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Commonwealth of Kentucky KY Medicaid Provider

1. De ae tue HELL dig d 1 1 2 1 Plastic Swipe KY Medicaid 2 2 1 2 2 Member Eligibility Categories 0 22 0 0000 1 scenes 3 1 2 3 Verification of Member 5 2 Electronic Data Interchange 7 2 1 HOW Te Get SIarted inei te a eie d eau aae ei aux 7 2 2 Format and Testing e tee o ue etd 7 2 9 E 7 2 4 Companion Guides for Electronic Claims 837 7 3 eer eee err eti shen exes ee ee eret 8 3 1 How Io Get Started tai ee citing tee eri ARRA eeu 8 3 2 KyHealth Net Companion 2 4 0 nennen enne 8 4 General Billing Instructions for Paper Claim Forms 9 AT General Instr ctioris 3 odii oa dore ea cci pr va cope 9 4 2 uicti iia itis a iaa adi idit 9 4 3 Optical Character enne 9 5 Additional Information and Forms 4 224 1 0511 10 5 1 Claims with Dates of
2. 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS I certify that the statements on the reverse apply to this bill and are made a part thereof NUCC Instruction Manual available at www nucc org PLEASE PRINT OR TYPE APPROVED OMB 0938 1197 FORM 1500 02 12 12 12 2013 Page 41 7 5 Completion of New CMS 1500 02 12 Claim Form With NPI and Taxonomy 7 5 1 Detailed Instructions Claims are returned or rejected if required information is incorrect or omitted Handwritten claims must be completed in black ink ONLY The following fields must be completed FIELD NUMBER FIELD NAME AND DESCRIPTION Insured s I D Number Enter the 10 digit Member Identification number exactly as it appears on the current Member Identification card Patient s Name Enter the member s last name first name and middle initial exactly as it appears on the Member Identification card Date of Birth Enter the date of birth for the member Other Insured s Name Enter the Insured s Name Required only if member is covered by insurance other than Medicaid or Medicare and the other insurance has made a payment on the claim Required only if member is covered by insurance other than Medicaid or Medicare and the other insurance has made a payment on the claim If this field is completed also complete Fields 9D and 29 NOTE If other insurance denies the submitted claim leave Fields 9 9A 9D and 29 blank and attach d
3. Form Locator 6 is not the actual discharge date and Form Locator 4 indicates Final Bill 12 12 2013 Page 26 Date of Birth Enter the Member s date of birth Enter the code for the time of admission to the facility Admission hour is required for both inpatient and outpatient services Patient Status Code Enter the appropriate two digit patient status code indicating the disposition of the patient as of the through date in Form Locator 6 Medicare EOMB Date Enter the EOMB date from Medicare if applicable 39 41 Value Codes Enter the appropriate value code s for Medicare Medicaid crossover claims A1 Deductible Payer A Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due Attach EOMB A2 Coinsurance Payer A Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due Attach EOMB B1 Deductible Payer B Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due Attach EOMB B2 Coinsurance Payer B Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due Attach EOMB 80 Covered Days Enter the total number of covered days from Form Locator 6 Data entered in Form Locator 39 must agree with accommodation units in Form Locator 46 82 Coinsurance Days Enter the number of coinsurance days billed to the Medicaid Program during this billing period Atta
4. codes listed throughout the Remittance Advice is defined in this section Summary EOB Code Descriptions Any Explanation of Benefit Codes EOB which appear in the RA are defined in this section NOTE For the purposes of reconciliation of claims payments and claims resubmission of denied claims it is highly recommended that all remittance advices be kept for at least one year 12 12 2013 Page 54 10 2 Title The header information that follows is contained on every page of the Remittance Advice REPORT CRA XBPD R COMMONWEALTH OF KENTUCKY M1 DATE 01 25 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE CLAIM TYPE The type of claims listed on the Remittance Advice PROVIDER NAME The name of the provider that billed The type of provider is listed directly below the name of provider PAYEE ID The eight digit Medicaid assigned provider ID of the billing provider The NPI number of the billing provider The category type of page begins each section and is centered for example PAID CLAIMS All claims contained in each Remittance Advice are listed in numerical order of the prescription number 10 3 Banner Page All Remittance Advices have a banner as the first page The banner page contains provider specific information regarding upcoming meetings and workshops top ten billing errors policy updates billing changes etc Please pay close a
5. CREATION DATE 013107 s 0 E fafano T t oice Bi OTHER SB INSURED S NAME 51 HEALTH PLAN ID 59 REL 60 INSURED S UNIQUE 10 2 INSURANCE GROUP NO DOE 65 EMPLOYER qe oop Om 76 ATTENDING ust JONES _ roewme uer pulos Just neum THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF 08 04 OMS 1450 nit Marg Come 009213257 12 12 2013 30 6 4 Completion of UB 04 Claim Form With NPI Alone 6 4 1 Detailed Instructions The following is a representative sample of codes and or services that may be covered by KY Medicaid NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the NPI number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim FIELD NUMBER FIELD NAME AND DESCRIPTION Provider Name Address and Telephone Enter the complete name address and telephone number including area code of the facility Patient Control Number Enter the patient control number The first 14 digits aloha numeric will appear on the remittance advice as the invoice number Type of Bill Enter the appropriate code to indicate the type of bill 3rd Digit Bill Classification 4 Outpa
