of claims paid 11 10 1 Payments Any money owed to providers Total check amount Any money refunded to Medicaid by a provider The 1099 amount 07 07 2015 Page 70 11 Appendix C EXPLANATION OF BENEFITS DESCRIPTION A five digit number denoting the EXPLANATION OF BENEFITS detailed on the Remittance Advice EOB CODE DESCRIPTION Description of the EOB Code EOB Codes detailed on the Remittance Advice are listed with a
39. d e The letter must have the signature of an insurance representative or be on the insurance company s letterhead 3 Letter from a provider that states they have contacted the insurance company via telephone The letter must include the following information e Member name Date s of service e Name of insurance carrier e Name of and phone number of insurance representative spoken to or a notation indicating a voice automated response system was reached e Termination or effective date of coverage and e Statement of benefits available if applicable 07 07 2015 Page 12 5 Additional Information and Forms 4 Acopy of a prior remittance statement from an insurance company may be considered an acceptable form of documentation if it is e For the same Member For the same or related service being billed on the claim and e The date of service specified on the remittance advice is no more than six months prior to the claim s date of service NOTE If the remittance statement does not provide a date of service the denial may only be acceptable by HP Enterprise Services if the date of the remittance statement is no more than six months from the claim s date of service 5 Letter from an employer that includes e Member name e Date of insurance or employee termination or effective date if applicable and e Employer letterhead or signature of company representative 5 4 3 When there is no response wi
40. description definition COUNT Total number of times an EOB Code is detailed on the Remittance Advice EXPLANATION OF REMARKS DESCRIPTION 0 five cci number denoting the remark identified on the Remittance Advice REMARK CODE Description of the Remark Code All remark codes detailed on DESCRIPTION the Remittance Advice are listed with a description definition COUNT Total number of times a Remark Code is detailed on the Remittance Advice EXPLANATION OF ADJUSTMENT CODE FIELD DESCRIPTION ADJUSTMENT CODE A two digit number denoting the reason for returning the claim ADJUSTMENT CODE Description of the adjustment Code All adjustment codes DESCRIPTION detailed on the Remittance Advice are listed with a description definition COUNT Total number of times and adjustment Code is detailed on the Remittance Advice 07 07 2015 Page 71 11 Appendix EXPLANATION OF RTP CODES FIELD DESCRIPTION RTP CODE A two digit number denoting the reason for returning the claim RETURN CODE Description of the RTP Code All RTP codes detailed on the DESCRIPTION Remittance Advice are listed with a description definition COUNT Total number of times and RTP Code is detailed on the Remittance Advice 07 07 2015 Page 72 12 Appendix D 12 Appendix D 12 1 Remittance Advice Location Codes LOC CD The following is a code indicating the Department for Medicaid Services branch division or oth
41. dvice including separate page types for each type of claim however if a provider does not have activity in that particular category those pages are not included Following are examples of pages which may appear in a Remittance Advice DESCRIPTION This section lists all claims that have been returned to the provider with an RTP letter The RTP letter explains why the claim is being returned These claims are returned because they are missing information required for processing Paid Claims This section lists all claims paid in the cycle Denied Claims This section lists all claims that denied in the cycle Claims In Process This section lists all claims that have been suspended as of the current cycle The provider should maintain this page and compare with future Remittance Advices until all the claims listed have appeared on the PAID CLAIMS page or the DENIED CLAIMS page Until that time the provider need not resubmit the claims listed in this section Adjusted Claims This section lists all claims that have been submitted and processed for adjustment or claim credit transactions Mass Adjusted Claims This section lists all claims that have been mass adjusted at the request of the Department for Medicaid Services DMS Financial Transactions This section lists financial transactions with activity during the week of the payment cycle NOTE It is imperative the provider maintains any A R page with an outstanding balance
42. ection for the reasons noted above Helpful Hints When Billing for Services Provided to a Medicaid Member The Member s Medicaid number on the CMS 1500 08 05 must be entered Field 9A The Member s Medicaid number on the CMS 1500 02 12 must be entered Field 1A The Member s Medicaid number on the UB04 must be entered in Block 60 Medicare numbers are not valid Medicaid numbers Please refer to your billing manual if you have any concerns about billing the Medicaid program correctly Please make the necessary corrections and resubmit for processing If you have any questions please feel free to contact our Provider Relations Group open Monday through Friday 8 00 a m until 6 00 p m eastern standard daylight savings time at 1 800 807 1232 If you are interested in billing Medicaid electronically please contact HP Enterprise Services at 1 800 205 4696 7 30 AM to 6PM Monday through Friday except holidays Initials of clerk ProviderName_ LL Provider Number Reason Code _ 07 07 2015 Page 23 5 Additional Information and Forms 5 10 Provider Representative List 5 10 1 Phone Numbers and Assigned Counties KELLY GREGORY VICKY HICKS 502 209 3100 502 209 3100 Extension 2021273 Extension 2021263 Kelly dio gregory hp com vicky hicks hp com Assigned Counties Assigned Counties ADAIR GREEN MCCREARY ANDERSON GARRARD MENIFEE ALLEN
