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AmeriHealth Caritas Louisiana Provider Manual Appendix

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1. AmeriHealth Caritas Louisiana Claim Filing Instructions For AmeriHealth Caritas Louisiana Providers Revised January 2015 AmeriHealth Caritas Louisiana Claim Filing Instructions Contents Claim FATING 000 ccccccssceccccesssseeccecessseeecccessssseeeceeesssseeecceessseeeeeeesssseeeeeeesaaes 1 Procedures Tor Claim SUDMISS100 sis cscctsccssactsnctecessactencteteneaceeacactcasacesacececasectsacececesictsacecaceeeceaats l QUE Tae Why Cvihy arog leo i6 d 610k Meee ete ee rer 2 Caon TS AAS 8 2 3 cc ae ss re cars re E E 2 Refunds for Claims Overpayments or Errors ccccccseecccceseeeeceeesececaeeececaeseeesaeeseeseeeseeesaees 2 Claim Form Field Requirements cccccccceccccssecccsescceenecceeesceesescesseseceeeseesseseeesseesaseeeeeseesaages 3 Required Fields CMS 1500 Claim Form cccccccceccccccsseeecccceeeececaeecceeseeeceeeseseeeseeeeesaees 4 PTUs Tor CMS a cea etapa tc ee wee renee eee 13 Required Fields UB 04 Claim Forms ccccccceccccseeecceeseceeeseceeesceeeeseeeeseeeaeseessaeseeeseeeess 19 FDM ppm Bes om UBO AEEA 31 Special Instructions and Examples for CMS 1500 UB 04 and EDI 837 Claims Submissions 42 I Supplemental Tit OF AG Of 5 csasssnansasgesasasonndenosananssosansasdcoanansbsonhanssoashaaacoanneanhoanaabababanansoss 42 A CM5 1500 Paper Claims Field 24 sessen anaE AEA AEEA 42 B EDI Field 24D Professional 0 cece ccecceccescecccecceseesesccecceseuseuscesceeseuse
2. Insured ID Number AmeriHealth Caritas Louisiana member s identification number Patient s Birth Date Sex Insured s Name Last First Middle Initial 1 la 2 Patient s Name Last First Middle Initial 5 Patient s Address Number Street City State Zip Telephone include area code Check only the type of health coverage applicable to the claim This field indicates the payer to whom the claim is being filed AmeriHealth Caritas Louisiana member identification number If submitting a claim for a newborn that does not have an identification number enter the baby s Medicaid ID number For electronic submissions ID must be less than 13 alphanumeric characters Enter the patient s name as it appears on the member s AmeriHealth Caritas Louisiana I D card Refer to page 51 for additional newborn billing information including Multiple Births MMDDYY M or F If submitting a claim for a newborn enter newborn and DOB Sex Enter the patient s name as it appears on the member s AmeriHealth Caritas Louisiana I D card or enter the newborn s name when the patient is a newborn Enter the patient s complete address and telephone number Do not punctuate the address or phone number Patient Relationship To Insured Always indicate self Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situa
3. 2300 DTP03 Admission Type CL1 01 2300 CL101 Source of Referral for CL1 02 If 2300 CL102 blank Admission or Visit 2300 CL102 Discharge Hour Loop 2300 DITP03 Patient Discharge Status Loop 2300 DTPO1 18 28 Condition Codes 1 Not Required 15 16 17 ce 2300 CRC07 Accident State 2300 REF02 C 29 30 1 3la b Occurrence Codes and Dates E HI 01 If C 34a b CLCL_CL_SUB TYPE M Move BH Qualifier 2300 HI06 found 06 2300 HI07 found 07 If 2300 HI08 found 08 35a b Occurrence Span Codes And 2300 HI01 Value for BI 36a b Dates qualifier 38 Responsible Party Name and 2010BD Address 39a b c d_ Value Codes and Amounts 2300 H101 5 BE qualifier C C C C 41a b c d Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 33 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Rey Cd SV2 01 If 2400 SV2 2400 SV201 Refer to the DHH web site for a list of billable revenue codes http www lamedicaid com pro vweb1 billing information reve nuecodes htm Revenue Description Not mapped HCPCS Accommodation SV2 02 If 2400 SV2 segment Rates HIPPS Rate Codes 2400 SV202 2 2400 SV202 3 Serv Date DTP 08 If 2400 DTP01 472 2400 DTPOS If 240
4. A copy of the EOB from all third party insurers must be submitted with the onginal claim form Include pages with run dates coding explanations and messages AmeriHealth Caritas Louisiana accepts EOBs via paper or electronic format External Cause of Injury Codes External Cause of Injury E diagnosis codes should not be billed as primary and or admitting diagnosis Important Include all primary and secondary diagnosis codes on the claim Important Missing or invalid data elements or incomplete claim forms will cause claim processing delays inaccurate payments rejections or denials Important Regardless of whether reimbursement is expected the billed amount of the service must be documented on the claim Missing charges will result in rejections or denials Important All billed codes must be complete and valid for the time period in which the service is rendered Incomplete discontinued or invalid codes will result in claim rejections or denials Important State level HCPCS coding takes precedence over national level codes unless otherwise specified in individual provider contracts Important The services billed on the claim form should exactly match the services and charges detailed on the accompanying EOB Ifthe EOB charges appear different due to global coding requirements of the primary insurer submit claim with the appropriate coding which matches the total charges on the EOB Important EP
5. s Payer Edits as described in Exhibit 99 at Emdeon Claims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon error report The name of this report can vary based upon the provider s contract with their intermediate EDI vendor or Emdeon Accepted claims are passed to the Plan and Emdeon returns an acceptance report to the sender immediately Claims forwarded to the Plan by Emdeon are immediately validated against provider and member eligibility records Claims that do not meet this requirement are rejected and sent back to Emdeon which also forwards this rejection to its trading partner the intermediate EDI vendor or provider Claims passing eligibility requirements are then passed to the claim processing queues Claims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data Providers are responsible for verification of EDI claims receipts Acknowledgements for accepted or rejected claims received from Emdeon or other contracted EDI software vendors must be reviewed and validated against transmittal records daily Since Emdeon returns acceptance reports directly to the sender submitted claims not accepted by Emdeon are not transmitted to the Plan e If you would like assistance in resolving submission issues reflected on either the Acceptance or R059 Plan Claim Status reports contact the Emdeon Provider Support Line
6. NICU for any days prior to discharge with mother facility must notify and receive authorization in order to receive payment for NICU days If baby is detained and not in NICU the facility would be eligible for reimbursement under border baby rate if authorized by Medical Management If baby is detained and in NICU facility would be eligible for payment at the NICU rate which for rural facilities 1s the general per diem rate if authorized Note Border baby rate is payable for detained babies only when authorized it should not be authorized for babies discharged with mother Note NICU rate is only payable for babies in NICU when NICU bed type is authorized authorization begins with date admitted to NICU Note Well Baby per diem rate is only payable to facilities that have published well baby per diem rate well baby is paid to those facilities when baby is discharged with mother and stay is not in NICU can be covered under mother s maternity authorization Observation The entire observation visit may not exceed 30 hours duration Provider should bill no more than 30 hours units for observation visit Observation services must be billed in units and populated in the units field When billing for these services hospitals must include the admission hour and discharge hour in addition to the other required items on the observation claim An Observation visit should be billed as follows Revenue code 720 HCPCS Code G0378 Hospi
7. code and an invalid detail procedure code or a procedure code that is not on the Louisiana Medicaid Fee for Service Fee Schedule All claim line items must be billed with a valid detail procedure code that is listed on the Louisiana Medicaid Fee for Service Fee Schedule for payment consideration e RHC FQHCs will not be reimbursed for family planning services in addition to the encounter payment e Maternity Care Visits RHC FQHC requires the submission of procedure code T1015 in conjunction with TH modifier in the first position after the CPT procedure code Obstetricians providing maternity care must append TH modifier to the CPT code e RHC FQHCs may bill for adjunct services Requires the submission of procedure code T1015 in conjunction with adjunct procedure codes Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 70 Provider Services 1 888 922 0007 01 2015 Appendix Home Health Care HHC e Provider must bill on UB04 or via 837 Format e Bill the appropriate revenue code for the homecare service e Eligible revenue codes procedure code combinations and modifiers can be found below e Providers must bill the appropriate modifier in the first position when more than one modifier is billed See tables
8. 3 or 4 Diagnosis codes must be valid ICD9 codes for the date of service 24F Charges Enter charges Value entered must be greater than zero 0 00 24G Days Or Units Enter quantity Value entered must be greater than zero Field allows up to 3 digits 24H EPSDT Family Plan Leave blank or enter a Y if services were performed as a result of an EPDST referral 241 ID Qualifier If the rendering provider does not have a NPI number the qualifier indicating what the number represents is reported in the qualifier field in 24I If the Other ID number is the AmeriHealth Caritas Louisiana ID number enter G2 If the Other ID number is another unique identifier refer to the NUCC guidelines for the appropriate qualifier C 24J Rendering Provider ID The individual rendering the service 1s reported in 24J In the top shaded portion enter Enter the AmeriHealth Caritas Recomended the AmeriHealth Caritas Louisiana Louisiana ID number in the shaded area Provider ID number of the field In the bottom unshaded portion Enter the NPI number in the R enter the NPI unshaded area of the field Use qualifier G2 25 Federal Tax ID Number SSN EIN Physician or Supplier s Federal Tax ID oe number Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional in
9. 800 586 4872 Freedom From Smoking Online www ffsonline org Injectable Pharmacy Services 888 922 0007 All other pharmacy services are covered through the Louisiana Medicaid FFS program more information and the formulary can be found at www lamedicaid com Injectable questions and supplies 888 922 0007 Referral Information 888 922 0007 Referrals to Non Participating providers always require prior authorization Contact Utilization Management at 888 913 0350 to request authorization Transportation 888 913 0364 Services provided by MTM i EEE A A AAN oot Neder ane TA 866 428 7588 Services requiring prior authorization include but are not limited to the list below The most up to date and detailed listing of services that require prior authorization can be found in the Provider Center at www amerihealthcaritasla com Services Requiring Prior Authorization The following is a partial list of services requiring prior authorization review for medical necessity and or place of service Please refer to the AmeriHealth Caritas Louisiana Provider Handbook or contact Provider Services for a detailed list e In patient services Home based services e Therapy and related services e Transplants including transplant evaluations e Air Ambulance e Durable Medical Equipment e Billed charges 500 and over including prosthetics and orthotics e All DME rentals e All Enteral Nutritional Supplements and Supplies e All Diapers pu
10. 837 format e Behavioral Health diagnosis code must be billed in the primary diagnosis code position to be considered a Behavioral Health claim e All other Behavioral health Claims should be submitted to Merit Health Magellan Health For information call 800 424 4399 or TTY 800 424 4416 Chemotherapy e Services may be billed electronically via 837 Format or via paper on a CMS 1500 or UB 04 e Chemotherapy administration is covered by Louisiana Medicaid Providers are to use the appropriate chemotherapy administration procedure code in addition to the J code for the chemotherapeutic agent e Ifa significant separately identifiable Evaluation and Management service is performed the appropriate E M procedure code may also be reported Chiropractic Care e Claims for chiropractic services are billed on a CMS 1500 or via 837 format e Chiropractors are to bill for services using the appropriate CPT code for the service provided HCPCS modifier AT Acute Treatment may be appended Dental Services e Dental Services for members under 21 are handled by DHH Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 61 Provider Services 1 888 922 0007 01 2015 Appendix e Dental Services for members over 21 are limited to f
11. 9 970 970 0 970 1 970 8 970 9 Medication Error Patient death or 971 971 0 971 1 971 2 971 3 971 9 serious disability associated with a 972 972 0 972 1 972 2 972 3 972 4 972 5 medication error continued 972 6 972 7 972 8 972 9 973 973 0 973 1 973 2 973 3 973 4 973 5 973 6 973 8 973 9 974 974 0 974 1 974 2 974 3 974 4 974 5 974 6 974 7 975 975 0 975 1 975 2 975 3 975 4 975 5 975 6 975 7 975 8 976 976 0 976 1 976 2 976 3 976 4 976 5 APPENDIX 18 976 6 976 7 976 8 976 9 977 977 0 977 1 977 2 977 3 977 4 977 8 977 9 978 978 0 978 1 978 2 978 3 978 4 978 5 978 6 978 8 978 9 979 979 0 979 1 979 2 979 3 979 4 979 5 979 6 979 7 979 9 E850 0 E850 1 E850 2 E850 3 E850 4 E850 5 E850 6 E850 7 E850 8 E850 9 E851 E852 0 E852 1 E852 2 E852 3 E852 4 E852 5 E852 6 E852 8 E852 9 E853 0 E853 1 E853 2 E853 8 E853 9 E854 0 E854 1 E854 2 E854 3 E854 8 E855 0 E855 1 E855 2 E855 3 E855 4 E855 5 E855 6 E855 8 E855 9 E856 E857 E858 0 E858 1 E858 2 E858 3 E858 4 E858 5 E858 6 E858 7 E858 8 E858 9 Claim should reflect 20 Discharge Status Code if applicable
12. Categories At this time these claim records must be submitted on paper Claim records requiring supportive documentation Claim records for medical administrative or claim appeals Excluded Provider Categories Claims issued on behalf of the following providers must be submitted on paper Providers not transmitting through Emdeon or providers sending to Vendors that are not transmitting through Emdeon NCPDP Claims Pharmacy through Emdeon Common Rejections Important Requests for adjustments may be submitted electronically on paper or by telephone By Telephone Provider Claim Services 1 888 922 0007 Select the prompts for the correct Plan and then select the prompt for claim issues On Paper If you prefer to write please be sure to stamp each claim submitted corrected or resubmission and address the letter to Claims Processing Department AmeriHealth Caritas Louisiana P O 7322 London KY 40742 Administrative or medical appeals must be submitted in writing to Provider Appeals Department AmeriHealth Caritas Louisiana PO Box 7324 London KY 40742 Refer to the Provider Handbook or the Provider Center online at www amerihealthcaritasla com for complete instructions on submitting administrative or medical appeals Important Contact Emdeon Provider Support Line at 1 800 845 6592 Important Claims submitted can only be verified using the Accept and or Reject Reports Contact you
13. EPSDT ODjective Hearne Sorecnmiie oetra TEETER E 68 EPSDT Interperodie Scree A Gs E E once RA E R E A E 69 Family POMAS erie e EE e aE 70 FOHC RHAHC EPSDT Claim Filing MSU UCU ONS xc vevivectvarivevivewviwlxivireriniuloawieraaleniralcaeions 70 FQHC RHC Non EPSDT Claim Filing Instructions ceccccssececcseecceeeeeeeeeseeeeeseeeeeseeeaes 70 Home Heati e ate TAC asses dts cu cacises eucedutacuvacedeacdesetanedacndocsdaandeesdeaadaontaandeacdacodiendeandeantac ees 71 B Vig 0 0001421 O eE ETEA nee 12 B O a erenene ren VENtnnnt vant vErtunr even Crrtner Terr Cerinny rtrrtertner Terr eet err rian ae 73 NA CEA TS ae 73 Mate TITY ose ahi Sires Se eee Sire See Seca E T 73 OB Ss mates 0 0 eee erence ire eee ee nee E ee TY ee er ee eee Te 75 RUE UTS EG TT DM SE VICE a ag ag sg tes nas sya ania snc se ee 75 FRAGT ONORY SOT VIC CS ere EEE E eee ates 79 SUDETY ee E 79 Physical Occtipatiomal ang Speech TNS r apes sss oes ees oo vias So RA 79 Le a a E en en TE ee 79 Pioc tone B Uin Tng eS eae a E EET AR 80 Claim Filing Procedures for Claim Submission AmeriHealth Caritas Louisiana hereinafter referred to as the Plan or AmeriHealth Caritas Louisiana is required by state and federal regulations to capture specific data regarding services rendered to its members All billing requirements must be adhered to by the provider in order to ensure timely processing of claims When required data elements are missing or are invalid claims will
14. NM103 2010BA NM1 04 2010BA NM105 2010BA NM107 2010CA N301 N302 2010CA N401 2010CA N402 2010CA N403 2010BA N301 2010BA N302 2010BA N401 2010BA N402 2010BA N403 2330 NM103 NM104 NM105 2320 DMGO02 2320 SBR04 2000B SBR04 Required if 9 is completed Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 13 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim EDI Mapping CMS 1500 Claim EDI Mapping Field Field Description Instructions and Comments Required or Conditional Other Insured s Birth Date Sex 2000B SBRO3 2330C REFO1 Move IG 9c Employer s Name Or School Name 2330C REFO1 Move IG 2320 DMG02 Insurance Plan Name Or Program 2320 SBRO04 2000b SBR04 10a b c_ Is Patient s Condition Related To 2300 CLM11 10d Reserved For Local Use 2300 CLM11 C 11 Insured s Policy Group Or FECA 2010 REFO1 C 2010 DMG02 2010 DMG03 2310 NM103 2000B SBR05 Insured s Birth Date Sex 2010 REFO1 2010 DMG02 Employer s Name Or School Name _ 2010 DMG03 Insurance Plan Name Or Program 2310 NM103 Name Is There Another Health Benefit 2000B SBR05 Plan Patient s Or Authorized Person s 2320 0104 Signature 13 Insured s Or Authorized Person s 2320 Ol04 Not required Si
15. No Enter the number assigned by the federal government for tax reporting purposes Statement Covers Enter dates for the full ranges of Period services being invoiced MMDDYY From Through Unlabeled Not Used Leave Blank Patient Identifier Patient AmeriHealth Caritas Louisiana ID is conditional if number is different from field 60 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 20 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Patient name is required Last name first name and middle initial Enter the patient name as it appears on the AmeriHealth Caritas Louisiana ID card Use a comma or space to separate the last and first names Titles Mr Mrs etc should not be reported in this field Prefix No space should be left after the prefix of a name e g McKendrick Hyphenated names Both names should be capitalized and separated by a hyphen no space Suffix A space should separate a last name and suffix Newborns and Multiple Births If submitting a claim for a newborn that does not have a name enter Baby Girl or Baby Boy and last name Refer to page 51 for additional newborn billing information including Multiple Births The mailing address of the patient
16. Requires new W 9 Effective Date of Ownership Please mail or fax this change form and supporting documents to AmeriHealth Caritas Louisiana Provider Network Management 10000 Perkins Rowe Block G 4 Floor Fax 1 888 972 4290 or 225 300 9126 AmeriHealth Caritas Louisiana PROVIDER CLAIM DISPUTE FORM A Dispute is defined as a request from a health care provider to change a decision made by AmeriHealth Caritas Louisiana related to claim payment or denial for services already provided A provider dispute is not a pre service appeal of a denied or reduced authorization for services or an administrative complaint C First Level Dispute C Second Level Dispute Submitter Contact Information Name Last First Phone Number Provider Information Name Last First Phone Number NPI Number Tax ID LJiama participating provider C iam nota participating provider Member Information Name Last First Member Date of Birth Member ID Claim Information Claim Number Billed Amount Date s of Services To ensure timely and accurate processing of your request please complete the Payment Dispute section below by checking the applicable reason for your dispute C inaccurate payment C Denied for no primary payer EOB EOB attached C Post service authorization denial J Denied for no authorization service does not require authorization C Denied as a duplicate C Denied for no authorization auth o
17. SBRO1 7 i oe Treatment Authorization 2300 REF02 Codes Employer Name Not Mapped Diagnosis and Procedure Hard coded to 9 Not Code Qualifier ICD Version Indicator Z Required pe Prin Diag Cd and Present HI 01 the first occurring on Admission POA 2300 HI01 2 value Indicator where HI01 1 BK or BJ fp o 67 A Q Other Diagnosis Codes ee C Admitting Diagnosis Code HI 02 If CLCL_CL_SUB_TYPE M BJ qualifier If 2300 HI01 found 2300 HI01 2 Patient s Reason for Visit 2300 HIO1 PR qualifier Prospective Payment System DR qualifier information Up to PPS Code 4 digits Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 37 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping External Cause of Injury Not Mapped C C ECI Code Unlabeled Field Not Mapped 74 Principal Procedure code If 2400 SV2 segment and Date 2400 SV202 2 And if Found 2400 SV202 3 2300 HIXX 4 for each corresponding occurrence of the HI segment Principal BP qualifier other BO or BQ qualifier segment Principal BP qualifier other BO or BQ qualifier 75 Unlabeled Field Not Mapped Other Procedure Codes and_ If 2400 SV2 segment Dates 2400 SV202 2 And if Found 240
18. below Home Health Services Fee Schedule G0151 420421 SERVICES OF PTINHHSETTING 15MIN G0152 430 431 SERVICES OF OT HH SETTING 15MIN G0153 440 441 SERVICES OF SPEECH LANG HH 15MIN G0154 550 551 580 581 SERVICES OF SKILLED NURSE HH 15 MIN G0156 570 571 SERVICES OF HH AIDE EACH 15 MINS __ 89123 552 ____ NURSE CARE IN HOME RN PER HOUR 89124 582 NURSE CARE IN HOME LPN PER HOUR 92506 440 EVAL OF SPEECH LANG VOICE AUDITOR 97001 424 PHYSICAL THERAPY EVALUATION 97001 PHYSICAL THERAPY EVALUATION 97003 434 OCCUPATIONAL THERAPY EVALUATION 97003 OCCUPATIONAL THERAPY EVALUATION NOTE ALL CPT CODES AND DESCRIPTIONS ARE COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION Valid Home Health Procedure Modifiers For Nurse and Aide Services Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 71 Provider Services 1 888 922 0007 01 2015 Appendix U3 3rd third Daily Visit Immunization Single Administration e Providers must bill administration code s 90465 90467 90471 or 90473 and the specific CPT Code for the vaccine with 0 00 in the billed charges field e CPT Codes 90465 and 90467 may not be billed together on the same date of service e C
19. bill that may affect processing Please see NUCC Specifications Manual Instructions for condition codes and descriptions to complete fields 18 28 Accident State The accident state field contains the C C two digit state abbreviation where the accident occurred Required when applicable 30 Unlabeled Field Leave Blank 3la b Occurrence Codes Enter the appropriate occurrence code C C 34a b and Dates and date Required when applicable Occurrence Span A code and the related dates that C C Codes And Dates identify an event that relates to the payment of the claim Required when applicable 37a b Leave Blank 38 Responsible Party The name and address of the party C Name and Address responsible for the bill 39a b c d Value Codes and A code structure to relate amounts or Not Required 12 13 14 5 1 Not Required N N C C C values to identify data elements 41a b c d necessary to process this claim as qualified by the payer organization Value Codes and amounts If more Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 22 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping than one value code applies list in alphanumeric order Required when applicable Note I