6. B1 Deductible Payer B Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due Attach EOMB B2 Coinsurance Payer B Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due Attach EOMB 80 Covered Days Enter the total number of covered days from Form Locator 6 Data entered in Form Locator 39 must agree with accommodation units in Form Locator 46 82 Coinsurance Days Enter the number of coinsurance days billed to the Medicaid Program during this billing period Attach EOMB 83 Life Time Reserve Days 12 12 2013 Page 32 Revenue Codes Enter the four digit revenue code identifying specific accommodation and ancillary services NOTE Total charge Revenue code 0001 must be the final entry in column 42 line 23 Total charge amount must be shown in column 47 line 23 Creation Date Enter the invoice date or invoice creation date Enter the quantitative measure of services provided per revenue code Total Charges Enter the total charges relating to each revenue code for the billing period The detailed revenue code amounts must equal the entry total charges NOTE Enter the total claim charge in field 47 line 23 Payer Identification KY Medicaid is payer of last resort Note If you are billing for a replacement policy to Medicare Medicare needs to be indicated instead of the name of replacement policy Medicare Paid Amo
7. 9 3 Accounts Fteceivable 5 cocco Cette eo e ai co deret 68 10 10 Summary Page etre eaaet etate et dtd fo 72 10 10 1 Payme S deco bem teet 72 Appendix Rr 76 11 1 Remittance Advice Location Codes LOC 76 Appendix ere cand nln dn aa Re Tre A a A aan aaa 77 12 1 Remittance Advice Reason Code ADJ RSN CD or RSN CD 77 Appendix F 5 er eere bene rere tte rir ei eere 80 13 1 Remittance Advice Status Code ST 80 12 12 2013 Page ii 1 General 1 General 1 1 Introduction These instructions are intended to assist persons filing claims for services provided to Kentucky Medicaid Members Guidelines outlined pertain to the correct filing of claims and do not constitute a declaration of coverage or guarantee of payment Policy questions should be directed to the Department for Medicaid Services DMS Policies and regulations are outlined on the DMS website at http chfs ky gov dms Regs htm Fee and rate schedules are available on the DMS website at http chfs ky gov dms fee htm 1 2 Member Eligibility Members should apply for Medicaid eligibility through their local Department for Community Based Services DCBS office Members with questions or concerns can contact Member Services at 1 800 635 2570 Monday through Friday This office is closed on Holidays The primary identification for M
8. Attending Physician NPI number Enter a 1G and the unique physician identification number UPIN followed by the last name and first name of the attending physician If the physician does not have a UPIN number enter the appropriate license number NOTE The UPIN number of the Attending Physician can be used for a limited time 12 12 2013 Page 34 7 Completion of CMS 1500 Claim Form The CMS 1500 claim form is used to bill services provided by Licensed Clinical Social Workers Psychologists Physical Therapists Physician Assistants and Occupational Therapists to eligible QMB members Following are billing instructions for required fields of information on the CMS 1500 claim form An original claim form and Medicare coding sheet must be sent to HP Enterprise Services P O Box 2101 Frankfort KY 40602 2101 12 12 2013 Page 35 7 1 Completion of Invoice CMS 1500 7 1 1 Crossover Medicare Medicaid 7 1 1 1 Original Submission to Medicare The AdminaStar Medicare office and the Medicaid Program has been mandated by CMS to exclusively use the CMS 1500 for billing purposes The CMS 1500 is a two part billing form Submit one copy to AdminaStar of Kentucky P O Box 37630 Louisville KY 40233 7630 Retain the second copy for your file If both the Medicare and the Medicaid blocks in field one of the CMS 1500 claim form are checked the YES block for accepting assignment in field 27 is checked and the provider
9. For the same or related service being billed on the claim and e The date of service specified on the remittance advice is no more than six months prior to the claim s date of service NOTE If the remittance statement does not provide a date of service the denial may only be acceptable by HP Enterprise Services if the date of the remittance statement is no more than six months from the claim s date of service 5 Letter from an employer that includes e Member name e Date of insurance or employee termination or effective date if applicable and e Employer letterhead or signature of company representative 5 4 3 When there is no response within 120 days from the insurance carrier When the other health insurance has not responded to a provider s billing within 120 days from the date of filing a claim a provider may complete a TPL Lead Form Write no response in 120 days on either the TPL Lead Form or the claim form attach it to the claim and submit it to HP Enterprise Services HP Enterprise Services overrides the other health insurance edits and forwards a copy of the TPL Lead form to the TPL Unit A member of the TPL staff contacts the insurance carrier to see why they have not paid their portion of liability 5 4 4 For Accident And Work Related Claims For claims related to an accident or work related incident the provider should pursue information relating to the event If an employer individual or an insurance carr