43. eld by field instructions for KYHealth Net claims submission are available at http www kymmis com kymmis Provider 20Relations K YHealthNetManuals aspx 07 07 2015 Page 9 4 General Billing Instructions for Paper Claim Forms 4 General Billing Instructions for Paper Claim Forms 4 1 General Instructions The Department for Medicaid Services is mandated by the Centers for Medicare and Medicaid Services CMS to use the appropriate form for the reimbursement of services Claims may be submitted on paper or electronically 4 2 Imaging All paper claims are imaged which means a digital photograph of the claim form is used during claims processing This streamlines claims processing and provides efficient tools for claim resolution inquiries and attendant claim related matters By following the guidelines below providers can ensure claims are processed as they intend e USE BLACK INK ONLY e Do not use glue Donot use more than one staple per claim Press hard to guarantee strong print density if claim is not typed or computer generated e Do not use white out or shiny correction tape and e Do send attachments smaller than the accompanying claim form 4 3 Optical Character Recognition Optical Character Recognition OCR eliminates human intervention by sending the information on the claim directly to the processing system bypassing data entry OCR is used for computer generated or typed claims only Information obt
44. eligible for the KY Medicaid benefits upon admission If the Member was not 07 07 2015 Page 27 eligible on the date of admission the FROM date is the effective date of eligibility The THROUGH date is the last covered day of the hospital stay Date of Birth Enter the member s date of birth Admission Date Enter the date on which the Member was admitted to the facility in numeric format MMDDY Y Admission Hour S Hour Enter the code for the time of admission to the facility Admission hour is required for both inpatient and outpatient services CODE STRUCTURE sss STRUCTURE 11 00 11 59 ai 07 07 2015 Page 28 CNN NEM 0202 CODESTRUCTURE 0 0 pre few er n eue C ce oem Wo lt 08 FM EN iis rA rm pm ils s KR NN ic Admission Enter the appropriate type of admission 1 Emergency 2 Urgent 3 Elective 4 Newborn Discharge Hour Enter the code for the hour the member was discharged from the facility using the code structure described for Field 13 above 7 Patient Status Code Enter the appropriate two digit patient status code indicating the disposition of the patient as of the through date in Form Locator 6 Status Codes Accepted by KY Medicaid Discharged or Transferred to Home Under Care of Organized Home Health Service Organization Left Against Medical Advice Discharged
45. equest form is HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 Attn Financial Services Please keep the following points in mind when filing an adjustment request Attach a copy of the corrected claim and the paid remittance advice page to the adjustment form For a Medicaid Medicare crossover attach an EOMB Explanation of Medicare Benefits to the claim Do not send refunds on claims for which an adjustment has been filed Be specific Explain exactly what is to be changed on the claim Claims showing paid zero dollar amounts are considered paid claims by Medicaid If the paid amount of zero is incorrect the claim requires an adjustment and An adjustment is a change to a paid claim a claim credit simply voids the claim entirely 07 07 2015 Page 18 5 Additional Information and Forms HP Enterprise Services ADJUSTMENT AND CLAIM CREDIT REQUEST FORM MAIL TO Enterprise Services P O BOX 2108 FRANKFORT 40602 2108 1 800 807 1232 ATTN FINANCIAL SERVICES NOTE CREDIT VOIDS THE CLAIM ICN FROM THE SYSTEM A NEW DAY CLAIM MAY BE SUBMITTED IF NECESSARY THIS FORM WILL BE RETURNED TO YOU IF THE REQUIRED INFORMATION AND DOCUMENTATION FOR PROCESSING ARE NOT PRESENT PLEASE ATTACH A CORRECTED CLAIM AND REMITTANCE ADVICE TO ADJUST A CLAIM CHECK APPROPRIATE BOX 1 Original Internal Control Number ICN CLAIM CLAIM ADJUSTMENT CREDIT 2 Member Name 3 Member Medicaid
46. er agency that originated the Accounts Receivable Active Hold Recoup Payment Plan Under Consideration Hold Recoup Other Other Inactive FFP Not Reclaimed Other Inactive FFP Paid in Full nm oou gt Payout Hold Involves Interest Cannot Be Recouped Hold Recoup Refund Inactive Charge off FFP Not Reclaimed Payout Complete Payout Set Up In Error Active Prov End Dated Active Provider A R Transfer HP Enterprise Services On Hold Hold Recoup Further Review Hold Recoup Bankruptcy Hold Recoup Appeal N lt x C A O ux Hold Recoup Resolution Hearing 07 07 2015 Page 73 13 Appendix E 13 Appendix E 13 1 Remittance Advice Reason Code ADJ RSN CD or RSN CD The following is a two byte alpha numeric code specifying the reason an accounts receivable was processed against a provider s account 07 07 2015 Page 74 13 Appendix E 01 Prov Refund Health Insur Paid 32 Payout Advance to be Recouped 02 Prov Refund Member Rel Paid 33 Payout Error on Refund 03 Prov Refund Casualty Insu Paid 34 Payout RTP 04 Prov Refund Paid Wrong Vender 35 Payout Cost Settlement 05 Prov Refund Apply to Acct Recv 36 Payout Other 06 Prov Refund Processing Error 37 Payout Medicare Paid TPL 07 Prov Refund Billing Error 38 Recoupment Medicare Paid TPL 08 Prov Refund Fraud 39 Recoupment DEDCO 09 Prov Refund Abuse 40 Provider Refund