20. blood products applicable APPENDIX 18 Patient death or serious disability 940 0 940 1 940 2 940 3 940 4 940 5 940 9 associated with a burn incurred from any 941 0 941 1 941 2 941 3 941 4 941 5 942 0 source while being cared for ina 942 1 942 2 942 3 942 4 942 5 943 0 943 1 healthcare facility 943 2 943 3 943 4 943 5 944 0 944 1 944 2 944 3 944 4 944 5 945 0 945 1 945 2 945 3 945 4 945 5 946 0 946 1 946 2 946 3 946 4 946 5 947 0 947 1 947 2 947 3 947 4 947 8 947 9 E925 0 E925 1 E925 2 F925 8 E925 9 E926 0 E926 1 E926 2 E926 3 F926 4 E926 5 E926 8 E926 9 Claim should reflect 20 Discharge Status Code if applicable Medication Error Patient death or 960 960 0 960 1 960 2 960 3 960 4 960 5 serious disability associated with a 960 6 960 7 960 8 960 9 medication error 961 961 0 961 1 961 2 961 3 961 4 961 5 961 6 961 7 961 8 961 9 962 962 0 962 1 962 2 962 3 962 4 962 5 962 6 962 7 962 8 962 9 963 963 0 963 1 963 2 963 3 963 4 963 5 963 8 963 9 964 964 0 964 1 964 2 964 3 964 4 964 5 964 6 964 7 964 8 964 9 965 965 0 965 1 965 4 965 5 965 6 965 7 965 8 965 9 966 966 0 966 1 966 2 966 3 966 4 967 967 0 967 1 967 2 967 3 967 4 967 5 967 6 967 8 967 9 968 968 0 968 1 968 2 968 3 968 4 968 5 968 6 968 7 968 9 969 969 0 969 1 969 2 969 3 969 4 969 5 969 6 969 7 969 8 969
21. chosen for you choose your Current Location from the dropdown menu at the top of the page gt Current Location BATON ROUGE CLINIC AMC THE i PART MOTHER S INFORMATION Complete all of the mother s personal information in Part I Mother s Information You are required to answer the question Upon release from the hospital will the newborn live with the mother Your answer to this question will determine the next section of the form See the two options below If you answer Yes the below section will appear Please choose the Parish of Residence from the dropdown menu and complete the Phone information if known If the Physical Address is the same as the mailing address check off the box at the bottom of this section next to Same as mailing address If the Physical Address is different than the Mailing Address complete the Physical Address section Upon release from the hospital will the newborn live with the mother Mailing Address kkk kkk ROKK AK KK Address 2 City State Zip DENHAM SPRINGS LA f0726 Parish of Residence Livingston i qm Fhone Physical Address kkk kkk kk Address 2 City State Zip FRR KK KKK LA k k same as mailing address Part II Baby s Responsible Party If you answer No the Part Il Baby s Responsible Party section will appear Fill in all categories in this section This information may consist of personal information or agency information depending on the c
22. click on the Resume Form link on the top left of the home page A list of forms that have been saved as a draft will be displayed Click Resume next to the form to open the saved form a Logout Start New Form gt Resume Form a History NOTE A Search field is available to make it easier to find saved drafts Enter your search criteria in the field provided and click the Go button Resume Form Current Location BATON ROUGE CLINIC AMC THE Resume Date Created Applicant Name Form Type Resume 04 23 2013 TPL KKK KK KKK Resume 04 23 2013 TPL Resume 04 23 2013 k k i K k K k k k TPL Resume 04 23 2013 kkkk FORK KK TPL Resume 04 23 2013 TPL Resume 04 23 2013 a TPL Resume 05 29 2013 KAKK KKKKKK TPL Resume 05 29 2013 KEK KKK KKK Newborn Request Resume 05 29 2013 J TPL Resume 05 29 2013 PEE EER TPL 10 The saved form will open prepopulated with the information previously saved Complete the required fields and click Submit A successful submission will bring you to the home page of FNS An unsuccessful submission will produce an error message detailing what required information is needed to submit the form History From the home page click the History link in the left menu Under the History section a grid view of all of the forms submitted will be displayed Paging arrows and links will appear on the bottom right hand side of the screen if more than one page of data is available From here a form can be view
23. death or serious disability associated with patient elooement disappearance for more than 4 hours e Patient suicide or attempted suicide resulting in serious disability while being cared for in a healthcare facility Care Management Events e Patient death or serious disability associated with a medication error e g error involving the wrong drug wrong dose wrong patient wrong time wrong rate wrong preparation or wrong route of administration e Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO HLA incompatible blood or blood products e Maternal death or serious disability associated with labor or delivery on a low risk pregnancy while being cared for in a healthcare facility e Patient death or serious disability associated with hypoglycemia the onset of which occurs while the patient is being cared for in a healthcare facility APPENDIX 17 Death or serious disability kernicterus associated with failure to identify and treat hyperbilirubinemia in neonates Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility excluding those the progress from Stage 2 to Stage 3 Patient death or serious disability due to spinal manipulative therapy Environmental Events Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility Any incident in which a line designated for oxygen or other gas to be deliver
24. digit qualifier followed by the other ID Enter the last name and first name of the Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information Enter the NPI number of the physician who www amerihealthcaritasla com 29 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping performed surgery Attending Physician Required when a surgical procedure code is listed Enter the AmeriHealth Caritas Louisiana issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the AmeriHealth Caritas Louisiana issued Provider ID number 78 79 Other Provider Enter the NPI of any physician other Individual Names than the attending physician who has and Identifiers responsibility for the patient s medical NPI Qualifier Oth care or treatment in the upper line er ID and their name in the lower line last name first If the other physician has ai ane A a iher another unique ID enter the attending physician appropriate descriptive two digit qualifier followed by the other ID Enter the AmeriHealth Caritas Louisiana issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the AmeriHealth Caritas Louisiana issued Provider ID number Remarks Field
25. field Additionally stamp resubmitted or corrected on the claim 7 Replacement of Prior Claim 8 Void cancel of Prior Claim En o s Prior Authorization Number Enter the prior authorization number Refer to the Provider Handbook to determine if services rendered require an authorization Date s Of Service From date MMDDYY and to date MMDDYY See page 43 for Important Note instructions for completing the shaded portion of field 24 Place Of Service Enter the CMS standard place of service code 00 for place of service is not acceptable EMG This is an emergency indicator field Enter Y for Yes or leave blank for No in the bottom unshaded area of the field Procedures Services Or Supplies Procedure codes 5 digits and modifiers Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 9 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements service Note Modifiers affecting reimbursement must be placed in the first modifier position See additional information on page 55 for EDI requirements 24E Diagnosis Pointer Diagnosis Pointer Indicate the associated diagnosis by referencing the pointers listed in field 21 1 2
26. must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 60 Provider Services 1 888 922 0007 01 2015 Appendix e AmeriHealth Caritas Louisiana covers basic behavioral health services which include but are not limited to screening prevention early intervention medication and referral services as defined the Medicaid State Plan Behavioral Health e Basic behavioral health services may further be defined as those provided in the member s PCP or medical office by the member s non specialist physician 1 e DO MD ARNP as part of routine physician evaluation and management activities e g CPT codes 99201 through 99204 and all behavioral health services provided at FQHCs RHCs e Behavioral health services performed in a FQHC RHC are reimbursed as encounters The encounter reimbursement includes all services provided to the recipient on that date of service In addition to the encounter code it is necessary to indicate the specific services provided by entering the individual procedure code description and total charges for each service provided on subsequent lines e FQHC RHC must bill HCPCS Code T1015 with detail level Behavioral Health codes e Behavioral Health services are billed on the CMS 1500 claim form or electronically in the
27. or resubmission and address the letter to Claims Processing Department AmeriHealth Caritas Louisiana P O 7322 London KY 40742 Administrative or medical appeals must be submitted in writing to Provider Appeals Department AmeriHealth Caritas Louisiana P O Box 7324 London KY 40742 Refer to the Provider Handbook or look online at the Provider Center of the AmeriHealth Caritas Louisiana website at www amerihealthcaritasla com for complete instructions on submitting appeals Important Claims originally rejected for missing or invalid data elements must be corrected and re submitted within 180calendar days from the date of service Rejected claims are not registered as received in the claim processing system Refer to the definitions of rejected and denied claims on page 1 Note AmeriHealth Caritas Louisiana EDI Payer ID 27357 273575066 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Claim Form Field Requirements HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLA COMMITTEE UCC bat i ries Peat 7 1 MEDICARE MEDD TRICARE CHAMPA GROUP iay FECA OTHER 15 MSURENS LO MUMDER For Program in hem 1 meann _ ems C ithe Dit teeter Ae rue j Jae 2 PATENTS HAME Last Alene Fimi Hamas idle Inirali a Pe a teh 4 INSUREO S HAME Last Alec Pins Hame Minde Innala kk F itn G PATENT S ADORESS Mo Sect E PATIE i TO IN
28. the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 66 Provider Services 1 888 922 0007 01 2015 Appendix 4 Laboratory tests including appropriate neonatal iron deficiency anemia urine and blood lead screening 5 Health education including anticipatory guidance NOTE All components including specimen collection must be provided on site during the same medical screening visit e Providers must bill with the V20 0 through V20 3 in the primary diagnosis position e These codes are billed hard copy on the CMS 1500 form or electronically using the 837P claim transaction The following procedure codes are used to bill for the medical screening Providers should use the TD Modifier in conjunction with the appropriate CPT code to report a screening that was performed by a registered nurse Note Providers must bill the age appropriate code in order to avoid claim denial EPSDT Vision Screening The purpose of the vision screening is to detect potentially blinding diseases and visual impairments such as congenital abnormalities and malfunctions eye diseases strabismus amblyopia refractive errors and color blindness EPSDT Subjective Vision Screening The subjective vision screening is part of the comprehensive history and physical exam or assessment component of the medical screening and must include the history of e any eye disorders of the child or his family e any systemi
29. to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 54 Provider Services 1 888 922 0007 01 2015 Invalid Electronic Claim Record Rejections Denials All claim records sent to the Plan must first pass Emdeon HIPAA edits and Plan specific edits prior to acceptance Claim records that do not pass these edits are invalid and will be rejected without being recognized as received at the Plan In these cases the claim must be corrected and re submitted within the required filing deadline of 180calendar days from the date of service Itis important that you review the Acceptance or R059 Plan Claim Status reports received from Emdeon or your EDI software vendor in order to identify and re submit these claims accurately Plan Specific Electronic Edit Requirements The Plan currently has two specific edits for professional and institutional claims sent electronically 837P 005010 X098A1 Provider ID Payer Edit states the ID must be less than 13 alphanumeric digits 8371 005010X096A1 Provider ID Payer Edit states the ID must be less than 13 alphanumeric digits Member Number must be less than 17 AN Statement date must be not be earlier than the date of Service Plan Provider ID is strongly encouraged Exclusions Certain claims are excluded from electronic billing These exclusions fall into two groups These exclusions apply to inpatient and outpatient claim types Excluded Claim
30. 0 Discharge Status Code if purposes of the American Society of applicable Anesthesiologists patient safety initiative Patient death or serious disability 999 6 999 7 999 8 E876 0 associated with a hemolytic reaction due to the administration of ABO Claim should reflect 20 Discharge Status if incompatible blood or blood products applicable Maternal death or serious disability No diagnosis code available for maternal death associated with labor or delivery on a Will be reported when claims group into Diagnostic low risk pregnancy while being cared for Related Groups DRG 370 through 375 in a healthcare facility Claim should reflect 20 Discharge Status Code if applicable Stage 3 or 4 pressure ulcers acquired 707 00 707 01 707 02 707 03 707 04 707 05 after admission to a healthcare facility 707 06 707 07 707 09 excluding those the progress from Stage 2 to Stage 3 Note that these codes do not reflect the stage of the pressure ulcer Severe Allergic Reaction 977 9 995 0 995 2 Use of Both ICD 9 and E Codes Retention of a foreign object in a patient 998 4 998 7 after surgery or other procedure E871 0 E871 1 E871 2 E871 3 E871 4 F871 5 E871 6 E871 7 E871 8 and E871 9 Patient death or serious disability 999 6 999 7 999 8 E876 0 associated with a hemolytic reaction due to the administration of ABO Claim should reflect 20 Discharge Status Code if incompatible blood or
31. 0 DTP02 RD8 first date in range Else if 2300 DTPO01 434 2300 DTPOS If 2300 DTP02 RD8 amp first date in se eas ae maaan kT 03 Compute using total of line item charges 2400 SV203 Else move zero Unlabeled Field Not hen Not required wand Payer 201 no 02 1 2010B NM103 2010BB NM102 1 2010BB NM1 04 Health Plan Identification 2330A NM109 Number o Raha Prior Payments Not Mapped a Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 34 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping 3 Est Amount Due Not Mapped 55 56 National Provider Identifier NM1 09 If 2010AA NM108 Billing Provider XX 2010AA NM109 2010AB NM108 XX 2010AB NM109 2310B NM108 XX 2310B NM109 2420A NM108 XX 2420A NM109 58 57 A B C Other Billing Provider Identifier Insured s Name NM1 03 If 2010CA 2010CA NM103 Else if 2000B SBRO02 18 2010BA NM103 NM1 04 If 2010CA 2010CA NM104 Else if 2000B SBR02 18 2010BA NM1 04 Else if 2000B SBR02 18 2010BA NM105 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or
32. 0 SV202 3 2300 HIXX 4 for each corresponding occurrence of the HI Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 38 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Attending Provider Name NM1 09 If 2310A NM101 71 and Identifiers If 2310A NM108 NPI Qualifier Other ID XX 2310A NM109 If 2310B NM101 72 Enter the NPI number of the a 0B NM108 attending physician 2310B NM109 If 2310C NM101 73 If 2310C NM108 Enter the AmeriHealth XX Caritas Louisiana issued 2310C NM109 Provider ID number REF 02 If 2310A NM101 71 If 2310A REFO1 1G 2310A REFO02 Enter the two digit qualifier ae oo i p that identifies the Other ID 310B REFO1 i 2310B REF02 number as the AmeriHealth If 2310C NM101 73 Caritas Louisiana issued If 2310C REF01 1G Provider ID number 2310C REF02 NM1 03 If 2310A NM101 71 If 2310A NM102 1 2310A NM103 If 2310B NM101 72 If 2310B NM102 1 2310B NM103 If 2310C NM101 73 If 2310C NM102 1 2310C NM103 NM1 04 If 2310A NM101 71 If 2310A NM102 1 2310A NM104 If 2310B BNM101 72 lf 2310B NM102 1 2310B NM104 If 2310C NM101 73 If 2310C NM102 1 2310C NM104 Required R fields must be completed on all claims Condit
33. 9002 ENTERAL PUMP WITH ALARM E0202 PHOTOTHERAPY BILIRUBIN LIGHT WITH TUB STOOL OR BENCH TIRE SOLID EACH OOOO o E0996 TIRE SOLID EACH E1001 WHEEL SINGLE E1009 ADD MECH LEG ELEVATION Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 64 Provider Services 1 888 922 0007 01 2015 Appendix E1590 HEMODIALYSIS MACHINE E1635 COMPACT PORTABLE TRAVEL HEMODIALYZ E1636 SORBENT CARTRIDGES PER CASE SIGNATURE 2000SEAT o E2609 SIGNATURE 2000 SEAT E2617 SIGNATURE 2000 BACK ADD JOINT UPPER EXT ORTHOSIS _ L3956 ADD JOINT UPPER EXT ORTHOSIS L3999 UNLISTED PROCEDURES FOR UPPER LIMB O L4210 REPAIR OF ORTHOTIC DEVICE REPAIR OR L5999 UNLISTED PROCEDURES FOR LOWER EXTREM Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 65 Provider Services 1 888 922 0007 01 2015 Appendix L7499 UNLISTED PROCEDURES FOR UPPER EXTREM L8004 CRANIAL CERVICAL ORTHOSIS CRANIAL CERVICAL ORTHOSIS L8499 L8604 8692 L9900 S1015 IV TUBING EXTENSION SET S8186 SWIVEL ADAPTOR V2629 PROSTHETIC EYE INTRAOC
34. 9a Street Address 9b City 9c State 9d ZIP Code 9e Country Code report if other than U S A Patient Birth Date The date of birth of the patient Right justified MMDDY YY Y Patient Sex The sex of the patient recorded at admission outpatient service or start of care Admission 12 15 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 21 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Admission Date The start date for this episode of care For inpatient services this is the date of admission Right justified Admission Hour The code referring to the hour during which the patient was admitted for inpatient or outpatient care Left Justified Admission Type A code indicating the priority of this admission visit Source of Referral A code indicating the source of the for Admission or referral for this admission or visit Visit 16 Discharge Hour Code indicating the discharge hour of the patient from inpatient care Patient Discharge A code indicating the disposition or Status discharge status of the patient at the end service for the period covered on this bill as reported in Field 6 18 28 Condition Codes A code used to identify conditions or C C events relating to the
35. Area to capture additional information necessary to adjudicate the claim 81CC a d Code Code Field To report additional codes related to Form Locator overflow or to report externally maintained codes approved by the NUBC for inclusion in the institutional data set p OQ OQ Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 30 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping EDI Mapping Table UB04 UB 04 Claim EDI Mapping Requirements Inpatient Outpatient Bill Types Bill Types 11X 12X 13X 23X Field Field Description Instructions and Comments Required or Required or Conditional Conditional Unlabeled Field 2010AA N402 o l 2010AA N403 Billing Provider Name 2010AA PER04 n Address and Telephone 2010AA PERO6 n Number 2010AA PER08 Provider Name Unlabeled Field 2010AB PER 02 _ l N3 01 Billing Provider s Designated N4 01 Pay to Name and Address N4 02 Pay to Provider Name Patient Control No CLM05 2 OR R Medical Health Record 2300 REF02 Number Medical record Fed Tax No 2010AA REF02 Ee Statement Covers Period 2400 DTPO3 From Through 2400 DTP02 RD8 move first date in ge If 2300 DTP02 RD8 n 7 of Required R fields must be comp
36. CC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 16 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim EDI Mapping Other ID Enter the Health Plan Legacy ID AmeriHealth Caritas Louisiana strongly encouraged issued Provider Identification ame Enter the G2 qualifier followed by the Strongly recommended Health Plan ID Refer to NUCC CMS 1500 claims Required when the Rendering Provider filing guidelines for the two digit is an Atypical Provider and does not qualifiers used to describe the non have an NPI number Enter the two NPI provider ID number digit qualifier identifying the non NPI number followed by the ID number Do not enter a space hyphen or other separator between the qualifier and number Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 17 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping gt amp amp amp E E E H H a E U Fae a pn Al a pT BrE BUC KURT eS Lice sr www amerihealthcaritasla com 18 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Required Fields UB 04 Claim Forms UB 04 Claim Form Field Requirements Field Field Description Instructions and C
37. Created Date Submitted Applicant Name Form Type Submitted By Status View Edit Cancel 06 17 2013 06 1 7 2013 Newborn Request Cassie Porche Submitted eR Ke a a k k View Edit Cancel 06 17 2013 06 17 2013 View Edit Cancel 06 17 2013 06 17 2013 View Edit Cancel 06 17 2013 O6 17 2013 Newborn Request Cassie Porche Submitted Newborn Request Cassie Porche Submitted Newborn Request Cassie Porche Submitted KKKKKK KKKKK KKKKKK KKKKK View Edit Cancel 06 14 2013 06 14 2013 a D cee Newborn Request Cassie Porche Submitted View Edit Cancel 06 05 2013 06 05 2013 LEER EE TPL Cassie Porche Submitted View Edit Cancel 06 05 2013 06 05 2013 eRe kkk kk TPL Cassie Porche Submitted View Edit Cancel 06 04 2013 06 04 2013 2K 2K KKK ok KK KOK Newborn Request Cassie Porche Submitted View Edit Cancel 06 04 2013 06 04 2013 TPL Cassie Porche Submitted 11 Newborn Request Eligibility Status The eligibility status of a Newborn Request submission will be faxed or emailed to the doctor and or pediatrician based on the information provided in Part IV and Pediatrician Information In addition the Status of the request can be found in Part V of the form when in viewing the form from the History window PART V To be completed by Medicaid Medicaid Representative Decision Details Child Name Child OneTwo Editing a Form In the event that an error has been made on a submitted form you can edit the form in the history Date 6271042504 782 Me
38. Health Caritas Louisiana Provider ID Required when the Rendering Provider is an Atypical Provider and does not have an NPI number Enter the two digit qualifier identifying the non NPI number followed by the ID number Do not enter a space hyphen or other separator between the qualifier and number Required Identifies the provider that is requesting to be paid for the services rendered and should always be completed Enter physical location Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 11 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements ef oe 33a NPI number Required unless Rendering Provider is an Atypical Provider and is not required to have an NPI number Other ID Enter the AmeriHealth Caritas Louisiana Provider ID strongly AmeriHealth Caritas Louisiana recommended issued Provider Identification Number Refer to NUCC CMS 1500 claims Enter the G2 qualifier followed by the filing guidelines for the two digit AmeriHealth Caritas Louisiana Provider qualifiers used to describe the non ID NPI provider ID number Required when the Rendering Provider is an Atypical Provider and does not have an NPI number Enter the two digit qualifier identifying