10. GROUP FE OTHER INSURED S 1 0 NUMBER For Program in Item 1 Meaicare meaicaia 9 2 PATIENT S i Name First Name Initial ATENTSE 3 4 INSURED S NAME Last Name First Name Middle initial 5 PATIENT S ADDRESS Street 6 PATIENT RELATIONSHIP TO INSURED 7 INSURED S ADDRESS No Street Self Spouse Child ote CITY STATE 8 PATIENT STATUS CITY STATE Single O Married Other L1 ZIP CODE TELEPHONE Include Area Code ZIP CODE TELEPHONE Include Area Code Full Time Part Time Employed Student Student L 8 OTHER INSURED S NAME Last Name First Name Middle Initial 10 18 PATIENT S CONDITION RELATED TO 11 INSURED S POLICY GROUP OR FECA NUMBER a OTHER INSURED S POLICY OR GROUP NUMBER EMPLOYMENT Current or Previous a INSURED DATE OF BIRTH SEX 40000000 ves e O b OTHER INSURED 8 DATE OF BIRTH SEX b AUTO ACCIDENT PLACE State 5 EMPLOYER S OR SCHOOL NAME f z NO EMPLOYER S NAME OR SCHOOL OTHER ACCIDENT INSURANCE PLAN NAME OR PROGRAM H m dd d INSURANCE PLAN NAME OR PROGRAM NAME 10d RESERVED FOR LOCAL USE 4 IS THERE ANOTHER HEALTH BENEFIT PLAN ves m NO If yes return to and complete item 9 a d READ BACK OF FORM BEFORE COMPLETING amp SIGNING THIS FORM 13 INSURED S OR AUTHORIZED PERSON S SIGNATURE authorize 12 PATIENT S OR AUTHORIZED PERSON S SIGNATURE authorize the release of any
11. INSURED S UNIQUE ID 61 GROUP NAME 000000004 pen 63 TREATMENT AUTHORIZATION CODES 84 DOCUMENT CONTROL NUMBER d OTHER PROCEDURE CODE DATE Comme 0 9213257 12 12 2013 25 6 2 Completion of UB 04 Claim Form with NPI and Taxonomy 6 2 1 Detailed Instructions The following is a representative sample of codes and or services that may be covered by KY Medicaid FIELD NUMBER FIELD NAME AND DESCRIPTION Provider Name Address and Telephone Enter the complete name address and telephone number including area code of the facility Patient Control Number Enter the patient control number The first 14 digits aloha numeric will appear on the remittance advice as the invoice number Type of Bill Enter the appropriate code to indicate the type of bill 3rd Digit Bill Classification 4 Outpatient Rehabilitation 5 Comprehensive Outpatient Facility ORF Rehabilitation Facility CORF 4th Digit Frequency 1 Admit through discharge 2 Interim first claim 3 Interim continuing claim 4 Interim final claim Statement Covers Period FROM Enter the beginning date of the billing period covered by this invoice in numeric format MMDDYY THROUGH Enter the last date of the billing period covered by this invoice in numeric format MMDDYY Discharge Code and Date Enter 42 and the actual discharge date when the THROUGH date
12. KENTUCKY M1 MEDICAID MANAGEMENT INFORMATION SYSTEM PROVIDER REMITTANCE ADVICE CMS 15 ICN SERVICE DATES BILLED PATIENT NUMBER FROM THRU AMOUNT MEMBER NAME JANE DOE MEMBER NO 9999999999 2007017999999 060606 060606 200 00 9999999XXX HEADER EOBS 3015 0011 PL SERV PROC CD MODIFIERS UNITS 22 88304 TC 1 00 TOTAL CMS 1500 CLAIMS DENIED SERVICE DATES FROM THRU 060606 060606 200 00 00 CLAIMS DENIED TPL AMOUNT 0 00 RENDERING BILLED PROVIDER AMOUNT MCD 64000000 200 00 0 00 10 Appendix C DATE 01 23 2007 PAGE 1 PAYEE ID 99999999 NPI ID CHECK EFT NUMBER 000999999 ISSUE DATE 01 26 2007 SPENDDOWN AMOUNT 0 00 DETAIL EOBS 0145 0011 0 00 12 12 2013 59 10 Appendix C 10 5 Denied Claims Page FIELD DESCRIPTION 14 digit Patient Control Number from Form Locator 3 MEMBER NAME The Member s last name and first initial PA M The Member s ten digit Identification number as it appears on the Member s Identification card B The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services CLAIM SERVICE DATE The date or dates the service was provided in month day FROM THRU and year numeric format TPL AMOUNT Amount paid if any by private insurance excluding Medicaid and Medicare The amount owed from the member TIENT ACCOUNT EMBER NUMBER N ILLED AMOUNT The usual and customary
13. Paymt Upat 1099 17 Acct Receivable HP Enterprise Services 48 Act Rec Demand Paymt No 1099 Request 49 PCG 18 Recoupment Warrant Refund 50 Recoupment Cold Check 19 Act Receivable SURS Other 51 Recoupment Program Integrity Post 20 Acct Receivable Dup Payt Payment Review Contractor A 21 Recoupment Fraud 52 Recoupment Program Integrity Post Payment Review Contractor B 22 Civil Money Penalty 53 Claim Credit Balance 23 Recoupment Health Insur TPL 54 Recoupment Other St Branch 24 Recoupment Casualty Insur TPL 55 Recoupment Other 25 Recoupment Member Paid TPL 56 Recoupment TPL Contractor 26 Recoupment Processing Error 57 Acct Recv Advance Payment 27 Recoupment Billing Error 58 Recoupment Advance Payment 28 Recoupment Cost Settlement 59 Non Claim Related Overage 29 Recoupment Duplicate Payment 60 Provider Initiated Adjustment 30 Recoupment Paid Wrong Vendor 61 Provider Initiated CLM Credit 31 Recoupment SURS 12 12 2013 Page 78 12 Appendix E 62 CLM CR Paid Medicaid VS Xover 95 Beginning Recoupment Balance 63 CLM CR Paid Xover VS Medicaid 96 Ending Recoupment Balance 64 CLM CR Paid Inpatient VS Outp 97 Begin Dummy Rec Bal 65 CLM CR Paid Outpatient VS Inp 98 End Dummy Recoup Balance 66 CLS Credit Prov Number Changed 99 Drug Unit Dose Adjustment 67 TPL CLM Not Found on History AA PCG 2 Part A Recoveries 68 FIN CLM Not Found on History BB PCG 2 Part B