47. ers DESCRIPTION The cash control tracking number assigned to refund checks for tracking purposes 07 07 2015 Page 65 11 Appendix 11 9 3 Accounts Receivable FIELD DESCRIPTION A R NUBMER ICN This is the 13 digit Internal Control Number used to identify records for one accounts receivable transaction SETUP DATE The date entered on the accounts receivable transaction in the MM DD CCYY format This date identifies the beginning of the accounts receivable event RECOUPED THIS CYCLE The amount of money recouped on this financial cycle ORIGINAL AMOUNT The original accounts receivable transaction amount owed by the provider TOTAL RECOUPED This amount is the total of the provider s checks and recoupment amounts posted to this accounts receivable transaction BALANCE The system generated balance remaining on the accounts receivable transaction REASON CODE A two byte alpha numeric code specifying the reason an accounts receivable was processed against a providers account ANY RECOUPMENT ACTIVITY OR PAYMENTS RECEIVED FROM THE PROVIDER list below the RECOUPMENT PAYMENT SCHEDULE All initial accounts receivable allow 60 days from the setup date to make payment on the accounts receivable After 60 days if the accounts receivable has not been satisfied nor a payment plan initiated monies are recouped from the provider on each Remittance Advice until satisfied This is your only notification of an accounts receivable
48. f a claim does not appear on your Medicaid remittance advice within 30 days of the Medicare adjudication date a paper UB 04 should be submitted to the Medicaid Program 07 07 2015 Page 45 9 9 1 Revenue Codes Following is a list of the revenue codes that are accepted by the Medicaid Program when billing for inpatient services on the UB 04 billing form INPATIENT REVENUE CODES CREE CU pum 0 cw J 740 EEG Pro Fee to be used only for hospital based physicians other than psychiatrists 07 07 2015 Page 46 71 Lab Pro fee 72 Radiology Diag Pro Fee 73 Radiology Ther Pro Fee 74 Radiology Nuclear Medicine EKG ECG Pro Fee EEG Pro Fee Note When billing professional component services for electro shock treatment use Revenue Code 960 PROFESSIONAL COMPONENT REVENUE CODES The following revenue codes column A are professional component revenue codes and cannot be billed unless they are billed in conjunction with the revenue codes in column B 71 Must be in conjunction with 300 72 Must be in conjunction with either 320 350 351 352 610 611 or 612 07 07 2015 Page 47 REVENUE CODES FOR ALL INCLUSIVE ANCILLARY BILLING Following is a list of revenue codes accepted by the Medicaid Program on the UB 04 billing form in Form Locator 42 when revenue code 240 All Inclusive Ancillary is used All Inclusive Ancillary ALL INCL ANCIL Pro Fee to
49. ganizations from which the provider receives payment For Medicaid use KY Medicaid All other liable payers including Medicare must be billed first KY Medicaid is payer of last resort Note If you are billing for a replacement policy to Medicare Medicare needs to be indicated instead of the name of replacement policy 07 07 2015 Page 40 Identification Number Enter the Member Identification number in Form Locators 60 A B and C that relates to the Member s name in Form Locators 58 A B and C Enter the 10 digit Member Identification number exactly as it appears on the Member Identification card Prior Authorization Number Enter the prior authorization number assigned by the PRO UR designating that the treatment covered by the bill is authorized by the PRO UR Diagnosis Indicator Enter the appropriate ICD indicator 9 ICD 9 0 ICD 10 e7 Diagnosis Code Enter the appropriate ICD 9 or ICD 10 CM code describing the principal diagnosis 67 Other Diagnosis Code Enter additional diagnosis codes that co exist at the time the service is provided Admitting Diagnosis Inpatient Only Enter the diagnosis code describing the admitting diagnosis 11 Attending Physician ID Enter the Attending Physician NPI number 07 07 2015 Page 41 6 5 Duplicate or Inappropriate Payments Any duplicate or inappropriate payment by the KY Medicaid Program whether due to erroneous billing o
50. ified health center look alikes or 10 Primary care services delivered by local health departments 1 2 2 4 PE for Hospitals 1 2 2 4 2 1 Eligibility A determination of presumptive eligibility can be made by an inpatient hospital participating in the Medicaid program using modified adjusted gross income for an individual who 1 Does not have income exceeding a 138 percent of the federal poverty level established annually by the United States Department of Health and Human Services or b 200 percent of the federal poverty level for children under age one and 147 percent of the federal poverty level for children ages 1 5 as established annually by the United States Department of Health and Human Services if the individual is a targeted low income child 2 Does not currently have a pending Medicaid application on file with the DCBS Is not currently enrolled in Medicaid and 4 Is not an inmate of a public institution 1 2 2 4 2 2 Covered Services Covered services for a presumptively eligible individual who meet the income guidelines above shall include 1 Services furnished by a primary care provider including a Afamily or general practitioner 07 07 2015 Page 5 1 General e A pediatrician An internist Bo 9 An obstetrician or gynecologist e A physician assistant f Acertified nurse midwife or g An advanced practice registered nurse Laboratory services Radiological services Den