39. IC AUDIOLOGY TREATMENT OTHER AUDIOLOGY CARDIOLOGY GENERAL CARDIAC CATH LAB STRESS TEST OTHER CARDIOLOGY AMBULATORY SURGICAL CARE GENERAL CLINIC GENERAL OB GYN CLINIC PEDIATRIC CLINIC FAMILY PRACTICE CLINIC OTHER CLINIC AMBULANCE GENERAL MAGNETIC RESONANCE IMAGE GEN CL MAGNETIC RESONANCE IMAGE BRAIN MAGNETIC RESONANCE IMAGE SPINE MAGNETIC RESONANCE IMAGE OTHER DRUGS REQUIRING DETAILED CODING EKG ECG GENERAL CLASSIFICATION HOLTER MONITOR TELEMETRY OTHER EKG ECG EEG GENERAL CLASSIFICATION GASTRO INTEST SERV GEN CLASSIFICATIO TREATMENT RM EXTRA CORPOREAL SHOCK WAVE THERAPY HEMDIAL OUTPAT HOME GEN CLASSIFICATI HEMODIALYSIS COMPOSITE HOME SUPPLIES HEMODIALYSIS HOME EQUIPMENT HEMODIALYSIS MAINTENANCE 100 HEMODIALY SIS SUPPORT SER VICES HEMODIALYSIS OTHER OP HEMODIALYSIS PERITONEAL DIALYSIS OP HM G CLASS PERITONEAL COMPOSITE RATE HOME SUPPLIES PERITONEAL DIALYSIS HOME EQUIPMENT PERITONEAL DIALYSIS MAINTENANCE 100 PERITONEAL DIALYSIS OTHER OUTPATIENT PERITONEAL DIALYSIS CAPD HOME OP GEN CLASS Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 78 Provider Services 1 888 922 0007 01 2015 Appendix HR841 CAPD COMPOSITE OR OTHER RATE HR850 GEN CLASSIF CCP DIALYSIS OP HM HR851 CCP DIALYSIS COMPOSI
40. LOOD OTHER DERIVATIVES OTHER BLOOD BLOOD STORAGE PROCESSING G C BLOOD ADMINISTRATRION BLOOD PROCESSING STORAGE OTHER BLOOD HANDLING OTHER IMAGING SERVICES DIAGNOSTIC MAMMOGRAPHY ULTRASOUND SCREENING MAMMOGRAPHY OTHER IMAGING SERVICES RESPIRATORY SERVICES GEN CLASS INHALATION SERVICES HYPERBARIC OXYGEN THERAPY OTHER RESPIRATORY SERVICES PHYSICAL THERAPY GENERAL PHYSICAL THERAPY VISIT CHARGE PHYSICAL THERAPY HOURLY CHARGE PT EVALUTION RE EVALUATION OCCUPATIONAL THERAPY GENERAL OCCUPATIONAL THERAPY VISIT CHARGE OCCUPATIONAL THERAPY HOURLY OT EVALUATION RE EVALUATION SPEECH LANGUAGE PATHOLOGY GENERAL SPEECH LANGUAGE VISIT CHARGE SPEECH LANGUAGE HOURLY CHARGE S L EVALUATION RE EVALUATION EMERGENCY ROOM GENERAL OTHER EMERGENCY ROOM PULMONARY FUNCTION GENERAL Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com T11 Provider Services 1 888 922 0007 01 2015 HR469 HR470 HR471 HR472 HR479 HR480 HR481 HR482 HR489 HR490 HR510 HR514 HR515 HR517 HR519 HR540 HR610 HR611 HR612 HR619 HR636 HR730 HR731 HR732 HR739 HR740 HR750 HR761 HR790 HR820 HR821 HR822 HR823 HR824 HR825 HR829 HR830 HR83 1 HR832 HR833 HR834 HR839 HR840 Appendix OTHER PULMONARY AUDIOLOGY GENERAL AUDIOLGY DIAGNOST
41. Management Dialysis Durable Medical Equipment DME EPSDT Medical Screening Vision Screening Hearing Screening Interperiodic Screening Consultation FQHCRHC EPSDT Home Health Care HHC Family Planning Immunization Infusion Therapy Injectable Drugs Maternity Observation Outpatient Hospital Services Radiology Services Surgery Therapies Transplants Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 58 Provider Services 1 888 922 0007 01 2015 Appendix Ambulance Ground and Air Ambulance Services are billed on CMS 1500 or 837 Format When billing for Procedure Codes A0425 A0429 and A0433 A0434 for Ambulance Transportation services the provider must also enter a valid 2 digit modifier at the end of the associated 5 digit Procedure Code Different modifiers may be used for the same Procedure Code e Providers must bill the transport codes with the appropriate destination modifier e Mileage must also be billed with the ambulance transport code and be billed with the appropriate transport codes e Providers who submit transport codes without a destination modifier will be denied for invalid missing modifier e Providers who bill mileage alone will be denied for invalid inappropriate billing e Mi
42. NUBC Reference Manuals for additional information www amerthealthcaritasla com 35 Provider Services 1 888 922 0007 01 2015 E Insured s Unique Identifier UB 04 EDI Mapping If 2000C PAT01 0 02 If 2000C PATO1 04 17 If 2000C PAT0O1 05 13 If 2000C PATO1 07 14 If 2000C PAT0O1 09 21 If 2000C PAT0O1 10 6 If 2000C PATO1 15 07 If 2000C PATO1 17 05 If 2000C PAT0O1 19 03 If 2000C PAT0O1 20 08 If 2000C PATO1 21 09 If 2000C PATO1 22 10 If 2000C PATO1 23 16 If 2000C PATO1 24 17 If 2000C PAT0O1 29 22 If 2000C PAT01 32 33 If 2000C PAT0O1 39 11 If 2000C PAT01 40 12 If 2000C PAT01 41 15 If 2000C PAT01 43 04 If 2000C PATO1 anything Set to self child soouse or NM1 09 If ClmeSfxOpt 1 If 2010BA NM108 MI 2010BA NM1 09 Else if 2010CA NM108 MI 2010CA NM109 If ClmeSfxOpt 2 If 2010BA NM108 MI positions 1 9 of 2010BA NM1 09 Else if 2010CA NM108 MI positions 1 9 of 2010CA NM109 If 201 0CA NM108 MI positions 1 9 of 2010CA NM109 Else if 2010BA NM108 MI positions 1 9 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 36 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Insurance Group No 200 2320
43. O UG ts ce T r T tds aes a aa suet laces Ans 17 DHH Facility Notification System The Department of Health and Hospitals Facility Notification System provides an electronic means of form submission from hospitals and facilities to Medicaid Office of Aging and Adult Services OAAS Statistical Resources Inc and Office of Citizens with Developmental Disabilities OCDD The following forms are available for electronic submission using this system Newborn Request Form Form 142BH Form 148 and 148W Notification of Admission Status Change Discharge for Facility Care or Waiver Services 148 PLI requests and Demographic Change forms Obtaining Access to the System To access the Facility Notification System type the following URL into your internet browser https bhsfweb dhh louisiana gov DHH148 DHH Provider Facilities Statewide Management Organization SMO and Support Coordination Agencies can request access to the system by clicking the link Register for Account in the left menu Each user will be required to sign a confidentiality agreement when requesting a user id The original signed copies must be mailed to the address on the form Each user within the facility must complete their own access form and provide a separate email address User names and passwords are not to be shared Login Process To log into the system enter your assigned username and password The password will appear as a series of hidden characters to prevent unautho
44. Onset of Current Symptoms or Illness 484 Last Menstrual Period LMP Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information pd www amerihealthcaritasla com 6 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Use the LMP for pregnancy Example 14 DATE OF CURRENT ILLNESS INJURY or PREGNANCY LMP 130 2005 ava i431 Other Date MMDDYY or MMDDYYYY C Enter applicable 3 digit qualifier between the left hand set of vertical dotted lines Qualifiers include 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X Ray 471 Prescription 090 Report Start Assumed Care Date 091 Report End Relinquished Care Date 444 First Visit or Consultation Dates Patient Unable To Work In Current Occupation Name Of Referring Physician Or Required if a provider other than the Other Source member s primary care physician rendered invoiced services Enter applicable 2 digit qualifier to left of vertical dotted line If multiple providers are involved enter one provider using the following priority order l Referring Provider 2 Ordering Provider a Supervising Provider Qualifiers include
45. PT Codes 90471 and 90473 may not be billed together on the same date of service Multiple Administrations e Providers must bill administration code s 90466 90468 90472 and 90474 with the appropriate number of units for the additional vaccines The specific CPT code for the vaccine must be billed with 0 00 in the billed charges field The number of vaccines billed must equal the number of units indicated for the administration code e Use CPT Codes 90466 and or 90468 with 90465 OR 90467 to report more than one vaccine administered Do NOT use CPT Codes 90466 and or 90468 with 90471 or 90473 e Use CPT Codes 90472 and or 90474 with 90471 OR 90473 to report more than one vaccine administered Do NOT use CPT Codes 90472 and or 90474 with 90465 or 90467 Billing For a Single Administration e Providers should bill the appropriate CPT immunization administration code s 90465 90467 90471 or 90473 Immunization administration first injection first administration one vaccine when administering one immunization The next line on the claim form must contain the specific CPT code for the vaccine with 0 00 in the billed charges field e Do not report CPT Codes 90465 and 90467 on the same date of service e Do not report CPT Codes 90471 and 90473 on the same date of service Billing for Multiple Administrations e When administering more than one immunization providers should bill as described above for a single administration The app
46. RMANENT AND NOT REVERSIBLE HAVE DECIDED THAT DO NOT WANT TO BECOME PREGNANT BEAR CHILDREN OR FATHER CHILDREN was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a Child in the future have rejected these alternatives and chosen to be sterilized understand that will be sterilized by an operation known as a The discomforts risks Specify Type of Operation and benefits associated with the operation have been explained to me All my questions have been answered to my satisfaction understand that the operation will not be done until at least thirty days after sign this form understand that can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs am at least 21 years of age and was born on Date l hereby consent of my own free will to be sterilized by Doctor or Clinic by a method called My Specify Type of Operation consent expires 180 days from the date of my signature below also consent to the release of this form and other medical records about the operation to Representatives of the Department of Health and Human Services or Employees of programs or projects funded by the Department but only for determining if Federal laws were observed have received a copy of this form S
47. Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 7 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Other ID Number Of Referring Physician AmeriHealth Caritas Louisiana Provider ID National Provider Identifier NPI enter the referring provider s NPI Hospitalization Dates Related To Current Services Additional Claim Information Designated by NUCC Reserved for Louisiana Medicaid Provider ID Outside Lab Optional Diagnosis Or Nature Of Illness Or Injury Relate To 24E DN Referring Provider DK Ordering Provider DQ Supervising Provider li NAME Ce DN Jane A Smith MD HEFERRING PROVIDER OR OTHER SOUFLE Enter the AmeriHealth Caritas Louisiana provider number for the referring physician The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a If the Other ID number is the AmeriHealth Caritas Louisiana ID number enter G2 If the Other ID number is another unique identifier refer to the NUCC guidelines for the appropriate qualifier Required if 17 1s completed Enter the NPI number of the referring provider ordering provider or other source Required if 17 is completed
48. Required when place of service is in patient MMDDYY indicate from and to date Enter the applicable ICD indicator to identify which version of ICD codes is being reported 9 ICD 9 CM 0 ICD 10 CM Enter the indicator between the vertical dotted lines in the upper right hand portion of the field Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 8 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Enter the codes to identify the patient s diagnosis and or condition List no more than 12 ICD diagnosis codes Relate lines A L to the lines of service in 24E by the letter of the line Use the highest level of specificity Do not provide narrative description in this field Note Claims with invalid diagnosis codes will be denied for payment Diagnosis codes must be valid ICD 9 codes for the date of service E codes are not acceptable as a primary diagnosis 22 Resubmission Code and or Original For resubmissions or adjustments enter C the appropriate bill frequency code 7 or 8 see below left justified in the Submission Code section and the Claim ID of the original claim in the Original Ref No section that appears on the remittance advice in this
49. S 5917 JONES CREEK RD STE 200A BATON ROUGE BATON ROUGE LA70817 3065 Phone 225 751 2409 Fax N A Email AGAPE PERSONAL CARE SERVICES 5917 JONES CREEK RD STE 200A BATON ROUGE BATON ROUGE LA70817 3065 Phone 225 751 2409 Fax N A Email N A N A N A N A If needed use the arrow icon s at the bottom of the screen to move to the next page The provider information you selected in the Find A Doctor window will prepopulate in the fields provided in Part IV An Email or Fax is required so Medicaid can provide the child s Medicaid number PART IV Only enter information for providers that are able to bill Medicaid for the newborn Name First MI Last Sufi a A Address 2 BATON ROUGE An Email or City State Zip BATON ROUGE BATONROUGE eee ROUGE z LA 70817 0000 Fax is required 905 761777 in Part IV Phone Pediatrician Information Complete the Pediatrician Information section in the same manner as you completed Part IV Additional Providers If additional providers are needed check the box next to Include Additional Providers in the section heading Complete this section in the same manner you completed Part IV and Pediatrician ADDITIONAL PROVIDERS Include Additional Providers Facility Representative Information The Facility Representative Information section will be prepopulated based on the information Medicaid has on file FACILITY REPRESEN
50. SDT services may be submitted electronically or on paper Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 46 Provider Services 1 888 922 0007 01 2015 Common Causes of Claim Processing Delays Rejections or Denials Future Claim Dates Claims submitted for Medical Supplies or Services with future claim dates will be denied for example a claim submitted on October 1 for bandages that are delivered for October 1 through October 31 will deny for all days except October 1 Handwritten Claims Completely handwritten claims will be rejected Legible handwritten claims are acceptable on resubmitted claims See Illegible Claim Information Highlighted Claim Fields See Illegible Claim Information Illegible Claim Information Information on the claim form must be legible in order to avoid delays or inaccuracies in processing Review billing processes to ensure that forms are typed or printed in black ink that no fields are highlighted this causes information to darken when scanned or filmed and that spacing and alignment are appropriate Handwritten information often causes delays or inaccuracies due to reduced clarity Incomplete Forms All required information must be included on the claim forms in orde
51. SURED TF INSURED S ADGRESS Ho Strom CIT STATE AATION CARRIER FF Cone TELEPHONE leche Area Codoj _ amp OTHER MESEC S MAME Last Mame First Meme Middle nnal ic 1S PATIENT S CONDITION ABLATED To a OTHER IRSURED S POLICY DA GAGE NUMBER a EMPLOYMENT Curren or Previous q _ YES me b RESERVED FOR MUCC LSE b AUTO ACCICEHNT _ ves a 2 RESERVED FOR AUC USE Gc OTHER AC CHHMT d INSUAARESE PLAN MARME OF PAGS RAM MAME lt P E COMP SIGMAG THES EEE D5 OR AUTHORIZED PERSONS SIGNATURE laahonz 12 PATIENTS OA AUTHORIZED PERSONS SIANATURE Ge i Bt x any wW EM ation AHSS b per H metha benli 1 Fe undereye pine Gr surge k te piten Pis damm sho russi payment of giair ie o g N t ek See See ors Si yar ey aa dietniteed bajir bole SIGNED aii E DATE SGNED Do MM a 16 DATES hal TIENT pee wy DRE IA CURRENT eee oi E FE HOSPITALIZATION GATES RELA TED T CURAENT SERVICES haba co i TY MM DD YE PAGT i T i CHARGES D PARSEDURPES SERVICES OR SUPPLIES Eda Weis Citebase GPT HEPES RAD IF ICA Aii nes i 20 AMOUNT PAID 30 Awd tor NUCE Loe I a1 S004 TURE OF PHS SEAR OR SUP LEM INCLUDING DEGREES OF CREDEHMTIALS il peii hal thet sisemanis or iho nA apy bo bhis Hf and are manio n part ihanaol j 4 PHYSICIAN OR SUPPLIER INFORMATION PATIENT AND INSURED INFO APPROVED OMD 0938 1197 FORM 1500 a2 12 The follow
52. TATIVE INFORMATION Name gie O umm o aii A Eee Say Suzie O O summer S Phone 225 555 7891 Additional Information You can provide additional information or clarification if needed in the text box provided ADDITIONAL INFO Make comments provide additional information or clarification here Submitting a Newborn Request Click the Submit button at the bottom of the form to send the form to DHH Click the Save Draft button to save the information entered and return later for completion Click Cancel to end and close the form you are completing Cancelling the form will not save any of the information entered Caneel gt When you click Submit one of two things will occur You will either receive a Please correct the following items error message or your request will be sent without an error and you ll be returned to the main screen of the Facility Notification System or the TPL page if a TPL is required An error message similar to the one shown below may appear when submitting a Newborn Request This message occurs when required fields are missing information Review the bulleted items in the error message and correct the required fields and click Submit Please correct the following items Facility Representative First Name is required Facility Representative Last Name is required Facility Representative Phone is required Resuming a Newborn Request To resume a form saved as a draft
53. TE RATE HR855 SUPPORT SERVICES CCP DIALYSIS HR880 MISC DIALYSIS GEN CLASS HR881 MISC DIALYSIS ULTRAFILTRATION HR920 OTHER DIAG SERV GEN CLASSIFICATION HR921 PERIPHERAL VASCULAR LAB HR922 ELECTROMYELGRAM HR923 PAP SMEAR HR924 ALLERGY TEST HR925 PREGNANCY TEST HR929 OTHER DIAGNOSTIC SERVICE Radiology Services Free Standing radiology centers should bill on CMS 1500 Outpatient hospitals should bill on UB 04 837 electronic format is also acceptable Hospitals must bill the appropriate revenue code from the Louisiana Medicaid Outpatient hospital fee schedule Surgery Bill on UB 04 or via 837 electronic format Surgery services should be billed with Revenue Code 490 only Multiple modifiers Bilateral secondary procedures should be billed with modifiers 50 51 Physical Occupational and Speech Therapies Therapy services may be billed on a UB 04 or CMS 1500 claim form or via 837 electronic format Transplants Transplants should be billed on an UB 04 for facility services and CMS 1500 for professional services or via appropriate 837 electronic format Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information Provider Services 1 888 922 0007 01 2015 www amerthealthcaritasla com 79 Electronic Billing Inquiries Electronic Billing Inquiries Please d
54. TIENT HOME LAB NON ROUTINE DIALYSIS LAB HEMATOLOGY LAB BACTERIOLOGY AND MICROBIOLOGY LABORATORY UROLOGY LABORTORY OTHER LABORATORY LAB PATHOLOGY GENERAL CLASS LAB PATHOLOGY CYTOLOGY LAB PATHOLOGY HISTOLOGY LAB PATHOLOGY BIOPSY LAB PATHOLOGY OTHER RADIOLOGY DIAGNOSTIC GEN CLASS ANGIOCARDIOLOGY CHEST X RAY RADIOLOGY DIAGNOSTIC OTHER RADIOLOGY THERAPEUTIC GEN CLASS CHEMOTHERAPY INJECTED CHEMOTHERAPY ORAL RADIATION THERAPY CHEMOTHERAPY IV RADIOLOGY THERAPEUTIC OTHER NUCLEAR MEDICINE GENERAL NUCLEAR MEDICINE DIAGNOSTIC NUCLEAR MEDICINE THERAPEUTIC NUCLEAR MEDICINE OTHER Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 76 Provider Services 1 888 922 0007 01 2015 HR350 HR351 HR352 HR359 HR370 HR379 HR380 HR381 HR382 HR383 HR384 HR385 HR386 HR387 HR389 HR390 HR391 HR392 HR399 HR400 HR401 HR402 HR403 HR409 HR410 HR412 HR413 HR419 HR420 HR421 HR422 HR424 HR430 HR431 HR432 HR434 HR440 HR441 HR442 HR444 HR450 HR459 HR460 Appendix CT SCAN GENERAL CLASSIFICATION CT SCAN HEAD CT SCAN BODY OTHER CT SCANS ANESTHESIA GENERAL OTHER ANESTHESIA BLOOD GENERAL CLASSIFICATION PACKED RED CELLS WHOLE BLOOD PLASMA PLATELETS BLOOD LEUKOCYTES BLOOD OTHER COMPONENTS B
55. U S Department of Health amp Human Services OS OCIO PRA 200 Independence Ave S W Suite 537 H Washington D C 20201 Attention PRA Reports Clearance Officer HHS 687 03 10 WD DEPARTMENT OF g HEALTH AND HOSPITALS Medicaid Newborn Request Form Facility Notification System User Guide 7 1 2013 Table of Contents DHH Facility Notification System cccccccssseccccseccccescceceesecccceneceeseuseceseueceseueeceeseeecessunecetseneceesenecessenesss 3 OD Pal ACCESS FO ES Gy SFO Mil ee scones deaenantcesaebueesdacinaaauanpnedsatunpadaeiatosdueussaamaneoeadecesenasortees 3 LORI PO CSS S sa issn e vcs ecg cea mene ten oes sae ae len asa he eaceatea cdo anos E E 3 R setorChange reich 6 60 enn ene eae ner ne ee a ee oe eee ee 4 Completing a Newborn ReEquest N WDOMN cccccsssccccessecccceneccccesececeusececeenecceteuseceseuaecesseneceesenaeeessuaeceseenes 4 Pare k Mother SINTOMMAUION ac1u cscnctenenadsnnncncncentenanwentoonadunsuicounnncaeainarcoustonnsiuniuatiounsunseWaienieuniamaluetoves 5 PUI Bay RESPO IDE a y ee cnn ene ne ee ee ee ne ee eee 6 Part NCO 7 Brih Mormota EE E 7 Part IV Provider Information essssssseeensssssssserrrsssssssrerresssssssrrresssssrereresssssseerrreessssstrreeesssssteereesssseeerreee 8 Padatan Oa O ea A EA E E TA E EA A 9 Additonal PPOvVid ETS eee ee EE EE ENS 9 Facility Representative Information ccecccccsssecccceseccccesececauseccceuecceeeusccessuececsunecesseueeesee
56. ULAR LENES NOC V5269 ALERTING DEVICE ANY TYPE V5272 ASSISTIVE LISTENING DEVICE TDD e The following list of B HCPCS codes for enterals will require the submission of an NDC number and NDC units B9998 NOC FOR ENTERNAL SUPPLIES B4149 EF BLENDERIZED FOODS B4149 EF BLENDERIZED FOODS e Submits bills based on a 30 day monthly cycle e Date span should be billed as a full month example 01 25 02 25 e Bill appropriate units 1 can is equal to a quantity of 1 e Do not bill in cases must bill in units only EPSDT Supplemental Billing Information EPSDT Medical Screening Billing for these screenings should be completed on the CMS 1500 Claim Form or electronically with the 837P claim transaction Providers must use the age appropriate code in order to avoid claim denial Billing may not be submitted for a medical screening unless all of the following components are administered COMPONENTS OF THE MEDICAL SCREENING 1 Comprehensive health and developmental history including assessment of both physical and mental health and development 2 Comprehensive unclothed physical exam or assessment 3 Appropriate immunizations according to age and health history unless medically contraindicated or parents or guardians refuse at the time Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to
57. aecessuaecetsenes 9 Addiuonaliniormatioesseeeree E E 9 Submitting a Newborn RS acetate este tea a cece EAA EE 10 Resuming a Newborn RegUES U ecsiseeeisiicien i E 10 FNS E T AE E A E A E E A E E A E E E E E A T 11 NS NU F ON e E E E E 11 Newborn Request Eligibility Status seseessenseseenesrresssrrressrerssrrresrrrresrrrsssreroserressrereserressreresereesseeee 12 POE FO e E E T E 12 Third Party Liability Form TPL e E sa cavemateosnare 12 FHS Oe I LOM Cl Oh e E E E ec setnssue rate tgs ease saeenecovnnares eee 13 Mother s MALO GIN EON eera n A E readin urea 14 MOE r EEMO a E A ene ee ore 14 FAC PIG ESTARI 1S PE E E A E E A N A EA E E E E A 14 Father SE IOV WMS sesasine EE A EEEE 14 Other Contact Land H2 wrecares cys sgus cocsemsarsassmsececun ss raasanserencon se aaineancec enous ian sssnerenonnisanenosmucaamapsreasaucesuies 15 NEWDONT S OC UO Nesp cxiecc on E E AE E E A EE A E E E EE 15 Health Insurance Primary Plan and Secondary Plan eseesssssssessseesssrerssrrerssrrrssrreresrrrsssreresrrresrreresreresene 15 D OCENO IO ree E E E E E A A E E 15 AOCIMOMal INTOP MA OMS cnsereaivaecrccaiurstetsenectennedtnlencuuteiansideutebanwictencsdtutaavudcnersiltetarduenchonaedatunseutonentidtavenss 15 Submitting a Third Party Liability RPE errusiera A 15 FRE SCN a TPD a ecectesenpt a a E 16 RESOUFCE Shaca a a a e a E E a E EA 16 CONTICE US esnean en E EE E E N E E a 16 GSRN AN ire E E econ ies 16 Tranne VIJE O Se a E E E E EA EA 17 BO
58. anges to CPT codes diagnosis codes or billed amounts It is not a request to review the processing of a claim Your EDI clearinghouse or vendor needs to v Use frequency code 6 for replacement of a prior claim or frequency code 7 for adjustment of prior claims utilizing bill type in loop 2300 CLM05 03 837P v Include the original claim number in segment REFO1 F8 and REFO2 the original claim number no dashes or spaces v Do include the plan s claim number in order to submit your claim with the 6 or 7 Y Do use this indicator for claims that were previously processed approved or denied Y Do not use this indicator for claims that contained errors and were not processed rejected upfront v Do not submit corrected claims electronically and via paper at the same time o For more information please contact the AmeriHealth Caritas Louisiana EDI Hotline at l 566 428 7419 or edi AmeriHealth Caritas Louisiana amerthealthcaritas com o Providers using our NaviNet portal www navinet net can view their corrected claims faster than available with paper submission processing Common Rejections Important Claims originally rejected for missing or invalid data elements must be corrected and re submitted within 180 calendar days from the date of service Rejected claims are not registered as received in the claim processing system Refer to the definitions of rejected and denied claims on page 1 Important Be