14. Service More than One Year 10 5 2 Retroactive Eligibility Back Dated 10 5 3 Unacceptable 442 442 10 5 4 Third Party Coverage Information sessi nnne nennen sitne 11 5 4 1 Commercial Insurance Coverage this does NOT include Medicare 11 5 4 2 Documentation That May Prevent A Claim from Being Denied for Other Coverage 11 5 4 3 When there is no response within 120 days from the insurance carrier 12 5 4 4 For Accident And Work Related 12 5 5 Provider Maguy FOr 14 5 6 Prior Authorization 16 5 7 Adjustments And Claim Credit 17 5 8 Cash Refund Documentation 19 5 9 Return To Provider 8 trennen nnne nnne nenas 21 5 10 Provider Representative nnne 23 5 10 1 Phone Numbers and Assigned Counties sse 23 6 Completion of UB 04 Billing Form With 24 6 1 UB 04 Claim Form with NPI and 2 2444000 0 25 6 2 Completion of UB 04 Claim Form with NPI and 26 6 2 1 Detailed Instructions rui tenti e e Hd teu
15. aee o EET IR eai 26 6 3 UB 04 Claim Form With NPI 1 nent 30 6 4 Completion of UB 04 Claim Form With NPI 31 6 4 1 optet ere eto HORE etes abr e FUR Fea sa 31 Completion of CMS 1500 Claim 4 4 0 4 00 35 7 1 Completion of Invoice 8 1500 244440403 0 1151 0000 entrent nnns nnne 36 7 1 1 Crossover Medicare Medicaid sese 36 7 2 CMS 1500 08 05 Claim Form with NPI and 37 7 3 Completion of CMS 1500 08 05 Claim Form With NPI and 38 7 3 1 Detailed Instructions eee dtr teret it center ee Rae euet 38 7 4 New CMS 1500 02 12 Claim Form with NPI and 41 12 12 2013 Pagei 10 11 12 13 7 5 Completion of New CMS 1500 02 12 Claim Form With NPI 42 7 5 1 rre Pete en Sei Ere een ae e eee 42 7 6 Helpful Hints For Successful CMS 1500 02 12 Filing sene 45 Appendix 46 8 1 Medicare Coding for LCSW Occupational Therapist and Psychologist 46 8 1 1 Medicare Coding Seetaram ti
16. form locators 05 19 2008 Cathy Hill Inserted revised 22 rep list and presumptive eligibility per Stayce Towles 06 12 2008 Ann Murray Deleted UB 04 Billing NPI and Legacy NPI Taxonomy and KY Medicaid ID claims and instructions VLL a REED with changes for Medicare 03 10 2009 Cathy Hill cd KyHealth Choices with KY Medicaid per Stayce Towles 4 03 11 2009 Cathy Hill Revised contact info from First Health to Dept for Medicaid Services per Stayce Towles 3 5 03 30 2009 Ann Murray Made global changes per DMS request V3 3 3 5 are actually the same as revisions were made back to back and no publication would have been made CE 7 Provider Rep list 3 7 10 21 2009 Ron Chandler Replace all instances of EDS with HP Enterprise Services 3 8 11 10 2009 Ann Murray Replaced all instances of eds com with hp com Removed the HIPAA section v3 7 3 8 are actually the same as revisions were made back to back and no publication would have been made Ron Chandler Insert new provider rep list E a Ann Murray updated global sections global sections 11 29 2011 Orberson 22 0 5010 changes Ann Murray DMS approved 12 27 2011 Renee Thomas 4 2 01 19 2012 Brenda Orberson Updated 5 in section 8 1 2 so indicate deductible Ann Murray amount DMS approved 01 25 2012 John Hoffman 4 3 02 08 2012 Stayce Towles Updated provider rep listing Ann Murray DMS Approved 02 14 2012 Jo
17. medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim also request payment of government benefits either to myself or to the party who accepts assignment services described below below SIGNED SIGNED _ 44 DATE OF CURRENT ILLNESS First symptom OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE WORK IN CURRENT OCCUPATION MM DD YY INJURY Accident OR GIVE FIRST DATE DD YY MM DD MM DD YY PREGNANCY LMP FROM 17 OF REFERRING PROVIDER OR OTHER SOURCE 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ay ape es MM DD YY MM DD YY FROM 19 20 OUTSIDE LAB CHARGES 22 MEDICAID RESUBMISSION CODE ORIGINAL REF NO 23 PRIOR AUTHORIZATION NUMBER 24 DATE S OF SERVICE B D PROCEDURES SERVICES OR SUPPLIES E 4 PLACE Explain Unusual Circumstances DIAGNOSIS 10 RENDERING OD DD YY__ SERVICE EMG CPT HCPCS MODIFIER POINTER UAL PROVIDER ID nomy PHYSICIAN OR SUPPLIER INFORMATION 9 PATIENT AND INSURED INFORMATION gt lt CARRIER 25 FEDERAL TAX NUMBER SSN EIN 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS I certify that the statements on the reverse apply to
18. of service enter four digit year for example MMDDCCYY 4 Respond by providing the appropriate information for the requested inquiry 5 Prompt for another inquiry 6 Conclude the call 12 12 2013 Page 5 1 General This system allows providers to take a shortcut to information Users may key the appropriate responses such as provider ID or Member number as soon a each prompt begins The number of inquiries is limited to five per call The VREV spells the member name and announces the dates of service Check amount data is accessed through the VREV voice menu The Provider s last three check amounts are available The telephone number for use by touch tone phones only for the VREV is 1 800 807 1301 The VREV system cannot be accessed via rotary dial telephones 1 2 3 1 2 KYHealth Net Online Member Verification KYHEALTH NET ONLINE ACCESS CAN BE OBTAINED AT http www chfs ky gov dms kyhealth htm The KyHealth Net website is designed to provide real time access to member information A User Manual is available for downloading and is designed to assist providers in system navigation Providers with suggestions comments or questions should contact the HP Enterprise Services Electronic Claims Department at KY_EDI_Helpdesk hp com All Member information is subject to HIPAA privacy and security provisions and it is the responsibility of the provider and the provider s system administrator to ensure all persons with access