51. ill Accident Related Codes 01 Auto Accident 02 No Fault Insurance Involved Including Accident or Other 03 Accident Tort Liability 04 Accident Employment Related 05 Other Accident Not described by the other codes 35 36 Occurrence Span Code and Dates Enter occurrence span code and the first and last days approved by the PRO UR when condition code C3 partial approval has been entered in Form Locators 18 28 37 Medicare EOMB Date Enter the EOMB date from Medicare if applicable 07 07 2015 Page 30 80 Covered Days Enter the total number of covered days from Form Locator 6 Data entered in Form Locator 39 must agree with accommodation units in Form Locator 46 Covered days are not required for Medicare crossover claims for coinsurance days or life reserve days 82 Coinsurance Days Enter the number of coinsurance days billed to KY Medicaid during this billing period 83 Life Time Reserve Days Enter the Lifetime Reserve days the patient has elected to use for this billing period A1 Deductible Payer Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due A2 Coinsurance Payer Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due B1 Deductible Payer B Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due B2 Coinsurance Payer B Enter the
52. ilure to correct any remarks may ultimately affect the instate provider s prospective payment rate NOTE Total charge Revenue code 0001 must be the final entry in column 42 line 23 Total charge amount must be shown in column 47 line 23 07 07 2015 Page 39 Enter the standard abbreviation assigned to each revenue code Creation Date Enter the invoice date or invoice creation date Enter the quantitative measure of services provided per revenue code Total Charges Enter the total charges relating to each revenue code for the billing period The detailed revenue code amounts must equal the entry total charges Claim total must be shown in field 47 line 23 Payer Identification Medicare Paid Amount Enter the paid amount from Medicare if applicable Enter the amount paid if any be a private insurance Enter the Pay To NPI number NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the NPI number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim Insured s Name Enter the Member s name in Form Locators 58 A B and C that relates to the payer in Form Locators 50 A B and C Enter the Member s name exactly as it appears on the Member Identification card in last name first name and middle initial format Enter the names of payer or
53. ip 1 2 2 4 Presumptive Eligibility Presumptive Eligibility PE is a program that offers certain individuals and pregnant women temporary medical coverage A treating physician or hospital may issue an Identification Notice to an individual if it is determined that the individual meets the criteria as described below PE benefits are in effect up to 60 days from the date the Identification Notice is issued or upon denial or issuance of Medicaid The 60 days includes current month through end of the next month This short term program is intended to allow financially needy individuals to have access to medical services while they are completing the application process for full Medicaid benefits Reimbursement for services is different for presumptively eligible individuals depending on the method by which eligibility is granted The two types of PE are as follows e PE for pregnant women e PE for hospitals 1 2 2 41 PE for Pregnant Women 1 2 2 4 1 1 Eligibility 07 07 2015 Page 3 1 General A determination of presumptive eligibility for a pregnant woman shall be made by a qualified provider who is enrolled as a Kentucky Medicaid provider in one of the following categories 1 o oc m A family or general practitioner A pediatrician An internist An obstetrician or gynecologist A physician assistant A certified nurse midwife An advanced practice registered nurse A federally qualified health ca
54. nts of this information is strictly prohibited If you have received this communication in error please notify us immediately and delete the original message 07 07 2015 Page 16 5 Additional Information and Forms 5 6 Prior Authorization Information The prior authorization process does NOT verify anything except medical necessity It does not verify eligibility or age The prior authorization letter does not guarantee payment It only indicates that the service is approved based on medical necessity If the individual does not become eligible for Kentucky Medicaid loses Kentucky Medicaid eligibility or ages out of the program eligibility services will not be reimbursed despite having been deemed medically necessary Prior Authorization should be requested prior to the provision of services except in cases of e Retro active Member eligibility e Retro active provider number Providers should always completely review the Prior Authorization Letter prior to providing services or billing Access the KYHealth Net website to obtain blank Prior Authorization forms http Avww kymmis com kymmis Provider 20Relations PriorAuthorizationForms aspx Access to Electronic Prior Authorization request EPA https sso kymmis com 07 07 2015 Page 17 5 Additional Information and Forms 5 7 Adjustments and Claim Credit Requests An adjustment is a change to be made to a PAID claim The mailing address for the Adjustment R