59. apable of bearing children Signature of Recipient Date Signature of Representative if any Date AmeriHealth Caritas en Appendix 19 Project Submission Form Louisiana Provider Name Contact Persons Provider Tax ID Telephone Number Provider Number E Mail Address For AmeriHealth Caritas Louisiana only Project Submission Form appendix 19 12 31 14 APPENDIX 17 ATTACHMENT A NATIONAL QUALITY FORUM SERIOUS REPORTABLE EVENTS IN HEALTH CARE Surgical Events e Surgery performed on the wrong body part e Surgery performed on the wrong patient e Wrong surgical procedure on a patient e Unintended retention of a foreign object in a patient after surgery or other procedure e Intraoperative or immediately post operative death in a normal health patient defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative Product or Device Events e Patient death or serious disability associated with the use of contaminated drugs devices or biologics provided by the healthcare facility e Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended e Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility Patient Protection Events e Infant discharged to the wrong person e Patient
60. at 1 800 845 6592 If you need assistance in resolving submission issues identified on the R059 Plan Claim Status report contact the AmeriHealth Caritas Louisiana EDI Technical Support Hotline at 1 866 428 7419 or by e mail at edi amerihealthcaritasla com Important Rejected electronic claims may be resubmitted electronically once the error has been corrected Common Rejections Important Emdeon will produce an Acceptance report and a RO59 Plan Claim Status Report for its trading partner whether that is the EDI vendor or provider Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have these reports forwarded to the appropriate billing or open receivable departments An Acceptance report verifies acceptance of each claim at Emdeon A R059 Plan Claim Status Report is a list of claims that passed Emdeon s validation edits However when the claims were submitted to the Plan they encountered provider or member eligibility edits Important Claims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data Timely filing Note Your claims must be received by the EDI vendor by 9 00 p m in order to be transmitted to the Plan the next business day Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer
61. ata elements on the claim form By the time a claim is successfully received electronically information needed for processing is present This reduces the chance of data entry errors that occur when completing paper claim forms e Quicker claim completion Claims that do not need additional investigation are generally processed quicker Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt All the same requirements for paper claim filing apply to electronic claim filing Important Please allow for normal processing time before resubmitting the claim either through EDI or paper claim This will reduce the possibility of your claim being rejected as a duplicate claim Important In order to verify satisfactory receipt and acceptance of submitted records please review both the Emdeon Acceptance report and the R059 Plan Claim Status Report Refer to the Claim Filing section for general claim submission guidelines Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 49 Provider Services 1 888 922 0007 01 2015 Electronic Data Interchange EDI Quick Tips Required R fields must be completed on all claims Conditional C fields must be completed if the information applie
62. ate medical attention to result in a placing the health of the individual or with respect to a pregnant woman the health of the woman or her unborn child in serious jeopardy b serious impairment to bodily functions or c serious dysfunction of any bodily organ or part Payment Emergency room services will be reimbursed using the Louisiana Medicaid Rates No prior authorization or notification is required for non participating providers or hospitals AmeriHealth Caritas Louisiana does reserve the right to request the emergency room medical records to audit the encounter if necessary Filing Your Claim Submit claims to AmeriHealth Caritas Louisiana at the following address AmeriHealth Caritas Louisiana Claims Processing Department P O Box 7322 London KY 40742 ACLA encourages all providers to submit claims electronically For those interested in electronic claim filing contact your EDI software vendor or Emdeon s Provider Support Line at 877 363 3666 to arrange transmission You can also obtain additional claims information by visiting our website at www amerihealthcaritasla com Providers Important Information Claims and Billing Billing Manual Disputes ACLA encourages providers to try to resolve their concerns by calling the AmeriHealth Caritas Louisiana Provider Services Line at 1 888 922 0007 If the provider continues to be dissatisfied after attempts to resolve a complaint or dispute please review the dispute pro
63. be rejected by AmeriHealth Caritas Louisiana for correction and re submission Claims for billable services provided to AmeriHealth Caritas Louisiana members must be submitted by the provider who performed the services Claims filed with AmeriHealth Caritas Louisiana are subject to the following procedures e Verification that all required fields are completed on the CMS 1500 or UB 04 forms e Verification that all Diagnosis and Procedure Codes are valid for the date of service e Verification of member eligibility for services under AmeriHealth Caritas Louisiana during the time period in which services were provided e Verification that the services were provided by a participating provider or that the out of plan provider has received authorization to provide services to the eligible member e Verification that the provider is eligible to participate with the Medicaid Program at the time of service e Verification that an authorization has been given for services that require prior authorization by the Plan e Verification of whether there is Medicare coverage or any other third party resources and if so verification that the Plan is the payer of last resort on all claims submitted to the Plan www amerthealthcaritasla com 1 Claims Filing Procedure IMPORTANT Rejected claims are defined as claims with invalid or required missing data elements such as the provider tax identification number or member ID numbe
64. bill the remaining immunizations as described above for billing multiple administrations Infusion Therapy e Drugs administered by physician or outpatient hospital on the Louisiana Medical Assistance Fee Schedule will be reimbursed but are subjected to Prior Authorization if billed charge is 250 or greater e Drugs require the provider to also bill the NDC and related NDC information e Failure to bill the NDC required information will result in denial e Infusion supplies can be provided by DME provider or home care providers nursing services are provided by home care agency e Infusions drugs provided in the home are not billed by the home care or DME provider and are not covered by the CCN e Drugs would need to be obtained through the pharmacy benefit for any home infusion e Nursing and supplies would be covered by the CCN Injectable Drugs All drugs billed are required to be submitted with NDC information and may be submitted via CMS 1500 or 837 electronic format Refer to NDC instructions in Supplemental Information section on page 47 The NDC number and the HCPCS code for drug products are required on both the 837 format and the CMS 1500 for reimbursable medications Claims submitted without NDC information and a valid HCPCS code will be denied Maternity Visits Pregnancy diagnosis code must be billed in primary or secondary DX code position Required R fields must be completed on all claims Conditional C fields m
65. c diseases of the child or his family which involve the eyes or affect vision e behavior on the part of the child that may indicate the presence or risk of eye problems e medical treatment for any eye condition Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 67 Provider Services 1 888 922 0007 01 2015 Appendix EPSDT objective vision screenings 99173 EP may be performed by trained office staff under the supervision of a LICENSED Medicaid physician physician assistant registered nurse or optometrist EPSDT Objective Vision Screening Objective vision screenings begin at age 4 The objective vision screening must include tests of e visual acuity Snellen Test or Allen Cards for preschoolers and equivalent tests such as Titmus HOTV or Good Light or Keystone Telebinocular for older children e color perception must be performed at least once after the child reaches the age of 6 using polychromatic plates by Ishihara Stilling or Hardy Rand Ritter and e muscle balance including convergence eye alignment tracking and a cover uncover test The following procedure code is used to bill for vision screening 99173 with EP modifier EPSDT Hearing Screening The purpose of the hearing screening is to detect central au
66. cess outlined on the website and submit your information in writing to Attn Provider Complaints AmeriHealth Caritas Louisiana P O Box 7323 London KY 40742 Please remember that you are not permitted to balance bill a member for services provided in the emergency room for any additional payment AmeriHealth Caritas Louisiana AmeriHealth Caritas Louisiana Health Plan Observation Billing Guidelines This is to clarify AmeriHealth Caritas Louisiana s billing policies with respect to observation stays AmeriHealth Caritas Louisiana considers observation to be an outpatient service When a hospital requests and receives authorization for an observation stay and bills for observation as an outpatient service claims will be paid without delay When a hospital requests authorization for an inpatient stay but the plan authorizes outpatient observation such medical necessity determinations may be disputed using standard dispute process If the plan has authorized outpatient observation and the hospital submits a claim for the service as an inpatient service the claim will be denied This claim denial may also be disputed using standard dispute process However if a hospital decides on further consideration that the request should be changed from inpatient to outpatient observation the hospital may resubmit the claim as outpatient observation and the claim will be processed using standard claims payment procedures Please note that the Ce
67. cide or attempted suicide E950 0 E950 1 E950 2 E950 3 E950 4 resulting in serious disability while being E950 5 E950 6 E950 7 E950 8 E950 9 cared for in a healthcare facility E951 0 E951 1 E951 8 E952 0 E952 1 E952 8 E952 9 E953 0 E953 1 E953 8 E953 9 E954 E955 0 E955 1 E955 2 E955 3 E955 4 E955 5 E955 6 E955 7 E955 9 E956 E957 0 E957 1 E957 2 E957 9 E958 0 E958 1 E958 2 E958 3 E958 4 E958 5 E958 6 E958 7 E958 8 E958 9 E959 Claim should reflect 20 Discharge Status Code if applicable Patient death or serious disability E873 0 E873 1 E873 2 E873 3 E873 4 E873 5 associated with a medication error e g E873 6 E873 8 E873 9 error involving the wrong drug wrong dose wrong patient wrong time wrong Claim should reflect 20 Discharge Status Code if rate wrong preparation or wrong route applicable of administration Patient death associated with a fall while E884 2 E884 3 E884 4 E884 5 E884 6 being cared for in a healthcare facility E885 9 E888 0 E888 1 E888 8 E888 9 Claim should reflect 20 Discharge Status Code if applicable APPENDIX 18 Unexpected Removal of Organ E878 6 Unexpected Amputation of Limb E878 5 Events Potentially Identifiable through ICD 9 Codes Only Intraoperative or immediately post 798 0 798 1 798 2 798 9 operative death in a normal healthy patient defined as a Class 1 patient for Claim should reflect 2
68. ctions within this booklet carefully with special attention to the information on exclusions limitations and especially the rejection notification reports e Contact your EDI software vendor and or Emdeon to inform them you wish to initiate electronic submissions to the Plan e Be prepared to inform the vendor of the Plan s electronic payer identification number Important Emdeon is the largest clearinghouse for EDI Healthcare transactions in the world It has the capability to accept electronic data from numerous providers in several standardized EDI formats and then forwards accepted information to carriers in an agreed upon format Important Contact AmeriHealth Caritas Louisiana s EDI Technical Support at 1 866 428 7419 Or by e mail at Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 51 Provider Services 1 888 922 0007 01 2015 Electronic Data Interchange EDI Quick Tips edi amerihealthcaritasla com Important Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have rejection reports forwarded to the appropriate billing or open receivable departments Important The Payer ID for AmeriHealth Caritas Louisiana is 27357 NOTE Plan payer specific edits are described i
69. der ID is sent using the G2 qualifier it is used as provider on the claim If you have submitted a claim and you have not received a rejection report but are unable to locate your claim via NaviNet it is possible that your claim is in review by AmeriHealth Caritas Louisiana Please check with provider services and update you NPI data as needed It is essential that the service location of the claim match the NPI information sent on the claim in order to have your claim processed effectively Common Rejections Contact the Emdeon Provider Support Line at 1 800 845 6592 Contact AmeriHealth Caritas Louisiana EDI Technical Support at 1 866 428 7419 Important Provider NPI number validation is not performed at Emdeon Emdeon will reject claims for provider NPI only if the provider number fields are empty Important The Plan s Provider ID is recommended as follows 837P Loop 2310B REF G2 PIN 8371 Loop 2310A REF G2 PIN Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 57 Provider Services 1 888 922 0007 01 2015 Appendix Supplemental Information Ambulance Ambulatory Surgical Centers Anesthesia Audiology Behavioral Health Chemotherapy Chiropractic Care Dental Services Diabetic Self
70. dicaid Moa Phone Eligible Yes 04 01 2013 window Find the form that need editing and click Edit to the left of the item Current Location Search BATON ROUGE CLINIC AMC THE View Edit Cancel Date Created Date Submitted Applicant Name Form Type Submitted By Status View Edit Cancel 06 17 2013 06 17 2013 kkkkkk kkkk Newborn Request Cassie Porche Submitted View Edit Cancel 06 17 2013 06 17 2013 re mi pean Newborn Request Cassie Porche Submitted Edit Cancel 06 17 2013 06 17 2013 aaa rs ee Newborn Request Cassie Porche Submitted 4 i ner i E gt cee anne eee A View Edit Cancel 06 05 2013 06 05 2013 TPL Cassie Porche Submitted View Edit Cancel 06 05 2013 06 05 2013 See eee TPL Cassie Porche Submitted View Edit Cancel 06 04 2013 06 04 2013 Sate ee ne eee Newborn Request Cassie Porche Submitted View Edit Cancel 06 04 7013 06 04 2013 TPL Cassie Porche Submitted The form will open with a red heading titled Corrected Copy Make the necessary edits and click Submit at the bottom of the screen A successful submission will return you to the home page of FNS Third Party Liability Form TPL If a parent has private insurance a Third Party Liability TPL form is required You ll be directed to the page below To print or view a copy of the TPL click the hyperlink labeled Click here to view or print the completed form When ready to proceed click the Continue button To resume the TPL form later click
71. ditory problems sensorineural hearing loss conductive hearing impairments congenital abnormalities or a history of conditions which may increase the risk of potential hearing loss EPSDT Subjective Hearing Screening The subjective hearing screening is part of the comprehensive history and physical exam or assessment component of the medical screening and must include the history of e the child s response to voices and other auditory stimuli e delayed speech development e chronic or current otitis media e other health problems that place the child at risk for hearing loss or impairment EPSDT Objective Hearing Screening EPSDT objective hearing screenings may be performed by trained office staff under the supervision of a licensed Medicaid audiologist or speech pathologist physician physician assistant or registered nurse Objective hearing screenings begin at age 4 The objective hearing screening must test at 1000 2000 and 4000 Hz at 20 decibels for each ear using the puretone audiometer Welsh Allyn audioscope or other approved instrument The following procedure code is used to bill for hearing screening 92551 with EP Modifier Hearing Screening Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 68 Provider S
72. dual s illness SI GNATURES Physicians must date at time of signature Signature of Hospice Medical Director or Physician Member of I nterdisciplinary Group IDG Date Signed MM DD YYYY Printed Name of Above Hospice Medical Director or Physician Member of IDG REFFERI NG PHYSICIAN NARRATIVE STATEMENT Review of the individual s clinical circumstances and medical information to provide clinical justification for admission to hospice services Narrative must be written legible by the physician SI GNATURES Physicians must date at time of signature Signature Referring Physician Date Signed MM DD YYYY Printed Name of Above Physician NOTE If additional periods are to be certified use an additional form VERBAL VERI FI CATI ON within two days of election date certify that on the date signed below a verbal verification was obtained from the physician named below confirming that the recipient s prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course SI GNATURES Physician s Name printed Signature of IDG Member Taking Referral Printed Name of IDG Member Taking Referral Date Signed MM DD YYYY THI S FORM CANNOT BE ALTERED Please return to ACLA lization Management department via fax to 1 866 397 4522 www amerihealthcaritasla com AmeriHealth Caritas Louisiana PART TO BE COMPLETED BY PATIENT OR LEGAL REPRESENTATIVE ONLY Hospice is a program that gives h
73. e T1015 will be denied if detail procedure code lines are not billed with procedure code T1015 or any of the detail procedure codes billed is not present on the Louisiana Medicaid Fee for Service Fee Schedule e Procedure code T1015 cannot be billed as a single line claim EPSDT service will deny for payment if billed as a single line item The entire claim will deny if the provider bills procedure code T1015 with a valid detail procedure code and an invalid detail procedure code or a procedure code that is not on the Louisiana Medicaid Fee for Service Fee schedule e All claim line items must be billed with an valid detail procedure code that is listed on the Louisiana Medicaid fee for Service Fee Schedule e Providers must bill with the V20 0 through V20 3 in the primary diagnosis position FQHC RHC Non EPSDT Claim Filing Instructions e Requires the submission of procedure code T1015 in conjunction with detail level procedure codes including mental behavioral health If detail procedure code lines are not billed with procedure code T1015 or any of the detail procedure codes billed is not present on the Louisiana Medicaid Fee for Service Fee Schedule then procedure code T1015 will be denied Procedure code T1015 cannot be billed as a single lien claim Claims billed with a single line item will deny e The entire claim will deny if procedure code T1015 is billed with a valid detail procedure
74. ec onsS soisissa naii aeii 180 days COB submissions after primary payment cccccccessecseesesesesseesteeseeees 180 days Nurse Call Line 888 632 0009 A confidential line for members to ask health related questions 24 hours a day 7 days a week www amerihealthcaritasla com ACLA 1322 123 Beginning March 1 2012 call Merit Health Magellan Health at 800 424 4399 or TTY 800 424 4416 Websites and Email Addresses AmeriHealth Caritas Louisiana www amerihealthcaritasla com Louisiana Medicaid www lamedicaid com AmeriHealth Caritas Louisiana APPENDIX 18 ATTACHMENT B PREVENTABLE SERIOUS ADVERSE EVENT SCREENING CODES SCREENING ICD 9 OR E CODES MUST NOT BE PRESENT AT ADMISSION BUT PREVENTABLE SERIOUS ADVERSE EVENT APPEAR AT TIME OF DISCHARGE Events Potentially Identifiable by E Codes Only Wrong surgical procedure on a patient E876 5 Patient death or serious disability E875 0 E875 1 E875 2 E875 8 E875 9 associated with the use of contaminated drugs devices or biologics provided by Claim should reflect 20 Discharge Status Code if the healthcare facility applicable Patient death or serious disability E874 0 E874 1 E874 2 E874 3 E874 4 associated with the use or function of a E874 5 E874 8 E8749 E876 3 E876 4 device in patient care in which the device is used or functions other than as Claim should reflect 20 Discharge Status Code if intended applicable Patient sui
75. ed or edited The cancel feature cannot be used from History Any attempts to cancel a form will not be honored m Logout eee a Resume Form History Current Location BATON ROUGE CLINIC AMC THE Blank Forms 142BH o 142BH ncel Date Created Date Submitted Applicant Name Form Type Submitted By Status Cancel 06 17 2013 06 17 2013 pide nd aes Newborn Request Cassie Porche Submitted Blank Forms 148 View Edit dange 06 17 2013 06 17 2013 i Newborn Request Cassie Porche Submitted a AEEA View Edit Anf el 06 17 2013 06 17 2013 sR RE Newborn Request Cassie Porche Submitted Discharge View Edit CaWcel 06 17 2013 06 17 2013 Newborn Request Cassie Porche Submitted o Status Change View Edit Cafltel 06 14 2013 06 14 2013 CEES REER E Newborn Request Cassie Porche Submitted o Death View Edit Candel 06 05 2013 06 05 2013 TPL Cassie Porche Submitted o Transfer View Edit Chnchl 06 05 2013 06 05 2013 i i TPL Cassie Porche Submitted View Edit danc 06 04 2013 06 04 2013 Newborn Request KE 2a G Viewing a Form To view a printable report of a specific form click the View hyperlink to the left of the item NOTE A Search field is available to make it easier to find submitted forms Enter your search criteria in the field provided and click the Go button When viewing the form in history the status of the case can be found in Part V To be completed by Medicaid Current Location BATON ROUGE CLINIC AMC THE Search View Edit Cancel Date
76. ed to a patient contains the wrong gas or is contaminated by toxic substances Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility Patient death associated with a fall while being cared for in a healthcare facility Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility Criminal Events Any instance of care ordered by or provided by someone impersonating a physician nurse pharmacist or other licensed healthcare provider Abduction of a patient of any age Sexual assault on a patient within or on the grounds of a healthcare facility Death or significant injury of a patient resulting from a physical assault i e battery that occurs within or on the grounds of a healthcare facility EnA P O Box 83580 AmeriHealth Cari tas Baton Rouge LA 70884 Louisiana Non Participating Provider Emergency Services Payment Guidance AmeriHealth Caritas Louisiana will reimburse non participating hospital providers for emergency room services that are rendered to treat an Emergency Medical Condition for ACLA members An Emergency Medical Condition is defined as A medical condition manifesting itself by acute symptoms of sufficient severity including severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immedi