19. s Medicare Provider ID is on the KY Medicaid cross reference file the claim may automatically be forwarded to HP Enterprise Servicesvia file transfer by the Medicare office after Medicare has processed the claim Providers shall accept assignment for members who have dual eligibility Medicare Medicaid Medicare guidelines for filing these claims shall be followed when the claims are initially submitted to Medicare for payment In following Medicare guidelines however the provider must enter the member s ten digit Medicaid Identification number in the field as directed by Medicare if the claim is to automatically crossover to KY Medicaid as requested by the provider NOTE Claims will automatically crossover to KY Medicaid from Medicare ONLY when the provider s has made special arrangements for crossover with the KY Medicaid enrollment division Claims filed initially with Medicare carriers outside of KY shall not automatically crossover to KY Medicaid These claims shall be billed on paper claim form CMS 1500 and have attached an explanation of Medicare benefits EOMB issued from the Medicare carrier in the state where the service is provided 12 12 2013 Page 36 7 2 CMS 1500 08 05 Claim Form with NPI and Taxonomy 124 30051 3dO 13AN3 ASN 3H3H C104 gt 1500 HEALTH INSURANCE CLAIM FORM Sample Only APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08 05 PICA PICA 1 MEDICARE MEDICAID TRICARE CHAMPVA
20. the date received in the Internal Control Number ICN The ICN is a unique number assigned to each incoming claim and the claim s related documents during the data preparation process Refer to Appendix A for more information about the ICN For claims more than 12 months old to be considered for processing the provider must attach documentation showing timely receipt by DMS or HP Enterprise Services and documentation showing subsequent billing efforts if any To process claims beyond the 12 month limit you must attach to each claim form involved a copy of a Claims in Process Paid Claims or Denied Claims section from the appropriate Remittance Statement no more than 12 months old which verifies that the original claim was received within 12 months of the service date Additional documentation that may be attached to claims for processing for possible payment is Ascreen print from KYHealth Net verifying eligibility issuance date and eligibility dates must be attached behind the claim e A screen print from KYHealth Net verifying filing within 12 months from date of service such as the appropriate section of the Remittance Advice or from the Claims Inquiry Summary Page accessed via the Main Menu s Claims Inquiry selection of the Medicare Explanation of Medicare Benefits received 12 months after service date but less than six months after the Medicare adjudication date and of the commercial insur
21. understand the appropriate use of this data It is suggested that providers establish office guidelines defining appropriate and inappropriate uses of this data 12 12 2013 Page 6 2 Electronic Data Interchange EDI 2 Electronic Data Interchange EDI Electronic Data Interchange EDI is structured business to business communications using electronic media rather than paper 21 How To Get Started All Providers are encouraged to utilize EDI rather than paper claims submission To become a business to business EDI Trading Partner or to obtain a list of Trading Partner vendors contact the HP Enterprise Services Electronic Data Interchange Technical Support Help Desk at HP Enterprise Services P O Box 2016 Frankfort KY 40602 2016 1 800 205 4696 Help Desk hours are between 7 00 a m and 6 00 p m Monday through Friday except holidays 2 2 Format and Testing All EDI Trading Partners must test successfully with HP Enterprise Services and have Department for Medicaid Services DMS approved agreements to bill electronically before submitting production transactions Contact the EDI Technical Support Help Desk at the phone number listed above for specific testing instructions and requirements 2 3 ECS Help Providers with questions regarding electronic claims submission may contact the EDI Help desk 2 4 Companion Guides for Electronic Claims 837 Transactions 837 Companion Guides are available at http www kymmis com kymm
22. 02 2100 Please keep the following points in mind when using this form e Send the completed form to HP Enterprise Services A copy is returned with a response e When resubmitting a corrected claim do not attach a Provider Inquiry Form e toll free HP Enterprise Services number 1 800 807 1232 is available in lieu of using this form and e Tocheck claim status call the HP Enterprise Services Voice Response on 1 800 807 1301 12 12 2013 Page 14 fT 5 Additional Information and Forms Provider Inquiry Form HP Enterprise Services Corporation Did you know that electronic claim submission can reduce your processing time significantly You can also check claim status verify Post Office Box 2100 eligibility download remittance advices and many other functions Go to www kymmis com or contact Billing Inquiry at 1 800 807 1232 for more information You may also send an inquiry via e mail at Frankfort KY 40602 2100 ky_provider_inquiry hp com 1 Provider Number 3 Member Name first last 4 Medical Assistance Number 2 Provider Name and Address 5 Billed Amount 6 Claim Service Date 8 ICN if applicable Provider s Message 10 Signature Date HP Enterprise Services Response OFFICE USE ONLY This claim has been resubmitted for possible payment This claim paid on in the amount of This claim was denied on with EOB code Aged claim Please see attached documentation conce