55. number The first 14 digits alpha numeric will appear on the remittance advice as the invoice number Type of Bill Enter the appropriate code to indicate the type of bill 2nd Digit Type of Facility 1 Hospital 3rd Digit Bill Classification 1 Inpatient including Medicare Part A 2 Inpatient Medicare Part B only 3 Outpatient 4 Non patient 4th Digit Frequency 0 Non payment 1 Admit through discharge 2 Interim first claim 3 Interim continuing claim 4 Interim final claim Statement Covers Period FROM Enter the beginning date of the billing period covered by this invoice in numeric format MMDDYY THROUGH Enter the last date of the billing period covered by this invoice in numeric format MMDDYY Do not include days prior to when the Member s KY Medicaid eligibility 07 07 2015 Page 35 period began The FROM date is the date of the admission if the Member was eligible for the KY Medicaid benefits upon admission If the Member was not eligible on the date of admission the FROM date is the effective date of eligibility The THROUGH date is the last covered day of the hospital stay Date of Birth Enter the member s date of birth Admission Date Enter the date on which the Member was admitted to the facility in numeric format MMDDY Y Admission Hour Hour Enter the code for the time of admission to the Admission hour is required for both inpatient and outpa
56. or Transferred to Mental Health Center or Mental Hospital Discharge or Transfer to Court Law Enforcement to Home or Self Care Routine Discharge Discharged or Transferred to Acute Hospital 03 Discharged or Transferred to Skilled Nursing Facility SNF or NF 04 Discharged or Transferred to Intermediate Care Facility ICF Discharged or Transferred to Another Type of Institution ai a Resident 07 07 2015 Page 29 18 28 Condition Codes Peer Review Organization PRO Indicator Enter the appropriate indicator which describes the determination of the PRO Utilization Review Committee Approved as Billed C2 Automatic Approval as Billed Based on Focus Review C3 Partial Approval If the PRO authorized a portion of the Member s hospital stay the approved date s must be shown in Form Locator 36 Occurrence Span These dates should be the same as the dates of service in Form Locator 6 The condition codes are also included in the UB 04 Training Manual Information regarding the Peer Review Organization is located in the Reference Index 31 34 Occurrence Codes and Dates Enter the appropriate code s and date s defining a significant event relating to this bill Reference the UB 04 Training Manual for additional codes Discharge Code and Date Enter 42 and the actual discharge date when the THROUGH date Form Locator 6 is not the actual discharge date and Form Locator 4 indicates Final B
57. ossover claims Other reasons for return may include e Illegible claim date of service or other pertinent data e Claim lines completed exceed the limit and e Unable to image 07 07 2015 Page 22 5 Additional Information and Forms HP RETURN TO PROVIDER LETTER Dear Provider The attached claim is being returned for the following reason s These items require correction before the claim can be processed 01 PROVIDER NUMBER A valid NPI or provider number must be on the claim form in the appropriate field Missing _ Not a valid provider number 02 PROVIDER SIGNATURE All claims require an original signature in the provider signature block The Provider signature cannot be stamped or typed on the claim _ Missing _ Typed signature not valid ___ Stamped signature not valid 03 ___ Detail lines exceed the limit for claim type 04 _ UNABLE TO IMAGE OR KEY Claim form EOMB must be legible Highlighted forms cannot be accepted Please resubmit on a new form _ Print too light Printtoo dark Highlighted data fields Dark copy 05 Medicaid does not make payment when Medicare has paid the amount in full 06 _ Recipient s Medicaid MAID number is missing D E 07 ___ Medicare Coding Sheet does not match the claim ___ Dates of Service _ Member Number Charges _ Balance due in Block 30 08 _ Other Reason Claims are being returned to you for corr
58. page contains provider specific information regarding upcoming meetings and workshops top ten billing errors policy updates billing changes etc Please pay close attention to this page 07 07 2015 Page 52 11 Appendix REPORT CRA BANN R COMMONWEALTH OF KENTUCKY M1 DATE 01 23 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 1 PROVIDER REMITTANCE ADVICE PROVIDER BANNER MESSAGES PROVIDER PAYEE ID 99999999 555 ANY STREET NPI ID 99999999 CITY KY 55555 0000 NUMBER 999999999 ISSUE DATE 01 26 2007 Commonwealth of Kentucky 07 07 2015 Page 53 REPORT CRA IPPD R RA 9999999 PROVIDER 5555 ANY STREET CITY KY 55555 5555 ICN PAT ACCT NUM ATTENDING PROV MEMBER NAME JANE DOE ICN9999999999 NPI9999999 PATACCT 99999999999 HEADER EOBS 9932 00A2 REV CD HCPCS RATE SRV DATE LVL CARE 120 030806 DEF 250 030806 DEF 258 030806 DEF 270 030806 DEF 300 030806 DEF 310 030806 DEF 360 030806 DEF 370 030806 DEF 710 030806 DEF MEMBER NAME JANE DOE 9999999999999 9999999999 99999999999 HEADER EOBS 9932 0018 REV CD HCPCS RATE SRV DATE LVL CARE 120 030806 DEF 250 030806 DEF 258 030806 DEF 270 030806 DEF 300 030806 DEF 310 030806 DEF 360 030806 DEF 370 030806 DEF 710 030806 DEF TOTAL UB CLAIMS PAID COMMONWEALTH OF KENTUCKY M1 MEDICAID MANAGEMENT INFORMATION SYSTEM PROVIDER REMITTANCE ADVICE UB CLAIMS PAID SERVICE DATES DAYS ADMIT BILLED AMT FROM TH