77. elp and support to patients during the final months of life The program also helps loved ones cope choose to receive services from the Hospice provider named below starting Election Admission Date MM DD YYYY NOTE To get hospice services must have Medicaid and my doctor must write that am in my final months of life PATIENT S STATEMENT understand and accept e can get hospice for 3 months if approved for the service If need more days the hospice provider will ask for these days for me If my illness is better will no longer get hospice services under the Medicaid Program IfI no longer receive hospice services can keep on using my Medicaid card for other services By choosing hospice understand that will not be treated for my terminal sickness and any related condition If have Medicaid and Medicare must choose hospice with Medicaid and Medicare at the same time am signing this paper because understand hospice services The hospice provider explained the services to me my legal representative and also explained to me that can choose to not receive hospice care at any time SIGNATURES Signature of Patient Legal Representative Date of Signed MM DD YYYY Representative s Daytime Phone incl area code Printed Name of Above Signee Legal Representative s Relationship to Patient PART II TO BE COMPLETED BY HOSPI CE PROVIDER PATIENT INFORMATION Patient Name First Middle In
78. ens o Do not use 99999999999 for a compound medication bill each drug as a separate line item with its appropriate NDC e Immediately following the last digit of the NDC no delimiter enter the Unit of Measurement Qualifier o F2 International Unit o GR Gram o ML Milliliter o UN Unit e Immediately following the Unit of Measure Qualifier enter the unit quantity with a floating decimal for fractional units limited to 3 digits to the right of the decimal o Any unused spaces for the quantity are left blank Note that the decision to make all data elements left justified was made to accommodate the largest quantity possible The description field on the UB 04 is 24 characters in length An example of the methodology is illustrated below NIA TET V8 ATS POT 8 fe OFT POINT Aye ye fe yet 3 NDC via EDI The NDC is used to report prescribed drugs and biologics when required by government regulation or as deemed by the provider to enhance claim reporting adjudication processes EDI claims with NDC info should be reported in the LIN segment of Loop ID 2410 This segment is used to specify billing reporting for drugs provided that may be part of the service s described in SV1 Please consult your EDI vendor if not submitting in X12 format for details on where to submit the NDC number to meet this specification Required R fields must be completed on all claims Conditional C fields must be completed if the information app
79. enter search criteria and press search _ In the Applicant Search section fill in any information you have for the mother of the child then click Search Applicant Search Name O anam o ssn 11 11 1111 Case Number Persono OOO mp Scarch Results will appear in the Search Results section at the bottom of the screen If the applicable result appears click the hyperlink titled Select next to the search result By choosing to search for an applicant before starting the form the applicant s personal information will prepopulate the Newborn Request Search Results Applicant Name KKKKKKK KKKKK If your search doesn t produce a result proceed by clicking the New Applicant hyperlink in the Select Form Type section Select Form Type Form Type Newborn Request gt New Applicant The Create Newborn Forms screen will appear Answer the two questions provided in this step If the answer to the second question Does the mother or father have access to employer sponsored health insurance is Yes you ll be required to complete a Third Party Liability TPL form after completing the Newborn Request Click Start Form s when finished answering the questions Create Newborn Forms Does the mother have Medicaid Does the mother or father have access to employer sponsored health insurance Start Form s Part I Mother s Information The next screen that appears is the Newborn Request form If not already
80. equired if the health care provider is a Covered Entity as defined in HIPAA Regulations 10 digit NPI 53 54 55 C 56 57 A B C Other Billing A unique identification number Provider Identifier assigned to the provider submitting the bill to AmeriHealth Caritas Louisiana Complete if NPI is not AmeriHealth mandated in Field 56 The UB 04 Caritas Louisiana does not use a qualifier to specify the issued Provider type of Other Billing Provider Identification Identifier Use this field to report Number other provider identifiers as assigned by the health plan listed in Field 50 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 25 Provider Services 1 888 922 0007 01 2015 Insured s Name Patient Rel Insured s Unique Identifier AmeriHealth Caritas Louisiana member s Identification number Insurance Group No Treatment Authorization Codes UB 04 EDI Mapping A B C Information refers to the payers listed in field 50 In most cases this will be the patient name When other coverage is available the insured is indicated here Enter the patient s relationship to insured For Medicaid programs the patient is the insured Code 01 Patient is Insured Enter the pat
81. er Name Missing The name of the provider of service must be present on the claim form and must match the service provider name and TIN on file with the Plan For claims with COB the adjudication date of the other payer is required for EDI and paper claims Provider NPI Number Missing or Invalid The individual NPI and group NPI numbers for the service provider must be included on the claim form Revenue Codes Missing or Invalid Facility claims must include a valid four digit numeric revenue code Refer to UB 04 coding manuals for a complete list of revenue codes Spanning Dates of Service Do Not Match the Listed Days Units Span dating is only allowed for identical services provided on consecutive dates of service Always enter the corresponding number of consecutive days in the days unit field Tax Identification Number TIN Missing or Invalid The Tax ID number must be present and must match the service provider name and payment entity vendor on file with the Plan Third Party Liability TPL Information Missing or Incomplete Any information indicating a work related illnessinjury no fault or other liability condition must be included on the claim form Additionally a copy of the primary insurer s explanation of benefits EOB or applicable documentation must be forwarded along with the claim form Type of Bill A code indicating the specific type of bill e g hospital inpatient outpatient adjustments
82. erence Manuals for additional information www amerthealthcaritasla com 40 Provider Services 1 888 922 0007 01 2015 78 81CC a d Code Code Field 79 Other Provider Individual Names and Identifiers NPI Qualifier Other ID Enter the NPI number of another attending physician Enter the AmeriHealth Caritas Louisiana issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the AmeriHealth Caritas Louisiana issued Provider ID number UB 04 EDI Mapping 78 NM1 09 If 2310A NM101 71 If 2310A NM108 XX 2310A NM109 If 2310B NM101 72 If 2310B NM108 XX 2310B NM109 If 2310C NM101 73 If 2310C NM108 XX 2310C NM109 REF 02 If 2310A NM101 71 If 2310A REFO1 1G 2310A REFO2 If 2310B NM101 72 If 2310B REFO1 1G 2310B REF0O2 If 2310C NM101 73 If 2310C REFO1 1G 2310C REFO2 NM1 08 If 2310A NM101 71 If 2310A NM102 1 2310A NM103 If 2310B NM101 72 If 2310B NM102 1 2310B NM103 If 2310C NM101 73 If 2310C NM102 1 2310C NM103 NM1 04 If 2310A NM101 71 If 2310A NM102 1 2310A NM104 If 2310B BNM101 72 If 2310B NM102 1 2310B NM104 If 2310C NM101 73 If 2310C NM102 1 2310C NM104 79 Reserved Remarks Field Not Mapped Not Mapped Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refe
83. ervices 1 888 922 0007 01 2015 Appendix An interperiodic screening can only be billed if the recipient has received an age appropriate medical screening If their medical screening has not been performed the provider should bill an age appropriate medical screening It is not acceptable to bill for an interperiodic screening if the age appropriate medical screening had not been performed EPSDT Interperiodic Screenings An interperiodic screening by a AmeriHealth Caritas Louisiana provider must include all of the components required in the periodic screening This includes a complete unclothed exam or assessment health and history update measurements immunizations health education and other age appropriate procedures Medically necessary laboratory radiology or other procedures may also be performed and should be billed separately These codes are billed hard copy on the CMS 1500 form or electronically using the 837P claim transaction EPSDT Registered Nurse Interperiodic screening codes Procedure Modifier Description Code 99391 TD plus TS nterperiodic Re evaluation and Management infant under 1 year 99392 TD plus TS Interperiodic Re evaluation and Management ages 1 4 99393 TD plus TS Interperiodic Re evaluation and Management ages 5 11 99394 TD plus TS Interperiodic Re evaluation and Management ages 12 17 99395 TD plus TS Interperiodic Re evaluation and Management ages 18 21 TD To be used to re
84. etiatteiaiterit ereta iddia a e an i iaaea erkakda 56 Resubmitted Professional Corrected Claims cccccccccecececcccccccccecececcecececcscececucecesuseseecs 56 Supplemental MONNA O eeir EEEE EET 58 if MMA UL VLG a sone cacacesssacacosesesasncsensssosacnsesosesesacasasasesasacnsasesacnsesasesacasesssesacnsasesesacasass esas 59 AMDA SUS Cal EO ras cosa sa ac ai a cc tate 59 RUG SUNG SOC ehacte orice tae aaa eats see eects edad Sacdect iad Oia ance acetone one teacaten secede 60 OOE aeenenR ee eRe EN tee ne Sn a 60 Bebavioral Heale ete en ene ee ee eee ey eee R 61 Gate MOET I ee eere ene en Ce ene E OP ren Ee er nn Per Ra nE nn eRe eee ee er ee ee eee 61 CIPO PLAC CC AIG sisi testa Rca a Mester aa haan deaa tuna deue Misa dane diulbtecindastedieirahauaiamadamahenabannhamahanabanahamananatelnins 61 BEERS E ae E E O E he men ne nee ee E eee ee eee 61 Diabetic Selt Manacemient Training cuctccstocstocstocstocsiocstocttousianenaneumneraneuarararaueeiesGlautesgoonetaees 62 TAD a 62 B Bree Coat aren excell ee H i 0 a A A A E 62 EPSDT Supplemental Billing Information cc cc ceccccccseesccceeeeececeeeececeseseeeeaeeseesaaeeeeeeaees 66 FERS DOW NV EOE Che Cite E E ee eee 67 BPSD PT S bjec ve Vision SCC CII sic sarc soso snes oa snes E E EEEE E EOE REN 67 EPSDT ODectuve VISIONS Chee Oss ssi 68 BPSD MW Wcatin See eA E A A 68 EPSDT Subjective Hearne SCENE r sisssisrsisscierisersrisisesesss esssS EEEE ESEESE EEEE EEEE EEEE EEEE 68
85. f value code is populated then value amount must also be populated and vice versa Please see NUCC Specifications Manual Instructions for value codes and descriptions to complete fields 39 4l Documenting covered and non covered days Value Code 81 non covered days 82 to report co insurance days 83 Lifetime reserve days Code in the code portion and the Number of Days in the Dollar portion of the Amount section Enter 00 in the Cents field Revenue Code Codes that identify specific accommodation ancillary service or unique billing calculations or arrangements Refer to the DHH web site for a list of billable revenue codes http www lamedicaid com provweb1 billing information revenuecodes ht m Revenue The standard abbreviated description Description of the related revenue code categories included on this bill See NUBC instructions for Field 42 for description of each revenue code category HCPCS Accommod 1 The Healthcare Common ation Rates HIPPS Procedure Coding system Rate Codes HCPCS applicable to ancillary service and outpatient bills The accommodation rate for inpatient bills Health Insurance Prospective Payment System HIPPS rate codes represent specific sets of patient characteristics or case mix groups on which payment determinations are made under several prospective payment Required R fields must be completed on all claims Conditional C fields
86. fore resubmitting claims check the status of your submitted claims online at www navinet net Important Corrected Professional Claims may be sent in on paper via CMS 1500 or via EDI If sending paper please stamp each claim submitted corrected or resubmission and send all corrected or resubmitted claims to Claims Processing Department AmeriHealth Caritas Louisiana P O Box 7322 London KY 40742 Important Corrected Institutional and Professional claims may be resubmitted electronically using the appropriate bill type to indicate that it is a corrected claim Adjusted claims must be identified in the bill type Common Rejections continued Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 56 Provider Services 1 888 922 0007 01 2015 NPI Processing The Plan s Provider Number is determined from the NPI number using the following criteria l Plan ID Tax ID and NPI number If no single match is found the Service Location s ZIP code is used If no service location is include the billing address ZIP code will be used If no single match is found the Taxonomy is used If no single match is found the claim is sent to the Invalid Provider queue IPQ for processing If a plan provi
87. formation www amerthealthcaritasla com 10 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Patient s Account No Amount Paid 26 27 Total Charge 29 0 Signature Of Physician Or Supplier Including Degrees Or Credentials 31 32 32a Name And Address Of Facility Where Services Were Rendered If Other Than Home Or Office NPI number Other ID AmeriHealth Caritas Louisiana issued Provider Identification Number Refer to NUCC CMS 1500 claims filing guidelines for the two digit qualifiers used to describe the non NPI provider ID number Billing Provider Info amp Ph Enter the patient s account number assigned by the provider a Accept Assignment Yes or No must be checked C 3 Reserved for NUCC Use Not Required Enter the total of all charges listed on the claim Required when another carrier is the primary payer Enter the payment received from the primary payer prior to invoicing the Plan Medicaid programs are always the payers of last resort Signature on file signature stamp computer generated or actual signature is acceptable Required Enter the physical location P O Box s are not acceptable Required unless Rendering Provider is an Atypical Provider and is not required to have an NPI number Enter the AmeriHealth Caritas Louisiana Provider ID strongly recommended Enter the G2 qualifier followed by the Ameri
88. gnature Date Of Current Illness First 2300 DTP03 C Symptom Or Injury Accident Or Pregnancy LMP If Patient Has Same Or Similar 2300 DTP02 C Illness Give First Date Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information lla C 11b C lic C 11d 12 pd U pd www amerihealthcaritasla com 14 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim EDI Mapping Current Occupation 17 Name Of Referring Physician Or Other Source 17a Other ID Number Of Referring 2310A NM103 04 05 Physician AmeriHealth Caritas Louisiana Provider ID 17b National Provider Identifier NPD 2310A NM109 enter the referring provider s NPI 18 Hospitalization Dates Related To 2300 DTP02 C Current Services Reserved For Local Use Reserved NOT USED C pd for Louisiana Medicaid Provider ID Diagnosis Or Nature Of Illness Or 2300 HI01 H104 Injury Relate Items 1 2 3 Or 4 To Item 24E By Line N N jd Medicaid Resubmission Code Not mapped Original Ref No Prior Authorization Number 2400 REFO1 G1 24A Date s Of Service 2400 DTP03 24B Place Of Service 2300 CLMO05 24D __ Procedures Services Or Supplies 2400 HCP09 CPT HCPCS Modifier Diagnosis Pointer 2400 SV101 1 ek secant a Required R fields
89. h Industry Business Communications Council HIBCC OZ Product Number Health Care Uniform Code Council Global Trade Item Number GTIN CTR Contract rate To enter supplemental information begin at 24A by entering the qualifier and then the information Do not enter a space between the qualifier and the number code information Do not enter hyphens or spaces within the number code More than one supplemental item can be reported in the shaded lines of Item Number 24 Enter the first qualifier and number code information at 24A After the first item enter three blank spaces and then the next qualifier and number code information B EDI Field 24D Professional Details pertaining to Anesthesia Minutes and corrected claims may be sent in Notes NTE or Remarks NSF format e Details sent in NTE that will be included in claim processing Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 4 Provider Services 1 888 922 0007 01 2015 Supplemental Information e Please include L1 L2 etc to show line numbers related to the details Please include these letters AFTER those specified below o Anesthesia Minutes need to begin with the letters ANES followed by the specific times o Corrected claims need to begin with the lette
90. he Plan within 180 calendar days from the date services were rendered or compensable items were provided Re submission of previously denied claims with corrections and requests for adjustments must be submitted within 1 80calendar days from the date services were rendered or compensable items were provided Claims with Explanation of Benefits EOBs from primary insurers must be submitted within 180days of the date of the primary insurer s EOB Refunds for Claims Overpayments or Errors It is the provider s responsibility to return any Medicaid Program funds that were improperly paid If the provider s practice determines that it has received overpayments or improper payments the provider is required to make arrangements immediately to return the funds Please follow the process listed below to return overpayments For all overpayments please submit a check in the correct amount to AmeriHealth Caritas Louisiana P O Box 7322 London KY 40742 Note Please include the member s name and ID date of service and Claim ID www amerthealthcaritasla com 2 Claims Filing Procedure Important Requests for adjustments may be submitted electronically on paper or by telephone By Telephone Provider Claim Services 1 888 922 0007 Select the prompts for the correct Plan and then select the prompt for claim issues On Paper If you prefer to write please be sure to stamp each claim submitted corrected
91. hould bill Revenue Code 170 Well Baby Nursery Newborn Well Baby claim should be billed with Revenue Code Nursery Premature 171 172 and 179 Other Nursery PICU Pediatric Intensive Care PICU per diem is paid when PICU bed type is authorized Provider should bill Revenue Code 203 BURN Burn BURN per diem is paid when BURN bed type is authorized Provider should bill Revenue Code 207 Note Babies admitted to NICU require prior authorization from date admitted to NICU even if during mother s stay NICU services require separate authorization for baby in order to be paid Note Mother s delivery and baby stay should be billed on two separate claims Mother s claim should only include mother s room board and ancillary charges Baby claim should only include baby s room board and ancillary charges Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 74 Provider Services 1 888 922 0007 01 2015 Appendix Note Rural facilities that have general per diem only rates and border baby rates if baby is discharged with mother and not in NICU for rural hospitals well baby is not eligible for payment on baby s claim Baby services are considered inclusive in mother s stay If baby is discharged with mother but goes to
92. ian However the ordering physician must contact Prior Authorization within 48 hours or the next business day to obtain proper authorization for the studies which willbe subject to medical necessity review Emergency room Observation Care and inpatient imaging procedures do not require Prior Authorization Claims Submission Remittance Advice Electronic Funds Transfer Arrange Electronic Claims Submission through your EDI vendor Other Important Contact Information Louisiana Enrollment Services BAYOU HEALTH ot Miroir MIDEOING fesiossnncossoscsinassions scepasbescilasialaieandeniianisutuasieencoasiieawidsesn 877 363 3666 Arrange Electronic Funds Transfer EFT through EMDEON saa Gc rl sd 06 vaca teva Gaui nance wo ese sen ge EEA A EET hea 866 506 2830 www bayouhealth com 855 BAYOU 4U 855 229 6848 TTY 855 LAMed4Me 855 526 3346 Oe opine aoe AmeriHealth Caritas Contact Information MAA EENE EN I AE E E ec EA E T 866 428 7419 Department Phone Fax 888 922 0007 888 756 0004 888 913 0350 888 913 0350 888 913 0350 888 913 0350 888 913 0350 888 913 0350 866 426 7393 866 397 4521 866 397 4522 866 397 4522 866 397 4522 866 397 4522 866 397 4522 866 397 4522 Provider Services P AE E P AAE E EE E E E E E E 866 922 0007 l l Member Services Submit paper claims to AmeriHealth Caritas Louisiana Claims Processing Department PO Box 7322 London KY 40742 Prior Authorization Adult Concurrent Review Pediatric C
93. ields a b c Patient s Reason The ICD diagnosis codes describing for Visit the patient s reason for visit at the time of outpatient registration Prospective The PPS code assigned to the claim to Payment System identify the DRG based on the PPS Code grouper software called for under contract with the primary payer Required when the Health Plan Provider contract requires this information Up to 4 digits 72a c External Cause of The ICD diagnosis codes pertaining to Injury ECI Code _ external cause of injuries poisoning or adverse effect External Cause of Injury E diagnosis codes should not be billed as primary and or admitting diagnosis Required if applicable 70 71 73 Unlabeled Field 74 Principal The ICD code that identifies the Procedure Code principal procedure performed at the and Date claim level during the period covered by this bill and the corresponding date Inpatient facility ICD code is required when a surgical procedure is performed Outpatient facility or Ambulatory Surgical Center CPT HCPCS or ICD code is required when a surgical procedure 1s performed 74a e Other Procedure The ICD codes identifying all Codes and Dates significant procedures other than the principal procedure and the dates identified by code on which the procedures were performed Required R fields must be completed on all claims Conditional C fields must be completed if the information appl
94. ient s AmeriHealth Caritas Louisiana ID exactly as it appears on the patient s ID card on line B or C When other insurance is present enter the plan ID on line A Use this field only when a patient has other insurance and group coverage applies Do not use this field for individual coverage Line A refers to the primary payer B secondary and C tertiary Use this field only when a patient has other insurance and group coverage applies Do not use this field for individual coverage Line A refers to the primary payer B secondary and C tertiary Enter the AmeriHealth Caritas Louisiana prior authorization number Line A refers to the primary payer B secondary and C tertiary Field 63A is required Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 26 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping DCN Document Control Number New field The control number assigned to the original bill by the health plan or the health plan s fiscal agent as part of their internal control Note Resubmitted claims must contain the original claim ID 65 Employer Name The name of the employer that provides health care coverage for the insured individual identified in field 58 Required when the employe