23. 8 4 143 010 13 CLAIM ADJUSTMENTS 0 0 00 0 0 00 18 0 00 MASS ADJUSTMENTS 0 0 00 0 0 00 0 0 00 TOTAL CLAIMS PAYMENTS 43 130 784 46 43 130 784 46 2 006 4 143 010 13 CLAIMS DENIED 1 1 917 CLAIMS IN PROCESS 2 EARNINGS DATA PAYMENTS CLAIMS PAYMENTS 130 784 46 130 784 46 4 143 010 13 SYSTEM PAYOUTS NON CLAIM SPECIFIC 0 00 0 00 0 00 ACCOUNTS RECEIVABLE OFFSETS CLAIM SPECIFIC CURRENT CYCLE 0 00 0 00 0 00 OUTSTANDING FROM PREVIOUS CYCLES 0 00 0 00 44 474 35 NON CLAIM SPECIFIC OFFSETS 0 00 0 00 0 00 NET PAYMENT 130 784 46 130 784 46 4 098 535 78 REFUNDS CLAIM SPECIFIC ADJUSTMENT REFUNDS 0 00 0 00 0 00 NON CLAIM SPECIFIC REFUNDS 0 00 0 00 0 00 OTHER FINANCIAL MANUAL PAYOUTS NON CLAIM SPECIFIC 0 00 0 00 0 00 VOIDS 0 00 0 00 0 00 NET EARNINGS 130 784 46 130 784 46 4 098 535 78 12 12 2013 Page 70 10 Appendix C REPORT CRA EOBM R COMMONWEALTH OF KENTUCKY M1 DATE 02 01 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 14 PROVIDER REMITTANCE ADVICE EOB CODE DESCRIPTIONS PROVIDER PAYEE ID 99999999 NPI ID P O BOX 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 02 02 2007 EOB CODE EOB CODE DESCRIPTION 0022 COVERED DAYS ARE NOT EQUAL TO ACCOMMODATION UNITS 0271 CLAIM DENIED MEMBER AVAILABLE INCOME INFORMATION NOT ON FILE FOR THE MONTH OF SERVICE PLEASE CONTACT DMS AT 502 564 6885 0409 INVALID PROVIDER TYPE BILLED
24. ON CLAIM FORM 0883 CLAIM DENIED DEPLICATE PROCEDURE HAS BEEN PAID 9999 PROCESSED PER MEDICAID POLICY HIPAA REASON CODE HIPAA ADJ REASON CODE DESCRIPTION 0016 Claim service lacks information which is needed for adjudication Additional information is supplied using remittance advice remarks codes whenever appropriate 0018 Duplicate claim service 0052 The referring prescribing rendering provider is not eligible to refer prescribe order perform the service billed 0092 Claim Paid in full 00A1 Claim denied charges 12 12 2013 Page 71 10 Appendix C 10 10 Summary Page FIELD DESCRIPTION CLAIMS PAID The number of paid claims processed current month and year to date CLAIM ADJUSTMENTS The number of adjusted credited claims processed adjusted credited amount billed and adjusted credited amount paid or recouped by Medicaid If money is recouped the dollar amount is followed by a negative sign These figures correspond with the summary of the last page of the ADJUSTED CLAIMS section PAID MASS ADJ CLAIMS The number of mass adjusted credited claims mass adjusted credited amount billed and mass adjusted credited amount paid or recouped by Medicaid These figures correspond with the summary line of the last page of the MASS ADJUSTED CLAIMS section Mass Adjustments are initiated by Medicaid and HP Enterprise Services for issues that affect a large number of claims or providers These adjustments have their own sect
25. R GROUP NUMBER amp EMPLOYMENT Current or Previous B INSURED 8 DAE 9r BIRTH D n RESERVED FOR USE b AUTO AGOD NT PLACE State OTHER PTT D EET by c RESERVED FOR USE INSURANCE PLAN NAME OR PROGRAM NAME d INSURANCE PLAN NAME OR PROGRAM NAME 10d CLAIM CODES Designated by NUCC d IS THERE ANOTHER HEALTH BENEFIT PLAN IFOTHERINSURANCE MAKES PAYNENT __ ves no conion tons ana READ BACK OF FORM BEFORE COMPLETING amp SIGNING THIS FORM 13 INSURED S OR AUTHORIZED PERSON S SIGNATURE authorize 12 PATIENT S OR AUTHORIZED PERSON S SIGNATURE authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim also request payment of goverment benefits either to myself or to the party who accepts assignment services described below below DATE SIGNED 4 15 OTHER DA 1 1 XE ILLNESS INJURY or PREGNANCY LMP MM DD 6 DATES maou MA E DB IPEP WORK IN vo MT La ATION 1 17 NAME OF REFERRING OR OTHER SOURCE 18 cpm DATES RELATED TO gi SSES 1 19 ADDITIONAL CLAIM INFORMATION Designated by NUCC 20 OUTSIDE LAB CHARGES Dw 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A L to service line below 24E ICD Ind IBMISSION ORIGINAL REF NO 23 PRIOR AUTHORIZATION NUMBER DATEI OF YY po
26. Recoveries 69 Payout Withhold Release CB PCG 2 AR CDR Hosp 71 Withhold Encounter Data Unacceptable DG DRG Retro Review 72 Overage 99 or Less DR Deceased Member Recoupment 73 No Medicaid Partnership Enrollment IP Impact Plus 74 Withhold Provider Data Unacceptable IR Interest Payment 75 Withhold PCP Data Unacceptable CC Converted Claim Credit Balance 76 Withhold Other MS Prog Intre Post Pay Rev Cont C 77 A R Member IPV OR On Demand Recoupment Refund 78 CAP Adjustment Other RP Recoupment Payout 79 Member Not Eligible for DOS RR Recoupment Refund 80 Adhoc Adjustment Request 55 State Share Only 81 Adj Due to System Corrections UA HP Enterprise Services Medicare Part A 82 Converted Adjustment T Mass Adj Warr Refund XO Reg Psych Crossover Refund 84 DMS Mass Adj Request 85 Mass Adj SURS Request 86 Third Party Paid TPL 87 Claim Adjustment TPL 88 Beginning Dummy Recoupment Bal 89 Ending Dummy Recoupment Bal 90 Retro Rate Mass Adj 91 Beginning Credit Balance 92 Ending Credit Balance 93 Beginning Dummy Credit Balance 94 Ending Dummy Credit Balance 12 12 2013 Page 79 13 Appendix F 13 Appendix F 13 1 Remittance Advice Status Code ST CD The following is a one character code indicating the status of the accounts receivable transaction A T nmm oo N x HHO lt Active Hold Recoup Payment Plan Under Consideration Hold Recoup Other Other Inactive FFP Not Reclaimed Other Inact