59. priate responses such as provider ID or Member ID as soon as each prompt begins The number of inquiries is limited to five per call The VREV spells the member name and announces the dates of service Check amount data is accessed through the VREV voice menu The Provider s last three check amounts are available 1 2 3 1 2 KYHealth Net Online Member Verification KY Health Net online access be obtained at https sso kymmis com The KYHealth Net website is designed to provide real time access to member information Providers can download a User Manual to assist providers in system navigation Providers with suggestions comments or questions should contact the HP Enterprise Services Electronic Claims Department at KY EDI Helpdesk hp com or 1 800 205 4696 All Member information is subject to HIPAA privacy and security provisions and it is the responsibility of the provider and the provider s system administrator to ensure all persons with access understand the appropriate use of this data It is suggested that providers establish office guidelines defining appropriate and inappropriate uses of this data 07 07 2015 Page 7 2 Electronic Data Interchange EDI 2 Electronic Data Interchange EDI Electronic Data Interchange EDI is structured business to business communications using electronic media rather than paper 2 4 How to Get Started All Providers are encouraged to utilize EDI rather than paper claims submission To
60. ptive eligibility per Stayce Towles 5 05 20 2008 Cathy Hill Made revisions requested by Stayce Towles 2 8 2 9 are actually the same as revisions were made back to back and no publication would have been made Mu Ann Murray Updated with changes for Medicare with changes for Medicare 03 09 2009 Cathy Hill Made from KYHealth Choices to KY Medicaid per Stayce Towles i 03 11 2009 Cathy Hill Revised contact info from First Health to Dept for Medicaid Services per Stayce Towles 3 3 03 19 2009 Cathy Hill Added descriptions for Field 16 Discharge Hour for he UB 04 form per Stayce Towles 3 4 03 30 2009 Murray Made global revisions requested by DMS 3 1 3 4 are actually the same as revisions were made back to back and no publication would have been made al Provider Rep list 3 6 10 21 2009 Ron Chandler Replaced all instances of EDS with HP Enterprise Services 3 7 11 10 2009 Ann Murray Replaced all instances of eds com with hp com Removed HIPAA section 3 6 3 7 are actually the same as revisions were made back to back and no publication would have been made Es Ron Chandler Inserted new Ener d rep list 11 18 2010 Patti George 4 Patti George paper document with Ron Chandler markup 4 0 01 18 2011 Ann Murray Updated global sections 3 9 4 0 are actually the same as revisions were made back to back and no publication would have been made OE AU Patti
61. r payment system faults shall be refunded to the KY Medicaid Program Refund checks shall be made payable to KY State Treasurer and sent immediately to HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 ATTN Financial Services Unit Failure to refund a duplicate or inappropriate payment could be interpreted as fraud or abuse and prosecuted 07 07 2015 Page 42 7 24 Memorandum to Local Community Based Services The MAP 24 is used to report the discharge or death of any Title XIX resident to the local department for Community Based Services office This flow of information is essential to timely payment to the facility and efficient records for the Community Based Services office Complete all entries as appropriate and mail to the local Department for Community Based Services office within ten days of discharge or death 07 07 2015 Page 43 CABINET FOR HEALTH SERVICES COMMONWEALTH OF KENTUCKY FRANKFORT 40621 0001 DEPARTMENT FOR MEDICAID SERVICES An Equal Opportunity Employer MF D Date ME M CIR AN D LU M T Local Office Department for Community Based Services Cabinet for Families amp Children tue meio meto mte tee cot We at Rr ae t Sp _______________ Fail iptniaiuer Age rey ESL RR RERO Recipe Name oda orli Medea Wum her Sa eee Responsible Relalue s 5 Addess 77777 This is
62. r the Member s name in Form Locators 58 A B and C that relates to the payer in Form Locators 50 A B and C Enter the Member s name exactly as it appears on the Member Identification card in last name first name and middle initial format Enter the names of payer organizations from which the provider receives payment For Medicaid use KY Medicaid All other liable payers including Medicare must be billed first KY Medicaid is payer of last resort Note If you are billing for a replacement policy to Medicare Medicare needs to be indicated instead of the name of replacement policy 07 07 2015 Page 32 Identification Number Enter the Member Identification number in Form Locators 60 A B and C that relates to the Member s name in Form Locators 58 A B and C Enter the 10 digit Member Identification number exactly as it appears on the Member Identification card Prior Authorization Number Enter the prior authorization number assigned by the PRO UR designating that the treatment covered by the bill is authorized by the PRO UR Diagnosis Indicator Enter the appropriate ICD indicator 9 ICD 9 02 ICD 10 Principal Diagnosis Code Enter the ICD 9 or ICD 10 code describing the principal diagnosis 67A Q Other Diagnosis Code Enter the additional diagnosis codes that co exist at the time the service is provided Admitting Diagnosis Inpatient Only EN Enter the diagnosis code describing the admitting diagnosis