95. ies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 28 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Inpatient facility ICD code is required when a surgical procedure is performed Outpatient facility or Ambulatory Surgical Center CPT HCPCS or ICD code is required when a surgical procedure is performed a en 76 Attending Provider Enter the NPI of the physician who Name and has primary responsibility for the Identifiers patient s medical care or treatment in NPI Qualifier Oth the upper line and their name in the er ID lower line last name first If the F attending physician has another nter the NPI l i unique ID enter the appropriate number of the o ng ee attending physician descriptive two digit qualifier followed by the other ID Enter the last name and first name of the Enterihe Attending Physician AmeriHealth Caritas Louisiana issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the AmeriHealth Caritas Louisiana issued Provider ID number Operating Enter the NPI of the physician who Physician Name performed surgery on the patient in and Identifiers the upper line and their name in the NPI Qualifier Oth lower line last name first If the er ID operating physician has another unique ID enter the appropriate descriptive two
96. ignature Date You are requested to supply the following information but it is not re quired Ethnicity and Race Designation please check Ethnicity Race mark one or more L Hispanic or Latino _ American Indian or Alaska Native _ Not Hispanic or Latino _ Asian L_ Black or African American L_ Native Hawaiian or Other Pacific Islander L_ White E INTERPRETER S STATEMENT E If an interpreter is provided to assist the individual to be sterilized have translated the information and advice presented orally to the in dividual to be sterilized by the person obtaining this consent have also read him her the consent form in language and explained its contents to him her To the best of my knowledge and belief he she understood this explanation Interpreter s Signature Date HHS 687 05 10 E STATEMENT OF PERSON OBTAINING CONSENT E Name of Individual consent form explained to him her the nature of sterilization operation the fact that it is Specify Type of Operation intended to be a final and irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that steriliza tion is different because it is permanent informed the individual to be sterilized that his her consent can be withdrawn at any time and that he she will not lose any health services or a
97. ing charts describe the required fields that must be completed for the standard Centers for Medicare and Medicaid Services CMS CMS 1500 or UB 04 claim forms If the field is required without exception an R Required is noted in the Required or Conditional box If completing the field is dependent upon certain circumstances the requirement is listed as C Conditional and the relevant conditions are explained in the Instructions and Comments box Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 3 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements The CMS 1500 claim form must be completed for all professional medical services and the UB 04 claim form must be completed for all facility claims All claims must be submitted within the required filing deadline of 180 days from the date of service Although the following examples of claim filing requirements refer to paper claim forms claim data requirements apply to all claim submissions regardless of the method of submission electronic or paper Required Fields CMS 1500 Claim Form CMS 1500 Claim Form Field Field Description Instructions and Comments Required or Conditional Insurance Program Identification
98. inistration Eligibility Systems Section 628 North Fourth Street 6th Floor Post Office Box 91283 a Contact Us Baton Rouge Louisiana 70821 9283 ge User Manuals YL J Phone 225 342 0706 Fax 225 342 1782 Email DHHProviderRequests la gov User Manual In the left menu of FNS there is a User Manual hyperlink that will direct you to the available manuals and guides for the Facility Notification System ws Contact Us a User Manuals 16 Training Videos In the left menu of FNS there is a Training Videos section where you ll find hyperlinks to the available training videos on how to navigate and submit forms using FNS m Training Videos 148 Oo O oO Logout When you re ready to log out of the Facility Notification System click the Logout hyperlink from the left menu You ll be returned to the Log In screen of FNS Department of Health and Hospitals Medicaid Program TPL Logged in as cassie porche la gov f E Logout Start New Form Resume Form History 17 AmeriHealth Caritas Louisiana PATIENT INFORMATION Patient s Name First Middle Initial Last Patient s Medicaid ID 13 digits Patient s Date of Birth MM DD YYYY FIRST BENEFIT PERIOD 90 Days Having reviewed this patient s medical record and or examination of the patient certify this patient s prognosis Is for a life expectancy of six months or less if the terminal illness runs its normal co
99. ional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 39 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Operating Physician Name NM1 09 If 2310A NM101 71 and Identifiers If 2310A NM108 NPI Qualifier Other ID XX 2310A NM109 If 2310B NM101 72 Enter the NPI number of the a 0B NM108 physician who performed 2310B NM109 surgery If 2310C NM101 If 2310C NM108 XX Enter the AmeriHealth 2310C NM109 Caritas Louisiana issued REF 02 If 2310A NM101 71 Provider ID number If 2310A REFO1 1G 2310A REFO2 If 2310B NM101 72 _ oe If 2310B REFO1 1G Enter the two digit qualifier 2310B REF02 that identifies re Other ID If 2310C NM101 73 number as the meriHealth If 2310C REF01 1G Caritas Louisiana issued 2310C REF02 Provider ID number NM1 03 If 2310A NM101 71 If 2310A NM102 1 2310A NM103 If 2310B NM101 72 If 2310B NM102 1 2310B NM103 If 2310C NM101 73 If 2310C NM102 1 2310C NM103 NM1 04 If 2310A NM101 71 If 2310A NM102 1 2310A NM104 lf 2310B BNM101 72 lf 2310B NM102 1 2310B NM104 If 2310C NM101 73 If 2310C NM102 1 2310C NM104 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Ref
100. ircumstances Upon release from the hospital will the newborn live with the mother Ye No PART Il BABY S RESPONSIBLE PARTY Adoption Yes No Responsible Party Name LA Adoption Agency Relationship to Baby Adoption Agency Mailing Address 111 North Main St Address 2 City State Zip Baton Rouge LA 70802 Parish of Residence West Baton Rouge hi Phone 225 1234567 Physical Address 111 North Main St Address 2 City State Zip Baton Rouge LA 70802 unssnnnnnssnunnnnnnnnnnnnnnnnnnnnnnmnnnnnnn ec aannnnnnnnnmn nnmnnn annA Part III Child Birth Information The next section is Part IIl Child Birth Information From the dropdown menu next to Multiple Child Birth choose Yes or No This answer will determine the next step See the below information based on the choices If you answer No from the Multiple Child Birth dropdown personal information fields for one baby will appear Complete each field provided in this section If the Expired box is chosen you must fill in the baby s date of death You are required to answer the question Does the mother of the newborn have private health insurance coverage PART Ill CHILD BIRTH INFORMATION p Multiple Child Birth No Child s Name 1 John Smith Jr First Mi Last Suffix Child s DOB 0422 2013 Gender Male C Expired Race 1 White gt Does the mother of the newborn have private health insurance coverage O Yes No If you answer Yes f
101. irect inquiries as follows If you would like to transmit claims Contact Emdeon at electronically 877 363 3666 If you have general EDI questions Contact AmeriHealth Caritas Louisiana EDI Technical Support at 1 866 428 7419 or by e mail at edi amerihealthcaritasla com If you have questions about specific Contact your EDI Software Vendor or call the claims transmissions or acceptance and Emdeon Provider Support Line at 1 800 845 R059 Claim Status reports 6592 If you have questions about your R059 Contact Provider Claim Services at 1 888 922 Plan Claim Status receipt or completion 0007 dates If you have questions about claims that are Contact Provider Claim Services at 1 888 922 reported on the Remittance Advice 0007 for claim inquiries If you need to know your provider NPI Contact Provider Services at 1 888 922 0007 number If you would like to update provider Notify Provider Network Management in writing payee NPI UPIN tax ID number or at payment address information AmeriHealth Caritas Louisiana For questions about changing or verifying 10000 Perkins Rowe Block G 4 Floor provider information Baton Rouge LA 70810 Or by fax at 225 300 9126 Or by telephone at 1 877 588 2248 If you would like information on the 835 Contact your EDI Vendor or call Emdeon at 877 Remittance Advice 363 3666 Check the status of your claim Review the status of your submitted claims o
102. it newborn s facility bill for child at the time of delivery using the baby s Medicaid ID The newborn s Medicaid ID is to be used on well babies babies with extended stays sick babies past the mother s stay and on all aftercare and professional bills The facility or provider should obtain the newborn s Medicaid ID from DHH s Newborn Eligibility System before submitting the claim to AmeriHealth Caritas Louisiana Important The claim for baby must include the baby s date of birth as opposed to the mother s date of birth Important Date of service and billed charges should exactly match the services and charges detailed on the accompanying EOB If the EOB charges appear different due to global coding requirements of the primary insurer submit claim with the appropriate coding which matches the total charges on the EOB Place of Service Code Missing or Invalid A valid and appropriate two digit numeric code must be included on the claim form Refer to Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 47 Provider Services 1 888 922 0007 01 2015 Common Causes of Claim Processing Delays Rejections or Denials CMS 1500 coding manuals for a complete list of place of service codes Provid
103. itasla com 59 Provider Services 1 888 922 0007 01 2015 Appendix Procedure codes in the Anesthesia section of the Current Procedural Terminology manual are to be used to bill for surgical anesthesia procedures e Reimbursement for surgical anesthesia procedures will be based on formulas utilizing base units time units 1 15 min and a conversion factor Anesthesia e Reimbursement for moderate sedation and maternity related procedures other than general anesthesia for vaginal delivery will be a flat fee e Minutes must be reported on all anesthesia claims except where policy states otherwise The following modifiers are to be used to bill for surgical anesthesia services Servicing Provider Surgical Anesthesia Service AA Anesthesiologist Anesthesia services performed personally by the anesthesiologist Anesthesiologist Medical direction of one CRNA Medical direction of two three or four concurrent Anesthesiologist anesthesia procedures involving qualified individuals EE CRNA CRNA service with direction by an anesthesiologist QZ CRNA CRNA service without medical direction by an anesthesiologist The following is an explanation of billable modifiers e Modifiers which can stand alone AA QZ QK QX and QY e All ASA codes still require a valid ASA modifier to be billed in first position in conjunction with the ASA code Audiology Audiology services must be billed on a CMS 1500 claim form Required R fields
104. itial Last Patient s Address City State Zip Patient Medicaid ID Patient Medicare ID Date of Birth MM DD YYYY Primary Diagnosis Code List All Other Diagnosis Codes Type Bill Statement Covers Period From Through MM DD YYYY MM DD YYYY Discharge Revocation Reason s PROVI DER INFORMATION Hospice Provider Name Hospice Provider Hospice Provider Phone incl area code amp Fax Hospice City State Zip Attending Physician Printed Name Attending Physician Provider s Hospice Relationship Status SIGNATURES Hospice Provider Representative s Signature Hospice Representative s Printed Name This form cannot be altered Please return to ACLA lization Management department via fax to 1 866 397 4522 Hospice Address www amerihealthcaritasla com Appendix 9 AmeriHealth Caritas Louisiana Hospital Notification of EKmergent U rgent Admissions Patient Care Management Team Member 1 Fax to 1 866 397 4522 Date of Admission j I AmeriHealth Caritas Louisiana must be notified on the first business day following date of service Member ID DOB Member Name Type of Admission Q Inpatient O Medical Observation less than 23 hours stay LI Short Procedure J Obstetric Observation less than 23 hours stay Diagnosis Reason for Admission Attending Physician AmeriHealth Caritas Louisiana Provider ID Procedures Performed must be completed for SPU Admissions Is Member Pregnan
105. ld be entered as unit of service Standard rounding should be applied to the nearest whole number Durable Medical Equipment e Services are billed on a CMS 1500 claim form e An NU modifier is used for all purchases Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 62 Provider Services 1 888 922 0007 01 2015 Appendix e Repair codes on the DME Fee Schedule require the submission of procedure code K0739 in conjunction with RP modifier for payment consideration e An RR modifier is required for all rentals e The following DME procedure codes that are manually priced based on the Louisiana Fee Schedule will require an invoice A4244 ALCOHOL OR PEROXIDE PER PINT A4466 GARMENT BELT SLEEVE OR OTHER COVER A4483 MOISTURE EXCHANGER SURGICAL TRAYS A4670 A4680 A4750 A4755 A4760 A4765 A4770 A4860 A4918 A5119 A6020 A6025 A6215 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 63 Provider Services 1 888 922 0007 01 2015 Appendix A6531 GRAD COMP STOCKING BELOW KNEE 30 40M B
106. leage when billed will only be paid when billed in conjunction with a PAID transport code e A second trip is reimbursed if the recipient is transferred from first hospital to another hospital on same day in order to receive appropriate treatment Second trip must be billed with a HH destination modifier The following table identifies the valid modifiers for air ambulance Transfer Airport Heli Pad Hospital Accident Scene Acute Event Transfer Airport Heli Pad Ambulatory Surgical Centers e Ambulatory Surgical Centers ASC are required to bill on CMS 1500 or 837 Format e Providers are to bill only the highest compensable surgical code and all ancillary services e Outpatient hospitals are to bill only one 490 rev code line along with the highest compensable surgical code present on the Louisiana Ambulatory Surgical Fee Schedule e If providers is looking to perform a service in the Ambulatory Surgical Center that is not on the Louisiana Medical Assistance Fee Schedule provider must obtain prior authorization and rate negotiation prior to service being rendered Failure to obtain prior authorization for procedures not on Ambulatory Surgical Fee Schedule will result in claim denial Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcar
107. leted on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information 1 2 3a 3b 5 7 Type Of Bill CLMO5 1 www amerthealthcaritasla com 31 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Patient Identifier NM1 09 2010BA NM108 Patient Name 2010CA NM103 2010CA NM104 2010CA NM105 Patient Address 2010CA N301 1 Else if 2000B SBR02 18 2010BA N301 1 N3 2 If 2010CA 2010CA N302 1 Else if 2000B SBRO02 18 2010BA N302 1 N4 1 If 2010CA 2010CA N401 Else if 2000B SBRO02 18 2010BA N401 N4 2 If 2010CA 2010CA N402 2000B SBRO2 18 2010BA N402 N4 3 If 2010CA 2010CA N403 2000B SBRO02 18 2010BA N403 Patient Birth Date DMG 02 If 2010CA 2010CA DMG02 2000B SBR02 18 2010BA DMG02 Patient Sex DMG 038 If 2010CA 2010CA DMG03 Else if 2000B SBRO2 18 2010BA DMG03 1 Admission 12 15 DTP 03 If 2400 DTP01 472 SB2300 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information 11 2 www amerthealthcaritasla com 32 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping 12 Admission Date 13 Admission Hour DTP 03 If 2300 DTP01 435 move time portion of
108. lies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 44 Provider Services 1 888 922 0007 01 2015 Supplemental Information When LINO2 equals N4 LINO3 contains the NDC number This number should be 11 digits sent in the 5 4 2 format with no hyphens Submit one occurrence of the LIN segment per claim line Claims requiring multiple NDC s sent at claim line level should be submitted using CMS 1500 or UB 04 paper claim When submitting NDC in the LIN segment the CTP segment is requested This segment is to be submitted with the Unit of Measure and the Quantity When submitting this segment CTP04 Quantity and CTP05 Unit of Measure are required e Federal Tax ID on UB04 Federal Tax ID on UB04 Box 5 will come from Loop 2010AA REFO2 e Condition codes Condition codes Box number 18 thru 29 will come from 2300 CRCO1 CRC0O7 e Patient reason DX Patient reason DX Box 70 qualifier will be PR qualifier from 2300 HIO1 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 45 Provider Services 1 888 922 0007 01 2015 Common Causes of Claim Processing Delays Rejections or Denials Common Causes of Claim Processing Dela
109. list the payers as indicated below Line A refers to the primary payer Line B refers to the secondary and Line C refers to the tertiary Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 24 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Mn un N AmeriHealth The number used by the health plan to Caritas Louisiana identify itself AmeriHealth Caritas Identification Louisiana s Payer ID is 27357 Number Rel Info Release of Information Certification Indicator This field is required on Paper and Electronic Invoices Line A refers to the primary payer Line B refers to the secondary and Line C refers to the tertiary It is expected that the provider have all necessary release information on file Itis expected that all released invoices contain Y Asg Ben Valid entries are Y yes and N no Prior Payments The A B C indicators refer to the information in Field 50 Est Amount Due Enter the estimated amount due the difference between Total Charges and any deductions such as other coverage National Provider The unique NPI identification number Identifier Billing assigned to the provider submitting Provider the bill NPI is the national provider identifier R
110. ll up diapers for members ages 4 through 20 Not covered for members age 21 and over or children under 3 e All Wheelchair parts e Medications 17P and all infusion injectable medications listed on the Louisiana Medicaid Professional Services Fee Schedule with billed amounts of 250 or greater e Some surgical services and surgical procedures that may be considered cosmetic Cochlear Implantation covered for members under 21 e Gastric Bypass Vertical Band Gastroplasty e Medical Hysterectomy Only e Pain Management external infusion pumps spinal cord neurostimulators implantable infusion pumps radiofrequency ablation and nerve blocks e Radiology Services e CT Scan e MRI e MRA e Nuclear Cardiac Imaging e All unlisted and miscellaneous codes Providers must meet State requirements documentation for reimbursement Please see requirements and documentation necessary in the AmeriHealth Caritas Provider Handbook Prior Authorization for CT Scans MRIs MRAs and Nuclear Cardiology services are required for outpatient services only The ordering physician is responsible for obtaining a Prior Authorization number for the study requested Patient symptoms past clinical history and prior treatment information will be requested and should be available at the time of the call Outpatient studies ordered after normal business hours or on weekends should be conducted by the ordering facility as requested by the ordering physic
111. lt in a change on your W 9 you must submit a copy of your W 9 with this change form PLEASE NOTE Practitioners must complete AmeriHealth Caritas Louisiana Credentialing before they will be added to your practice as a participating provider Refer to the LaCare website for Credentialing Requirements www amerihealthcaritasla com Type of Change Adding a Practice Adding an office location Fax change Please check all that apply Joining a Practice Changing an office location Name change only Telephone change Other attach documentation PREVI OUS OFFICE INFORMATION NEW OFFICE INFORMATION AmeriHealth Caritas Provider ID NPI AmeriHealth Caritas Provider ID Name Name Street Address Street Address City Zip City State Zip Telephone Email address Telephone Email address ADD Practitioners New Practitioners must complete AmeriHealth Caritas Louisiana Credentialing before they are added as a participating provider 1 re Last First M I Degree NPI PPID 2 Last First M I Degree NPI PPID TERMI NATE Practitioners Please give LaCare 60 days advance notice when a practitioner is leaving the group 1 a Last First M I Degree NPI PPID 2 re Last First M I Degree NPI PPID BI LLI NG LOCATI ON CHANGE Street Address 1 Telephone Fax e mail address Street Address 2 Federal Tax ID change in Federal ID requires new W 9 City State Zip CHANGE OF OWNERSHIP Legal Business Name of New Owner and Federal Tax ID
112. must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 23 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping systems Enter the applicable rate HCPCS or HIPPS code and modifier based on the Bill Type of Inpatient or Outpatient HCPCS are required for all Outpatient Claims Note NDC numbers are required for physician administered drugs 45 Serv Date Report line item dates of service for each revenue code or HCPCS HIPPS code Serv Units Report units of service A quantitative measure of services rendered by revenue category or for the patient to include items such as number of accommodation days miles pints of blood renal dialysis treatments observation hours etc 47 Total Charges Total charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period Total charges includes both covered and non covered charges Report grand total of submitted charges Value entered must be greater than zero 0 00 Non Covered To reflect the non covered charges for Charges the destination payer as it pertains to the related revenue code Required when Medicare is Primary Unlabeled Field a Not required Not required 50 Payer Enter the name for each payer being invoiced When the patient has other coverage
113. must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information N U www amerihealthcaritasla com 15 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim EDI Mapping 24G Days Or Units 2400 SV502 24H EPSDT Family Plan 2400 SV111 Not required ID Qualifier 2400 SV101 1 Rendering Provider ID 2310 NM109 Recommended R Federal Tax ID Number SSN EIN 2010AAREFO1 Patient s Account No 2300 CMLO1 Accept Assignment hard coded yes C Total Charge Loop 2300 SV103 Amount Paid 2300 AMT02 C Signature Of Physician Or Supplier Not mapped Including Degrees Or Credentials Date Name And Address Of Facility Where Services Were Rendered If Other Than Home Or Office 32a NPI number 23010D NM101 32b Other ID 23010D NM109 AmeriHealth Caritas Louisiana issued Provider Identification Number Strongly recommended 2010AA NM103 Billing Provider Info amp Ph 24I 24J 25 26 27 28 29 30 31 32 2010AA N3012010AA N401 N402 N4032010AA NM109 Ua E 33a NPI number Required unless Rendering Provider is an Atypical Provider and is not required to have an NPI number Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NU
114. n NaviNet at www navinet net Sign up for NaviNet www navinet net NaviNet Customer Service 1 888 482 8057 Sign up for Electronic Funds Transfer Contact Emdeon at 866 506 2830 Option 1 Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 0 Provider Services 1 888 922 0007 01 2015 8 NOTES 82 NOTES APPENDIX 11 Form Approved OMB No 0937 0166 Expiration date 12 31 2012 CONSENT FOR STERILIZATION NOTICE YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS E CONSENT TO STERILIZATION E have asked for and received information about sterilization from When first asked Doctor or Clinic for the information was told that the decision to be sterilized is com pletely up to me was told that could decide not to be sterilized If de cide not to be sterilized my decision will not affect my right to future care or treatment will not lose any help or benefits from programs receiving Federal funds such as Temporary Assistance for Needy Families TANF or Medicaid that am now getting or for which may become eligible UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PE