27. UNBRIDLED SPIRIT Kentucky Commonwealth of Kentucky KY Medicaid Provider Billing Instructions For Qualified Medicare Beneficiary Provider Type 82 87 88 89 91 and 95 Version 5 0 December 12 2013 Document Change Log Document Comments Version 10 14 2005 EDS Initial creation of DRAFT Home Health Services Provider Type 34 EUN LEE LS Provider Rep list EE Carolyn Stearman Updated with revisions requested by Commonwealth 03 28 2006 Deane Updated with revisions requested by Commonwealth Commonwealth 2 0 11 15 2006 Murray Inserted new sections for UB 04 With NPI v1 5 2 0 are actually the same as revisions were made back to back and no publication would have been made a nai us with revisions requested by Stayce 2 2 01 30 2007 Murray Updated with revisions requested during alkthrough 23 5 2007 pois ley Appendix B KY Medicaid card and ICN MONIS em Provider Rep table 2 5 02 23 2007 Murray Revised according comment log Walkthrough v2 1 2 5 are actually the same as revisions were made back to back and no publication would have been made ELLE S and added claim forms and descriptors 05 14 2007 John McCormick Updated IAW comment log v2 6 2 7 are actually the same as revisions were made back to back and no publication would have been made ohn McCormick Updated Rep List 9 _ a pean forms and
28. USTMENT AND CLAIM CREDIT REQUEST FORM MAIL TO Enterprise Services P O BOX 2108 FRANKFORT KY 40602 2108 1 800 807 1232 ATTN FINANCIAL SERVICES NOTE CLAIM CREDIT VOIDS THE CLAIM ICN FROM THE SYSTEM NEW DAY CLAIM MAY BE SUBMITTED IF NECESSARY THIS FORM WILL BE RETURNED TO YOU IF THE REQUIRED INFORMATION AND DOCUMENTATION FOR PROCESSING ARE NOT PRESENT PLEASE ATTACH A CORRECTED CLAIM AND REMITTANCE ADVICE TO ADJUST A CLAIM CHECK APPROPRIATE BOX 1 Original Internal Control Number ICN CLAIM CLAIM ADJUSTMENT CREDIT 2 Member 3 Member Medicaid Number 4 Provider Name and Address 5 Provider 6 From Date of 7 To Date of Service Service 8 Original Billed 9 Original Paid 10 Remittance Amount Amount Advice Date 11 Please specify WHAT is to be adjusted on the claim You must explain in detail in order for an adjustment specialist to understand what needs to be accomplished by adjusting the claim 12 Please specify the REASON for the adjustment or claim credit request 13 Signature 14 Date DMS Approved January 10 2011 12 12 2013 Page 18 5 Additional Information and Forms 5 8 Cash Refund Documentation Form The Cash Refund Documentation Form is used when refunding money to Medicaid The mailing address for the Cash Refund Form is HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 Attn Financial Services Please keep the following points in m
29. VIDER FROM THRU MEMBER NO MEMBER NAME NO NON CLAIM SPECIFIC PAYOUTS TO PROVIDERS REFUND REASON CCN AMOUNT CODE MEMBER NO MEMBER NAME NO NON CLAIM SPECIFIC REFUNDS FROM PROVIDERS A R SETUP RECOUPED ORIGINAL TOTAL REASON NUMBER ICN DATE THIS CYCLE AMOUNT RECOUPED BALANCE CODE 1106 011306 0 00 22 41 0 00 22 41 92 TOTAL BALANCE 22 41 12 12 2013 Page 67 10 Appendix C 10 9 Financial Transaction Page 10 9 1 Non Claim Specific Payouts To Providers FIELD DESCRIPTION TRANSACTION NUMBER The tracking number assigned to each financial transaction CCN The cash control number assigned to refund checks for tracking purposes PAYMENT AMOUNT The amount paid to the provider when the financial reason code indicates money is owed to the provider 10 9 2 Non Claim Specific Refunds From Providers FIELD DESCRIPTION CCN The cash control tracking number assigned to refund checks for tracking purposes 10 9 3 Accounts Receivable FIELD DESCRIPTION A R NUBMER ICN This is the 13 digit Internal Control Number used to identify records for one accounts receivable transaction SETUP DATE The date entered on the accounts receivable transaction in the MM DD CCYY format This date identifies the beginning of the accounts receivable event 12 12 2013 Page 68 10 Appendix C RECOUPED THIS CYCLE The amount of money recouped on this financial cycle ORIGINAL AMOUNT The original accounts receivable transa
30. WHITLEY GALLATIN MEADE WOODFORD bordering their state unless noted above e Provider Relations 1 800 807 1232 NOTE Out of state providers contact the Representative who has the county closest 12 12 2013 6 Completion of UB 04 Billing Form With NPI Following are billing instructions for QMB services provided by Comprehensive Outpatient Rehabilitation Facilities CORF Comprehensive Outpatient Rehabilitation Facility CORF providers must bill on the UB 04 billing form Only the instructions for form locators required for HP Enterprise Services processing or by KY Medicaid Programs are included Instructions for fields not used by HP Enterprise Services or the Medicaid Program can be found in the UB 04 Training Manual The UB 04 Training Manual and UB 04 billing forms may be obtained from the Kentucky Hospital Association Kentucky Hospital Association P O Box 24163 Louisville KY 40224 Telephone 1 502 426 6220 An original UB 04 billing form must be sent to HP Enterprise Services P O Box 2106 Frankfort KY 40602 2106 12 12 2013 Page 24 6 1 UB 04 Claim Form with NPI and Taxonomy eS Se H 32 42REV CD 4 DESCRIPTION 46 SERV UNITS 47 TOTAL CHARGES 48NON COVERED CHARGES 49 31 5 000 00 9m CREATION DATE 01310 TOTALS m gt 50 51 HEALTH PLAN ID reale TE E a 58 INSURED S 60
31. ance carrier s Explanation of Benefits received 12 months after service date but less than six months after the commercial insurance carrier s adjudication date 5 2 Retroactive Eligibility Back Dated Card Aged claims for Members whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the eligilbility issuance date Claim submission must be within 12 months of the issuance date A copy of the KYHealth Net card issuance screen must be attached behind the paper claim 5 3 Unacceptable Documentation Copies of previously submitted claim forms providers in house records of claims submitted or letters detailing filing dates are not acceptable documentation of timely billing Attachments must prove the claim was received in a timely manner by HP Enterprise Services 12 12 2013 Page 10 5 Additional Information and Forms 5 4 Third Party Coverage Information 5 4 1 Commercial Insurance Coverage this does NOT include Medicare When a claim is received for a Member whose eligibility file indicates other health insurance is active and applicable for the dates of services and no payment from other sources is entered on the Medicaid claim form the claim is automatically denied unless documentation is attached 5 4 2 Documentation That May Prevent Claim from Being Denied for Other Coverage The following forms of documentation prevent claims from being denied for other healt