63. re center A primary care center 10 A rural health clinic 11 A local health department Presumptive eligibility shall be granted to a woman if she 1 2 3 7 Is pregnant Is a Kentucky resident Does not have income exceeding 195 percent of the federal poverty level established annually by the United States Department of Health and Human Services Does not currently have a pending Medicaid application on file with the DCBS Is not currently enrolled in Medicaid Has been previously granted presumptive eligibility for the current pregnancy and Is not an inmate of a public institution 1 2 2 4 1 2 Covered Services Covered services for a presumptively eligible pregnant woman shall be limited to ambulatory prenatal services delivered in an outpatient setting and shall include 1 Services furnished by a primary care provider including a A family or general practitioner b A pediatrician c Aninternist d An obstetrician or gynecologist 07 07 2015 Page 4 1 General e A physician assistant f Acertified nurse midwife or 0 An advanced practice registered nurse Laboratory services Radiological services Dental services Emergency room services Emergency and nonemergency transportation Pharmacy services Services delivered by rural health clinics oN o m Services delivered by primary care centers federally qualified health centers and federally qual
64. roofs to determine eligibility and e Whatto do when a method of eligibility is not available 07 07 2015 Page 6 1 General 1 2 3 1 Obtaining Eligibility and Benefit Information Eligibility and benefit information is available to providers via the following e Voice Response Eligibility Verification VREV available 24 hours 7 days a week at 1 800 807 1301 KYHealth Net at https sso kymmis com The Department for Medicaid Services Member Eligibility Branch at 1 800 635 2570 Monday through Friday except holidays 1 2 3 1 1 Voice Response Eligibility Verification VREV HP Enterprise Services maintains a VREV system that provides member eligibility verification as well as information regarding third party liability TPL Managed Care PRO review Card Issuance Co pay provider check write and claim status The VREV system generally processes calls in the following sequence 1 Greet the caller and prompt for mandatory provider ID 2 Prompt the caller to select the type of inquiry desired eligibility TPL Managed Care PRO review card issuance co pay provider check write claim status etc 3 Prompt the caller for the dates of service enter four digit year for example MMDDCCYY 4 Respond by providing the appropriate information for the requested inquiry 5 Prompt for another inquiry 6 Conclude the call This system allows providers to take a shortcut to information Users may key the appro
65. tal services Emergency room services Emergency and transportation Pharmacy services Services delivered by rural health clinics o o n Qo oc t amp N Services delivered by primary care centers federally qualified health centers and federally qualified health center look alikes 10 Primary care services delivered by local health departments or 11 Inpatient or outpatient hospital services provided by a hospital 1 2 2 5 Breast amp Cervical Cancer Treatment Program The Breast amp Cervical Cancer Treatment Program BCCTP offers Medicaid coverage to women who have a confirmed cancerous or pre cancerous condition of the breast or cervix In order to qualify women must be screened and diagnosed with cancer by the Kentucky Women s Cancer Screening Program be between the ages of 21 and 65 have no other insurance coverage and not reside in a public institution The length of coverage extends through active treatment for the breast or cervical cancer condition Those members receiving Medicaid through BCCTP are entitled to full Medicaid services Women who are eligible through BCCTP do not receive a Medicaid card for services The enrolling provider will provide a printed document that is to be used in place of a card 1 2 3 Verification of Member Eligibility This section covers Methods for verifying eligibility e How to verify eligibility through an automated 800 number function e How to use other p
66. tance Statement no more than 12 months old which verifies that the original claim was received within 12 months of the service date Additional documentation that may be attached to claims for processing for possible payment is e Ascreen print from KYHealth Net verifying eligibility issuance date and eligibility dates must be attached behind the claim Ascreen print from KYHealth Net verifying filing within 12 months from date of service such as the appropriate section of the Remittance Advice or from the Claims Inquiry Summary Page accessed via the Main Menu s Claims Inquiry selection Acopy of the Medicare Explanation of Medicare Benefits received 12 months after service date but less than six months after the Medicare adjudication date and of the commercial insurance carrier s Explanation of Benefits received 12 months after service date but less than six months after the commercial insurance carrier s adjudication date 5 2 Retroactive Eligibility Back Dated Card Aged claims for Members whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the eligibility issuance date Claim submission must be within 12 months of the issuance date A copy of the KYHealth Net card issuance screen must be attached behind the paper claim 5 3 Unacceptable Documentation Copies of previously submitted claim forms providers in house records of claims submitted