115. n Exhibit 99 at Emdeon Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 52 Provider Services 1 888 922 0007 01 2015 Electronic Data Interchange EDI Quick Tips Specific Data Record Requirements Claims transmitted electronically must contain all the same data elements identified within the EDI Claim Filing sections of this booklet EDI guidance for Professional Medical Services claims can be found beginning on page 10 EDI guidance for Facility Claims can be found beginning on page 31 Emdeon or any other EDI clearing house or vendor may require additional data record requirements Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information Provider Services 1 888 922 0007 www amerthealthcaritasla com 53 01 2015 Electronic Claim Flow Description In order to send claims electronically to the Plan all EDI claims must first be forwarded to Emdeon This can be completed via a direct submission or through another EDI clearinghouse or vendor Once Emdeon receives the transmitted claims the claim is validated for HIPAA compliance and the Plan
116. n file Clinical edit limitation or denial C Untimely filing proof of timely filing attached Other Additional Information Mail this form a listing of claims if applicable and supporting documentation to AmeriHealth Caritas of Louisiana Provider Dispute Department P O Box 7323 London KY 40742 Ene AmeriHealth Caritas Louisiana Provider Reference Guide Your Network Management Representative Phone Number Fax Number Provider Services 888 922 0007 7 a m to 7 p m CST Member Services 888 756 0004 24 hours a day 7 days a week NaviNet www navinet net 888 482 8057 Access to member eligibility claims status inquiry Care Gap and Member Clinical Dental Services Under 21 covered by DHH Enhanced Dental Benefit 21 and older 800 508 6785 Vision Benefits 800 877 7195 Administered through Vision Service Plan www vsp com Case Management Care Coordination 888 643 0005 Louisiana Early Steps Program http new dhh louisiana gov index cfm page 139 n 139 EPSDT formerly KidMed 888 643 0005 Rapid Response Outreach Team RROT 888 643 0005 Available from 8 00 am to 6 30 pm Monday Friday Call for inquiries on EPSDT expanded services and outreach services 888 643 0005 1 800 784 8669 Tobacco Cessation Helpline http new dhh louisiana gov index cfm page 608 Tobacco Smoking Cessation Hotline 800 LUNG USA 800 586 4872 Freedom From Smoking Clinics 800 LUNG USA
117. nter for Medicare and Medicaid Services CMS has issued Publication 100 04 Claims Processing effective April 1 2004 that permits a hospital to bill an outpatient service such as observation even if the physician ordered an inpatient service If a member is admitted as an inpatient following a Medical Observation Stay notification is required to the Utilization Management Department through NaviNet by fax to 866 397 4522 or by calling 1 888 913 0350 for authorization Thank you for participating in the AmeriHealth Caritas Louisiana Provider Network and for your continued commitment to our members If you have any questions regarding this letter our Provider Services Department is available from 7am 7pm Central Time Monday through Friday at 888 922 0007 or you may contact your Provider Account Executive AmeriHealth Caritas Louisiana PROVIDER CHANGE FORM CURRENT PRACTICE INFORMATION Group Practice Name Individual Name Please Circle One Group Practice D Individual ID AmeriHealth Caritas ID NPI PPID Please Circle One amp Contact Person Name please print clearly Telephone Fax E mail address Authorizing Signature physician office manager Today s Date Effective Date of Change Change will not be completed without signature _______PROVIDERCHANGEINFORMATION O O O O OOOO OO Provide Complete Information This Request will be processed for AmeriHealth Caritas Louisiana If any of these changes resu
118. ny benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent He She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure Signature of Person Obtaining Consent Date Facility Address E PHYSICIAN S STATEMENT E Shortly before performed a sterilization operation upon on Name of Individual Date of Sterilization explained to him her the nature of the sterilization operation the fact that itis Specify Type of Operation intended to be a final and irreversible procedure and the discomforts risks and benefits associated with it counseled the individual to be sterilized that alternative methods of birth control are available which are temporary explained that steriliza tion is different because it is permanent informed the individual to be sterilized that his her consent can be withdrawn at any time and that he she will not lose any health services or benefits provided by Federal funds To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent He She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure Instructions for use of alternative final paragraph Use the first paragraph below except in the case of premat
119. ollowing three codes which should be submitted to the dental vendor o D1110 prophylaxis adult o D0120 periodic oral evaluation o D0150 comprehensive oral evaluation e Submit on an ADA Dental Claim form to DentaQuest Claims 12121 N Corporate Parkway Mequon WI 53092 or to submit electronically contact DentaQuest at 800 508 6785 to arrange EDI submission e All other D codes for members over 21 are not covered Diabetic Self Management Training e Services are billed using GO108 individual session and GO109 group session e Services may be billed on either a HCFAI500 or UB04 or via 837 Format e Services billed on UB04 should be billed with revenue code 0942 e Services for pregnant members must be billed with a TH modifier Dialysis e Reimbursement for dialysis services must be billed using the UB 04 claim form or using the electronic submission 8371 e Epogen must be reported using procedure code Q4081 in conjunction with revenue code 0634 and revenue code 0635 e The following formula is used in calculating Epogen units of service Total number of Epogen units 100 units of services e The units of service field for Epogen must be reported based on the HCPCS code dosage description as is done with all other physician administered drugs For example The HCPCS code description for Q4081 is Injection Epogen If the provider administers 12 400 units of Epogen on that date of service then 124 shou
120. omments Required or Required or Conditional Conditional Inpatient Outpatient Bill Bill Types Types 13X 23X 11X 12X 21x 2X 33X 83X Unlabeled Field Service Location no P O Boxes Billing Provider Left justified Name Address and Telephone Number Line a Enter the complete provider name Line b Enter the complete address Line c City State and zip code Line d Enter the area code telephone number number Left justified Patient Control No Provider s patient account control number Medical Health The number assigned to the patient s Record Number medical health record by the provider p Unlabeled Field Enter Remit Address Billing Provider s Billing Provider s designated pay to Designated Pay to _ address A Enter the AmeriHealth Caritas Louisiana Facility Provider I D Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 19 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Type Of Bill Enter the appropriate three or four digit code First position is a leading zero Do not include the leading zero on electronic claims Second position indicates type of facility Third position indicates type of care Fourth position indicates billing sequence Fed Tax
121. oncurrent Review NICU Concurrent Review Please indicate Resubmitted or Corrected Claim on the Claim Form aa OB Concurrent Review Discharge Notification 888 756 0004 Review Member Services 888 913 0350 888 913 0350 888 913 0327 888 913 0349 877 588 2248 866 397 4522 866 397 4522 888 877 5925 866 242 3461 225 300 9126 Discharge Planning Review DME Authorization Bright Start Credentialing Ist Level Dissatisfaction NOT concerning Medical Necessity AmeriHealth Caritas Louisiana PO Box 7323 London KY 40742 Network Contracting Provider Disputes Formal lst Level Dissatisfaction NOT concerning Medical Necessity Selene leis ao AmeriHealth Caritas Louisiana PO Box 7323 London KY 40742 Prior to March 1 2012contact DHH Office of Behavioral Health at 225 342 2540 or http new dhh louisiana gov index cfm subhome 10 Provider Appeals Formal MUGS AS roaie 888 913 0362 a a remnant Saver ent RNY ec amTeEN AE reer ese ne 877 724 4835 Written request for the reversal of a medical denial 1st and 2nd Level Appeals AmeriHealth Caritas Louisiana PO Box 7323 London KY 40742 Please indicate Provider Appeals 1st or 2nd Level on the envelope Timely Filing Limits When Submitting an EOB with a claim the Dates and Dollars must all match to avoid a rejection of the claim Faial clans ss stepecpateeredinsbamsaasrossinph ia iechostety E ER e omarion 180 days R s bmissions CoOrr
122. or Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 5 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements Exacerbated by the Pregnancy Itself W3 Level 1 Appeal 11 Insured s Policy Group Or FECA Required when other insurance is available Complete if more than one Other Medical insurance is available or if yes to 10a b c lla Insured s Birth Date Sex Same as 3 Required if 11 is completed 11b Other Claim ID Enter the following qualifier and accompanying identifier to report the claim number assigned by the payer for worker s compensation or property and casualty Y4 Property Casualty Claim Number Enter qualifier to the left of the vertical dotted line identifier to the right of the vertical dotted line lic Insurance Plan Name Or Program Enter name of Health Plan Required if Name 11 1s completed Is There Another Health Benefit Y or N by check box 9 an If yes complete 9 a d Patient s Or Authorized Person s Signature 13 Insured s Or Authorized Person s Not ve Signature Date Of Current Illness Injury MMDDYY or MMDDYYYY Pregnancy LMP Enter applicable 3 digit qualifier to nght of vertical dotted line Qualifiers include 431
123. our facility Yes No Facility Provider Mo 1234567 Admission Date of Newborn Child 04 22 2013 Discharge Date 04 23 2013 Attending Provider Name STEP A Will the attending provider accept health insurance as Primary and Medicaid as Secondary Yes No Was the newborn discharged to another facility Yes No If yes Facility Name Telephone No 13 Mother s Information The mother s information will prepopulate with information from the Newborn Request The question Will the Mother enroll the newborn in her employer sponsored insurance plan requires an answer Mother s Information eee Paien S Date of Birth Kk kk kkk k ssn 2336 Edit Mailing Address kkkkk ok ake ok ake kok kk City State Zip DENHAM SPRINGS LA 70726 Phone Number Is the mother covered by medicaid Yes No Applied Yes No Date Applied Will the Mother enroll the newborn in her employer sponsored insurance plan Yes No al Mother s Employment If details regarding the mother s employment are known fill in the provided fields This section is not Mother s Employment Employer Telephone Pp required Father s Information If details about the father are known fill in the provided fields This section is not required Father s Information Name Date of Birth SSN Mailing Address City State Zip v Phone Number Is the father cove
124. port services provided by RN TS To be used to report interperiodic screenings Physician Interperiodic screening codes Procedure Modifier Description Code 99391 Interperiodic Re evaluation and Management infant under 1 year 99392 Interperiodic Re evaluation and Management ages 1 4 99393 Interperiodic Re evaluation and Management ages 5 11 99394 Interperiodic Re evaluation and Management ages 12 17 99395 Interperiodic Re evaluation and Management ages 18 21 TS To be used to report Interperiodic screening Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 69 Provider Services 1 888 922 0007 01 2015 Appendix Family Planning Submit claims via CMS 1500 UB 04 or via 837 Format AmeriHealth Caritas Louisiana members may access family planning services through any family planning clinic or provider without a referral Some services may require prior authorization Certain services such as abortion sterilizations and hysterectomy require the submission of a consent form with the claim FQHC RHC EPSDT Claim Filing Instructions e Bill using the CMS 1500 UB 04 or via 837 Format e EPSDT Services are billed with HCPCS Code T1015 with EP modifier and detail level procedure codes e Procedure cod
125. r that are returned to the provider or EDI claim processing system e Rejected claims are not registered in the claim processing system and can be resubmitted as a new claim Denied claims are registered in the claim processing system but do not meet requirements for payment under AmeriHealth Caritas Louisiana guidelines They should be resubmitted as a corrected claim e Denied claims must be re submitted as corrected claims within 180calendar days from the date of service if the error is a repairable edit Note These requirements apply to claims submitted on paper or electronically For more information on EDI review the section titled Electronic Data Interchange EDI for Medical and Hospital Claims in this booklet Provider Services 1 888 922 0007 01 2015 Claim Mailing Instructions Submit claims to AmeriHealth Caritas Louisiana at the following address AmeriHealth Caritas Louisiana Claims Processing Department P O Box 7322 London KY 40742 The Plan encourages all providers to submit claims electronically For those interested in electronic claim filing contact your EDI software vendor or Emdeon s Provider Support Line at 877 363 3666 to arrange transmission Any additional questions may be directed to the AmeriHealth Caritas Louisiana EDI Technical Support Hotline at 866 428 7419 or by e mail at edi amerihealthcaritasla com Claim Filing Deadlines Original invoices must be submitted to t
126. r EDI software vendor or Emdeon to verify you receive the reports necessary to obtain this information Important When you receive the Rejection report from Emdeon or your EDI vendor the plan does not receive a record of the rejected claim Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 55 Provider Services 1 888 922 0007 01 2015 Common Rejections Invalid Electronic Claim Records Common Rejections from Emdeon Claims with missing or invalid batch level records Claim records with missing or invalid required fields Claim records with invalid unlisted discontinued etc codes CPT 4 HCPCS ICD 9 or ICD 10 etc Claims without member numbers Invalid Electronic Claim Records Common Rejections from the Plan EDI Edits within the Claim System Claims received with invalid provider numbers Claims received with invalid member numbers Claims received with invalid member date of birth Resubmitted Professional Corrected Claims Providers using electronic data interchange EDI can submit professional corrected claims electronically rather than via paper to AmeriHealth Caritas Louisiana A corrected claim is defined as a resubmission of a claim with a specific change that you have made such as ch
127. r of the insured is known to potentially be involved in paying this claim Line A refers to the primary payer B secondary and C tertiary Diagnosis and The qualifier that denotes the version Procedure Code of International Classification of Qualifier ICD Diseases ICD reported Version Indicator 67 Prin Diag Cd and The ICD codes describing the Present on principal diagnosis 1 e the condition Admission POA _ established after study to be chiefly Indicator responsible for occasioning the admission of the patient for care 67 A 7A Q Other Diagnosis The ICD diagnoses codes corresponding to all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received and or the length of stay Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital stay LE Admitting The ICD diagnosis code describing Diagnosis Code the patient s diagnosis at the time of admission Required for inpatient and outpatient admissions Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 27 Provider Services 1 888 922 0007 01 2015 UB 04 EDI Mapping Required for all outpatient visits Up to three ICD codes may be entered in f
128. r s name address NPI number or tax identification number s must be reported to AmeriHealth Caritas Louisiana immediately Contact your Network Management Representative to assist in updating the AmeriHealth Caritas Louisiana s records Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 48 Provider Services 1 888 922 0007 01 2015 Electronic Data Interchange EDI Quick Tips Electronic Data Interchange EDI for Medical and Hospital Claims Electronic Data Interchange EDI allows faster more efficient and cost effective claim submission for providers EDI performed in accordance with nationally recognized standards supports the health care industry s efforts to reduce administrative costs The benefits of billing electronically include e Reduction of overhead and administrative costs EDI eliminates the need for paper claim submission It has also been proven to reduce claim re work adjustments e Receipt of clearinghouse reports makes it easier to track the status of claims e Faster transaction time for claims submitted electronically An EDI claim averages about 24 to 48 hours from the time it 1s sent to the time it is received This enables providers to easily track their claims e Validation of d
129. r to ensure prompt and accurate processing Member Name Missing The name of the member must be present on the claim form and must match the information on file with the Plan Member Plan Identification Number Missing or Invalid AmeriHealth Caritas Louisiana s assigned identification number must be included on the claim form or electronic claim submitted for payment Newborn Claim Information Missing or Invalid Always include the first and last name of the mother and baby on the claim form If the baby has not been named insert Baby Girl or Baby Boy in front of the mother s last name as the baby s first name Venfy that the appropriate last name is recorded for the mother and baby Payer or Other Insurer Information Missing or Incomplete Include the name address and policy number for all insurers covering the Plan member Important Submitting the original copy of the claim form will assist in assuring claim information is legible Important The individual provider name and NPI number as opposed to the group NPI number must be indicated on the claim form Important Do not highlight any information on the claim form or accompanying documentation Highlighted information will become illegible when scanned or filmed Important Do not attach notes to the face of the claim This will obscure information on the claim form or may become separated from the claim prior to scanning Important Subm
130. r to the NUCC or NUBC Reference Manuals for additional information 41 Provider Services 1 888 922 0007 www amerihealthcaritasla com 01 2015 Supplemental Information Special Instructions and Examples for CMS 1500 UB 04 and EDI 837 Claims Submissions I Supplemental Information A CMS 1500 Paper Claims Field 24 Important Note All unspecified Procedure or HCPCS codes require a narrative description be reported in the shaded portion of field 24 The shaded area of lines through 6 allow for the entry of 61 characters from the beginning of 24A to the end of 24G The following are types of supplemental information that can be entered in the shaded lines of Item Number 24 e Anesthesia duration in hours and or minutes with start and end times e Narrative description of unspecified codes e National Drug Codes NDC for drugs and then leave 1 space and enter qualifiers F2 International Unit ML Milliter GR Gram UN Unit e Vendor Product Number Health Industry Business Communications Council HIBCC e Product Number Health Care Uniform Code Council Global Trade Item Number GTIN formerly Universal Product Code UPC for products e Contract rate The following qualifiers are to be used when reporting these services 7 Anesthesia information ZZ Narrative description of unspecified code all miscellaneous fields require this section be reported N4 National Drug Codes VP Vendor Product Number Healt
131. rate line item with its appropriate NDC e Enter the drug name and strength e Enter the NDC quantity unit qualifier o F2 International Unit o GR Gram o ML Milliliter o UN Unit e Enter the NDC quantity Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 43 Provider Services 1 888 922 0007 01 2015 Supplemental Information o Do not use a space between the NDC quantity unit qualifier and the NDC quantity o Note The NDC quantity is frequently different than the HCPC code quantity Example of entering the identifier N4 and the NDC number on the CMS 1500 claim form NA qualifier NA qualifier NDC Unit Qualifier lata OF SERVICE B C D PROCEDURES SERVICES OR SUPPLIES E F G THRA opie Unueuai Coumetaced DIAGNOSIS Pa i ro RENDERING DO YY MM w OD YY SERVICE EMG CPT HCPCS MODIFIER POINTER CHARGES UNITS un PROVIDER iD t 148001665 UN a G2 12345678901 10 01 05 10 O1 05 10 01 05 J0400 250 00 40 nei 0123456789 11 digit NDC NDC Quantity 2 NDC on UB 04 J e NDC should be entered in Form Locator 43 in the Revenue Description Field e Report the N4 qualifier in the first two 2 positions left justified o Do not enter spaces o Enter the 11 character NDC number in the 5 4 2 format no hyph
132. red under health insurance coverage Yes No Name of Insurance Company Father s Employment If details regarding the father s employment are known fill in the provided fields This section is not Father s Employment Employer PT Telephone required 14 Other Contact 1 and 2 If additional contact information for the family is known fill in the Other Contact sections Other Contact 1 Other Contact 2 Newborn Section Depending on the number of births there may be more than one New Born section The following information is required in these sections Birth Weight Gestation Age and NICU information gt New Born 1 Name on Birth Certificate First Middle Last Suffix Name John Smith Jr F Birth Date 04 22 2013 6 oz 2 1 White Sex Male Female Births Single Multiple 39 Adopted Yes No Yes No Health Insurance Primary Plan and Secondary Plan If information regarding a primary or secondary plan are known fill in the fields provided in these sections These sections are not required Insurance Notification If information for an insurance company or insurance representative are known fill in the fields provided in this section This section is not required Additional Information If you feel additional information notes or further explanation is needed use the text box provided in this section Submitting a Third Par
133. rized persons from viewing the actual password Once both username and password are entered either click the Login button or press the Enter key If any information is incorrect or invalid you will be redirected to the login screen and prompted to make corrections before continuing NOTE In the left menu of the login screen there are links for blank forms If the system is unavailable or you are unable to log in you may still submit information to DHH by selecting a form to download print and mail Department of Health and Hospitals RTMENT edicaid Program eyed OF AND HOSPITALS Medicaid Blank Forms 142BH o 142BH Blank Forms 148 o Blank Forms 148W o Linkage o Discharge Status Change Blank Forms Newborn Request o Newborn Request o TPL s Contact Us User Manuals Training Videos o 1 Reset or Change Password Your username will always be your email address If you require a password reset or change there are Reset Password and Change Password options on the Login screen Your new password will be sent to you via email Completing a Newborn Request Newborn Once logged in you ll be directed to the main FNS screen shown below If not already selected for you choose the Newborn Request option from the dropdown provided in the Select Form Type section Select Form Type Form Type Newborn Request New Applicant Applicant Search Search Results Please