67. th From Date of Service To Date of Service Date of Admission Date of Discharge Insurance Carrier Name Address Policy Number Start Date End Date Date Claim Was Filed with Insurance Carrier Please check the one that applies No Response in Over 120 Days Policy Termination Date Other Please explain in the space provided below Contact Name Contact Telephone Signature Date DMS Approved January 10 2011 07 07 2015 Page 14 5 Additional Information and Forms 5 5 Provider Inquiry Form Provider Inquiry Forms may be used for any unique questions concerning claim status paid or denied claims and billing concerns The mailing address for the Provider Inquiry Form is HP Enterprise Services Provider Services P O Box 2100 Frankfort KY 40602 2100 Please keep the following points in mind when using this form e Send the completed form to HP Enterprise Services copy is returned with a response e When resubmitting a corrected claim do not attach a Provider Inquiry Form e Atoll free HP Enterprise Services number 1 800 807 1232 is available in lieu of using this form and To check claim status call the HP Enterprise Services Voice Response on 1 800 807 1301 or you may use the KYHealth Net by logging into https sso kymmis com 07 07 2015 Page 15 fT 5 Additional Information and Forms Provider Inquiry Form HP Enterprise Services Corporation Did you know that electronic
68. thin 120 days from the insurance carrier When the other health insurance has not responded to a provider s billing within 120 days from the date of filing a claim a provider may complete a TPL Lead Form Write no response in 120 days on either the TPL Lead Form or the claim form attach it to the claim and submit it to HP Enterprise Services HP Enterprise Services overrides the other health insurance edits and forwards a copy of the TPL Lead form to the TPL Unit A member of the TPL staff contacts the insurance carrier to see why they have not paid their portion of liability 5 4 4 For Accident and Work Related Claims For claims related to an accident or work related incident the provider should pursue information relating to the event If an employer individual or an insurance carrier is a liable party but the liability has not been determined claims may be submitted to HP Enterprise Services with an attached letter containing any relevant information such as names of attorneys other involved parties and or the Member s employer to HP Enterprise Services ATTN TPL Unit P O Box 2107 Frankfort KY 40602 2107 07 07 2015 Page 13 5 Additional Information and Forms 5 4 41 TPL Lead Form HP Enterprise Services HP Enterprise Services Attention TPL Unit P O Box 2107 Frankfort KY 40602 2107 Third Party Liability Lead Form Provider Name Provider Member Name Member Address Date of Bir
69. tient services CODE STRUCTURE STRUCTURE 12 00 12 59 midnight 01 00 01 59 ES E 22 000 Wem E s opem a _ p psu woes 7 e 2 08 pce E Kom Em p em s s 10 00 10 59 10 00 10 59 11 00 11 59 07 07 2015 36 07 00 07 59 08 00 08 59 TIME A M TIME P M Admission Enter the appropriate type of admission 1 Emergency 2 Urgent 3 Elective 4 Newborn Discharge Hour Enter the code for the hour the member was discharged from the facility using the code structure described for Field 13 above 7 Patient Status Code Enter the appropriate two digit patient status code indicating the disposition of the patient as of the through date in Form Locator 6 Status Codes Accepted by KY Medicaid Discharged or Transferred to Home Under Care of Organized Home Health Service Organization Left Against Medical Advice Discharged or Transferred to Mental Health Center or Mental Hospital Discharge or Transfer to Court Law Enforcement to Home or Self Care Routine Discharge Discharged or Transferred to Acute Hospital 03 Discharged or Transferred to Skilled Nursing Facility SNF or NF 04 Discharged or Transferred to Intermediate Care Facility ICF Discharged or Transferred to Another Type of Institution ai a Resident 07 07 2015 Page 37 18 28 Condition Codes Peer Review Organization PRO Indicator
70. to notify you that the above referenced recipient LJ Was admitted to this facilityiwaiveragency ___________________________ gI T itla oie Payment Status and was placed Cu Tor NF bed ICF MR OD bed MH bed EP SDT Bed Home amp Community Based Waiver Service SCL Waiver Service and or Was discharged from this facility waiver agency on Andwentto _ Home AddresziName E Address of Fmciliniauer Agency And or expired on Was re inztated to Home amp Community Based SCL waiver services within 6 days of the HF admission _ Dae 120 For Home amp Cum m unity Based waiver Clients only last date service uas provide d MA P 24 RB u 02200 1 07 07 2015 Page 44 8 Medicare Deductibles and Coinsurance Billing for Medicare Part A deductible or coinsurance days Medicare Part B deductible or coinsurance and Title XIX services must be on separate claim forms If the Member is covered by Medicare Part A Medicare Part B and Medicaid three separate claims must be submitted for payment for the three types of benefits Medicaid PRO certification is not required on Medicare deductible and coinsurance claims as certification is determined using Medicare guidelines If all Medicare benefits are exhausted and Title XIX days are being billed Medicaid PRO certification for Medicaid days is required I

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