134. rmation Recipient Name MEDS Person No Physician Name Provider No Payment by Louisiana s Medicaid Program cannot be authorized for any hysterectomy performed solely for the purpose of rendering an individual permanently incapable of reproducing or where if there is more than one purpose for the procedure the hysterectomy would not be performed except for the purpose of rendering the individual permanently incapable of reproducing Medicaid payment for a medically indicated hysterectomy can be authorized only if 1 the individual and her representative if any are informed orally and in writing that the hysterectomy will render her permanently incapable of reproducing and 2 the individual and her representative if any have signed a written acknowledgment of receipt of that information The written acknowledgment must be signed and dated prior to the operation and must be attached to the claim form when it is submitted for payment A representative is that person who has the legal authority to act for an individual For purposes of this acknowledgment a representative shall be defined as either the curator of an interdicted woman or the tutor or parent of an unmarried minor A minor emancipated by marriage is deemed capable of acting for herself in the matter hereby acknowledge that have been informed orally and in writing that a hysterectomy surgical removal of the uterus will render a woman permanently inc
135. rom the Multiple Child Birth dropdown an additional section will appear asking How many births From the dropdown provided choose the number of births The number chosen in this dropdown will dictate the number of personal information fields provided for each baby born Complete the appropriate sections If the Expired box is checked you must fill in the baby s date of death You are required to answer the question Does the mother of the newborn have private health insurance coverage PART lil CHILD BIRTH INFORMATION Multiple Child Birth Yes How many births 2 Child s Name 1 i John Smith dJ F First Ml Lasi Sufix Child s DOB 0422 2013 Gender Male hi C Expired Race 1 White 7 Chh Name 2 Smith lt First Mi Last Suffix Child s DOB 04 22 2013 Gender Female hi i 04 23 2013 Race 1 White Does the mother of the newborn have private health insurance coverage Yes No Part IV Provider Information To complete Part IV click the Find Doctor hyperlink at the top of this section PART IV Only enter information for providers that are able to bill Medicaid for the newborn Name First MI Last Suffix Mailing Address Address 2 City State Zip Email Phone Find coi Fax The Find A Doctor window will appear Search for the appropriate doctor using the Name City and or Zip Code fields and click Search City Zip Code ert Sean Based on the criteria yo
136. ropriate procedure code s 90466 90468 90472 and 90474 Immunization administration each additional injection administration vaccine should then be Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 72 Provider Services 1 888 922 0007 01 2015 Appendix listed with the appropriate number of units for the additional vaccines placed in the units column The specific vaccines should then be listed on subsequent lines The number of specific vaccines listed after CPT administration codes should match the number of units listed in the units field e Use CPT Codes 90466 and or 90468 with 90465 OR 90467 to report more than one vaccine administered Do NOT use CPT Codes 90466 and or 90468 with 90471 or 90473 e Use CPT Codes 90472 and or 90474 with 90471 OR 90473 to report more than one vaccine administered Do NOT use CPT Codes 90472 and or 90474 with 90465 or 90467 Hard Copy Claim Filing for Greater Than Four Administrations e When billing hard copy claims for more than four immunizations and the six line claim form limit is exceeded providers should bill on two CMS 1500 claim forms The first claim should follow the instructions above for billing the single administration A second CMS 1500 claim form should be used to
137. rs RPC followed by the details of the original claim as per contract instructions o DME Claims requiring specific instructions should begin with DME followed by specific details C EDI Field 33b Professional Field 33b Other ID Professional 2310B loop REFO1 G2 REFO2 Plan s Provider Network Number Less than 13 Digits Alphanumeric Field is required Note do not send the provider on the 2400 loop D EDI Field 45 and 51 Institutional Field 45 Service Date must not be earlier than the claim statement date Service Line Loop 2400 DTP 472 Claim statement date Loop 2300 DTP 434 Field 51 Health Plan ID the number used by the health plan to identify itself AmeriHealth Caritas Louisiana s Health Plan EDI Payer ID is 27357 E EDI Reporting DME DME Claims requiring specific instructions should begin with DME followed by specific details Example NTE DME AEROSOL MASK USED W DME NEBULIZER Example NTE ADD NO LIABILITY PATIENT FELL AT HOME F Reporting NDC on CMS 1500 and UB 04 and EDI 1 NDC on CMS 1500 e NDC should be entered in the shaded sections of item 24A through 24G e To enter NDC information begin at 24A by entering the qualifier N4 and then the 11 digit NDC information o Do not enter a space between the qualifier and the 11 digit NDC number o Enter the 11 digit NDC number in the 5 4 2 format no hyphens o Do not use 99999999999 for a compound medication bill each drug as a sepa
138. s to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 50 Provider Services 1 888 922 0007 01 2015 Electronic Data Interchange EDI Quick Tips Electronic Claims Submission EDI The following sections describe the procedures for electronic submission for hospital and medical claims Included are a high level description of claims and report process flows information on unique electronic billing requirements and various electronic submission exclusions Hardware Software Requirements There are many different products that can be used to bill electronically As long as you have the capability to send EDI claims to Emdeon whether through direct submission or through another clearinghouse vendor you can submit claims electronically Contracting with Emdeon and Other Electronic Vendors If you are a provider interested in submitting claims electronically to the Plan but do not currently have Emdeon EDI capabilities you can contact the Emdeon Provider Support Line at 877 363 3666 You may also choose to contract with another EDI clearinghouse or vendor who already has Emdeon capabilities Contacting the EDI Technical Support Group Providers interested in sending claims electronically may contact the EDI Technical Support Group for information and assistance in beginning electronic submissions When ready to proceed e Read over the instru
139. t LJ Yes U No EDC OB Practitioner For AmeriHealth 6087 UM Disclaimer Admissions 1A01 Caritas Louisiana Use Only The case reference number is for identification purposes only Authorization is based on medical necessity and is subject to member eligibility and applicable Plan benefit Case limitations This is not a guarantee of payment Member 2 Date of Admission AmeriHealth Caritas Louisiana must be notified on the first business day following date of service ___ Member ID DOB Member Name a Type of Admission Q Inpatient O Medical Observation less than 23 hours stay LI Short Procedure J Obstetric Observation less than 23 hours stay Diagnosis Reason for Admission Attending Physician AmeriHealth Caritas Louisiana Provider ID Procedures Performed must be completed for SPU Admissions Is Member Pregnant LJ Yes U No EDC OB Practitioner For AmeriHealth 6087 UM Disclaimer Admissions 1A01 The case reference number is for identification purposes only Authorization is based on medical necessity and is subject to member eligibility and applicable Plan benefit limitations This is not a guarantee of payment Caritas Louisiana Return response by W Fax UPhone This will be returned by the next business day If not indicated will be faxed AmeriHealth Caritas Louisiana APPENDIX 10 BHSF Form 96A Revised 05 06 Medicaid Program Acknowledgment of Receipt of Hysterectomy Info
140. tal observation service per hour HCPCS Code G0379 Direct admission of patient for hospital observation care Outpatient Hospital Services Providers are required to bill a revenue code on the Louisiana Medicaid FFS Hospital Outpatient Fee Schedule Most outpatient services must be billed with a CPT or HCPCS code Please see list Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 75 Provider Services 1 888 922 0007 01 2015 Appendix below of revenue codes that require valid hcpc cpt code when billed on OP UBO4 Drugs are required to be billed with NDC information valid NDC NDC units and NDC unit of measure The below revenue codes require a valid HCPC CPT code to be billed in order for the line to be reimbursable Rev Code HR251 HR252 HR258 HR259 HR260 HR261 HR269 HR278 HR300 HR301 HR302 HR303 HR304 HR305 HR306 HR307 HR309 HR310 HR311 HR312 HR314 HR319 HR320 HR321 HR324 HR329 HR330 HR33 1 HR332 HR333 HR335 HR339 HR340 HR341 HR342 HR349 Description PHARMACY GENERIC DRUGS PHARMACY NON GENERIC DRUGS PHARMACY IV SOLUTIONS PHARMACY OTHER PHARMACY IV THERAPY INFUSION PUMP OTHER IV THERAPY OTHER IMPLANTS LABORATORY GEN CLASSIFICATION LAB CHEMISTRY LAB IMMUNOLOGY LAB RENAL PA
141. the Resume Later button 12 Newborn Eligibility ID Assignment Request has been successfully submitted Press Continue to fill out the TPL Notification of Newborn Child ren form Click here to view or print the completed form In accordance with the Department of Health and Hospitals Third Party Liability Newborn Notification Rule the TPL Notification of Newborn Child ren form shall be completed by the hospital and submitted within seven days of the birth of a newborn child ED coins Hosen tte After clicking Continue the Third Party Liability form will appear prepopulated with the information from the Newborn Request Confirm that the Current Location at the top of the form is correct If it is not choose the location from the dropdown menu mp Current Location k k KR KK RK Rok RoR K K K k k K KK k k k x Hospital Information Complete the following required fields in the Hospital Information section Date Was the newborn delivered in your facility Facility Provider No Discharge Date Will the attending provided accept health insurance as Primary and Medicaid as Secondary and Was the newborn discharged to another facility If the newborn was discharged to another facility the Facility Name and Telephone No are required gt Hospital Information Date 04 23 2013 Hospital Name BATON ROUGE CLINIC AMC THE Phone Number 225 769 4044 Contact Person Suzie Summer Contact Person Email Was the newborn delivered in y
142. the non NPI number followed by the ID number Do not enter a space hyphen or other separator between the qualifier and number Required R fields must be completed on all claims Conditional C fields must be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 1 Provider Services 1 888 922 0007 01 2015 EDI Mapping for CMS 1500 CMS 1500 Claim EDI Mapping CMS 1500 Claim EDI Mapping Insurance Program Identification Insured ID Number AmeriHealth Caritas Louisiana member s identification number Patient s Name Last First Middle Initial Insured s Name Last First Middle Initial 1 la 2 3 5 Patient s Address Number Street City State Zip Telephone Include Area Code 7 Insured s Address Number Street City State Zip Code Telephone Include Area Code Other Insured s Name Last First Middle Initial Other Insured s Policy Or Group Patient s Birth Date Sex 2010CA DMG02 2010CA DMG03 6 Patient Relationship To Insured 2000C PATO1 Field Field Description Instructions and Comments Required or Conditional Check only the type of health coverage applicable to the claim This field indicates the payer to whom the claim is being filed 2330A NM109 2010BA NM103 2010BA NM1 04 2010CA NM105 2010CA NM107 2010BA
143. tion or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerihealthcaritasla com 4 Provider Services 1 888 922 0007 01 2015 CMS 1500 Claim Form Field Requirements RC Insured s Address Number Street City State Zip Code Telephone Include Area Code Reserved for NUCC use Other Insured s Name Last First Refers to someone other than the Middle Initial patient Completion of fields 9a through 9d is Required if patient is covered by another insurance plan Enter the complete name of the insured Not Required Other Insured s Policy Or Group Required if 9 is completed Input the 6 digit TPL carrier code if 9a is completed from Medicaid Eligibility Verification System MEVS Reserved for NUCC use Not Required 9c Reserved for NUCC use Not Required Insurance Plan Name Or Program Required if 9 is completed C Name Is Patient s Condition Related To Indicate Yes or No for each category Is condition related to 10a b c a Employment b Auto Accident c Other Accident 10d Claim Codes Designated by Enter new Condition Codes as NUCC appropriate Available 2 digit condition codes include nine codes for abortion services and four codes for worker s compensation Please refer to NUCC for the complete list of codes Examples include AD Abortion Performed due to a Life Endangering Physical Condition Caused by Arising from
144. ty Liability TPL At the bottom of the TPL form click Submit to send the form to Medicaid click Save Draft to save your work and resume later or click Cancel to stop working on the form Cancelling the form will delete any work you ve done thus far 15 When you click Submit one of two things will occur If successful you ll be returned to the home page of the Facility Notification System If unsuccessful you ll be directed to the top of the TPL form where you ll see an error message detailing what required information was missing from the form See an example of the error message below E An error message was returned from the submission web service Unable to save TPL request because of the following data validation errors Discharge date must be specified Newborn 1 Gestation age must be specified Newborn 2 Gestation age must be specified Once you ve updated the form to include the required information click Submit at the bottom of the form Resuming a TPL Draft The TPL form can be saved as a draft and finished at a later time Follow the same process as shown in Resuming a Newborn Request Resources DHH has provided you with several useful resources in the Facility Notification System Contact Us In the left menu of FNS there is a Contact Us hyperlink that will direct you to DHH and Medical Vendor Administration contact information Louisiana Department of Health and Hospitals Medical Vendor Adm
145. u enter for the search the filtered results will appear in the Find A Doctor window Depending on the number of results you may need to move to the next page of search results to find the appropriate doctor Click the Select hyperlink next to the appropriate Provider Name Select Select Select Select Select Select Select Select Select Select Select Provider A STEP FORWARD 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 0000 City Zip Code Phone 225 751 1777 Fax N A Email example email com A STEP FORWARD 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 0000 Phone 225 751 1777 Fax N A Email A STEP FORWARD INC 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 5217 Phone 225 751 1777 Fax N A Email A STEP FORWARD INC 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 0000 Phone 225 751 1777 Fax N A Email A STEP FORWARD INC 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 0000 Phone 225 751 1777 Fax N A Email A STEP FORWARD INC 14918 JEFFERSON HWY BATON ROUGE BATON ROUGE LA70817 0000 Phone 225 751 1777 Fax N A Email ABRAMS JR MATHEW MD N A N A N A N A N A 500 RUE DE LA VIE STE 410 BATON ROUGE BATON ROUGE LA70617 5126 Phone 225 929 7070 Fax N A Email ADERHOLD LAWRENCE COD 5237 JONES CREEK RD BATON ROUGE BATON ROUGE LA70817 0000 Phone 225 755 3937 Fax N A Email AGAPE PERSONAL CARE SERVICE
146. ure delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual s signature on the consent form In those cases the second paragraph below must be used Cross out the para graph which is not used 1 At least thirty days have passed between the date of the individual s signature on this consent form and the date the sterilization was performed 2 This sterilization was performed less than 30 days but more than 72 hours after the date of the individual s signature on this consent form because of the following circumstances check applicable box and fill in information requested _ Premature delivery Individual s expected date of delivery E Emergency abdominal surgery describe circumstances Physician s Signature Date PAPERWORK REDUCTION ACT STATEMENT According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number The valid OMB control number for this information collection is 0937 0166 The time required to complete this information collection is estimated to average 1 hour 15 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection If you have comments concerning the accuracy of the time estimate s or suggestions for improving this form please write to
147. urse This certification of terminal illness is based on my clinical judg ing the normal course of the individual s illness SIGNATURES Physicians must date at time of signature Signature of Attending Physician Date Signed MM DD YYYY Printed Name of Above Attending Physician Signature of Hospice Medical Director or Physician Member of I nterdisciplinary Group IDG Date Signed MM DD YYYY Printed Name of Above Hospice Medical Director or Physician Member of IDG SECOND BENEFIT PERIOD 90 Days Having reviewed this patient s medical record and or examination of the patient certify this patient s prognosis Is for a life expectancy of six months or less if the terminal illness runs its normal course This certification of terminal illness is based on my clinical judgment regarding the normal course of the individual s illness SI GNATURES Physicians must date at time of signature Signature of Hospice Medical Director or Physician Member of I nterdisciplinary Group IDG Date Signed MM DD YYYY Printed Name of Above Hospice Medical Director or Physician Member of IDG THIRD BENEFIT PERI OD 60 Days Having reviewed this patient s Medical record and or Examination of the patient certify this patient s prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course This certification of terminal illness is based on my clinical judg ing the normal course of the indivi
148. useesceeees 42 C EDI Field 330 Professional j neirinne aiaiai aiaia 43 D EDI Field 45 and 51 Institutional oo ec cccccscccecceecesseeseesseessesseessessensees 43 E BEDE Report ng DM Biviiccsdacscscacesedacacececicndacaceactccesacatesaiasabaiadaaadaaaiassaeasasataesaiaaeianeianideas 43 F Reporting NDC on CMS 1500 and UB 04 and EDI ceccccceeeeeeeeseeseeeeaeeees 43 Common Causes of Claim Processing Delays Rejections or Dentals ccceeccceseeeeeeeeeeees 46 Electronic Data Interchange EDI for Medical and Hospital Claims cc cece cseeeceneeeeeeeees 49 Electronic Claims Submission EDD ou 0 ccc ceccecceeccecceceecceeceecesceeceeceecesceeseeeseesesseseeeesens 51 Hardware Software Requirements ccccccccccssesccccesescecceeecceseesceeseeesceeseeeeceesaeeseeseaeeseesaees 51 Contracting with Emdeon and Other Electronic Vendors ccccccccsseeeceeeeeceeeseeeaeseeeaeeeees 51 Contacting the EDI Technical Support Group ccccceccccseseccseeeceeeeceeeeeeeeeaeseeeeseeeaeseeeseseees 51 Spec tae Dita Record Require MENUS sssrin E EE 53 Flccironc Clam Flow Descnhphon soisi O REEE 54 Invalid Electronic Claim Record Rejections Dentals cccccseecccceseecceeaeeseceeseeseeseaeseesaees 55 Plan Specific Electronic Edit Requirements cccccccccseeececeeeeececeeeeceeeeensceesaeeseeeaeseeseaees 55 BOVIS ONG teresa store tae E seat neatee E T E E E E EA EA A 55 Common Ree ONS o
149. ust be completed if the information applies to the situation or the service provided Refer to the NUCC or NUBC Reference Manuals for additional information www amerthealthcaritasla com 73 Provider Services 1 888 922 0007 01 2015 Appendix Initial Prenatal Visits must be billed with modifier TH in the first position after the CPT code 99201 99205 Follow Up Prenatal Visits must be billed with modifier TH in the first position after the CPT code 99211 99215 Postnatal Visits CPT code 59430 Delivery The most appropriate CPT code should be billed for deliveries In cases of multiple births twins triplets etc the diagnosis code must indicate a multiple birth Modifier 22 for unusual circumstances should be used with the most appropriate CPT code for a vaginal or C Section delivery when the method of delivery is the same for all births If the multiple gestation results in a C Section delivery and a vaginal delivery the provider should bill the most appropriate CPT code for the C Section delivery without a modifier and should also bill the most appropriate CPT code for the vaginal delivery and append modifier 51 Acute Level of Description Revenue Code Care NICU Nursery Neonatal NICU payment is eligible if authorized for admission to NICU unit Provider should bill Revenue Code 174 Border Baby Nursery Border Baby Rate is only payable if baby is detained and services not approved as NICU Provider s
150. voids etc The first digit is a leading zero Do not include the leading zero on electronic claims Taxonomy The provider s taxonomy number is required if needed by the plan to determine the provider s plan ID when using NPI only is not effective Important The individual service provider name and NPI number must be indicated on all claims including claims from outpatient clinics Using only the group NPI or billing entity name and number will result in rejections denials or inaccurate payments Important When the provider or facility has more than one NPI number use the NPI number that matches the services submitted on the claim form Imprecise use of NPI numbers results in inaccurate payments or denials Important When submitting electronically the provider NPI number must be entered at the claim level as opposed to the claim line level Failure to enter the provider NPI number at the claim level will result in rejection Please review the rejection report from the EDI software vendor each day Important Claims without the provider signature will be rejected The provider is responsible for re submitting these claims within 180 calendar days from the date of service Important Claims without a tax identification number TIN will be rejected The provider is responsible for re submitting these claims within 180 calendar days from the date of service Important Any changes ina participating provide
151. ys Rejections or Denials Authorization Number Invalid or Missing A valid authorization number must be included on the claim form for all services requiring prior authorization from AmeriHealth Caritas Louisiana Attending Physician ID Missing or Invalid Inpatient claims must include the name of the physician who has primary responsibility for the patient s medical care or treatment and the medical license number on the appropriate lines in field number 82 Attending Physician ID of the UB 04 claim form A valid medical license number is formatted as two alpha six numeric and one alpha character AANNNNNNA OR two alpha and six numeric characters AANNNNNN Billed Charges Missing or Incomplete A billed charge amount must be included for each service procedure supply on the claim form Diagnosis Code Missing 4 or 5 Digit Precise coding sequences must be used in order to accurately complete processing Review the ICD 9 CM or ICD 10 CM manual for the 4 and 5 digit extensions Look for the V4 or 5 symbols in the coding manual to determine when additional digits are required Diagnosis Procedure or Modifier Codes Invalid or Missing Coding from the most current coding manuals ICD 9 CM ICD 10 CM CPT or HCPCS is required in order to accurately complete processing All applicable diagnosis procedure and modifier fields must be completed EQOBs Explanation of Benefits from Primary Insurers Missing or Incomplete

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