32. are examples of pages which may appear in a Remittance Advice DESCRIPTION This section lists all claims that have been returned to the provider with an RTP letter The RTP letter explains why the claim is being returned These claims are returned because they are missing information required for processing Paid Claims This section lists all claims paid in the cycle Denied Claims This section lists all claims that denied in the cycle Claims In Process This section lists all claims that have been suspended as of the current cycle The provider should maintain this page and compare with future Remittance Advices until all the claims listed have appeared on the PAID CLAIMS page or the DENIED CLAIMS page Until that time the provider need not resubmit the claims listed in this section Adjusted Claims This section lists all claims that have been submitted and processed for adjustment or claim credit transactions Mass Adjusted Claims This section lists all claims that have been mass adjusted at the request of the Department for Medicaid Services DMS Financial Transactions This section lists financial transactions with activity during the week of the payment cycle NOTE It is imperative the provider maintains any A R page with an outstanding balance 12 12 2013 Page 53 This section details all categories contained in the Remittance Advice for the current cycle month to date and year to date Explanation of Benefit
33. are payment For Medicare involved claims attach a copy of the Medicare EOMB indicating either payment or denial Enter the date in a month day year numeric format MMDDYY This date must be on or after the date s of service billed on the claim Service Facility Location Information If the address in Form Locator 33 is not the address where the service was rendered Form Locator 32 must be completed Physician s Supplier s Billing Name Address Zip Code and Phone Number Enter the Provider s name address zip code and phone number Enter the appropriate Pay to Number 12 12 2013 Page 44 Shaded Area Enter ZZ and the Pay To Taxonomy Number NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the number corresponds to more than one Medicaid provider number Taxonomy will be a requirement on the claim 7 6 Helpful Hints For Successful CMS 1500 02 12 Filing Any required documentation for claims processing must be attached to each claim Each claim is processed separately sure include the AS OF date and EOB code when copying a remittance advice as proof of timely filing or for inquiries concerning claim status e Please follow up on a claim that appears to be outstanding after four weeks from your submission date e Field 24B Place of Serv
34. ceive a medical card for services The enrolling provider will give a printed document that is to be used in place of a card 1 2 3 Verification of Member Eligibility This section covers e Methods for verifying eligibility e How to verify eligibility through an automated 800 number function e How to use other proofs to determine eligibility and e What to do when a method of eligibility is not available 1 2 3 1 Obtaining Eligibility and Benefit Information Eligibility and benefit information is available to providers via the following e Voice Response Eligibility Verification VREV available 24 hours 7 days a week at 1 800 807 1301 KYHealth Net at http www chfs ky gov dms kyhealth htm e The Department for Medicaid Services Member Eligibility Branch at 1 800 635 2570 Monday through Friday except Holidays 1 2 3 1 1 Voice Response Eligibility Verification VREV HP Enterprise Services maintains a Voice Response Eligibility Verification VREV system that provides member eligibility verification as well as third party liability TPL information Managed Care PRO review Card Issuance Co pay provider check write and claim status information The VREV system generally processes calls in the following sequence 1 Greet the caller and prompt for mandatory provider ID 2 Prompt the caller to select the type of inquiry desired eligibility check amount claim status and so on 3 Prompt the caller for the dates
35. ch EOMB 83 Life Time Reserve Days Revenue Codes Enter the four digit revenue code identifying specific accommodation and 12 12 2013 Page 27 ancillary services NOTE Total charge Revenue code 0001 must be the final entry in column 42 line 23 Total charge amount must be shown in column 47 line 23 Creation Date Enter the invoice date or invoice creation date Enter the quantitative measure of services provided per revenue code Total Charges Enter the total charges relating to each revenue code for the billing period The detailed revenue code amounts must equal the entry total charges NOTE Enter the total claim charge in field 47 line 23 Payer Identification Enter the names of payer organizations from which the provider expects payment For Medicaid use KY Medicaid All other liable payers including Medicare must be billed first KY Medicaid is payer of last resort Note If you are billing for a replacement policy to Medicare Medicare needs to be indicated instead of the name of replacement policy Medicare Paid Amount Enter the paid amount from Medicare if applicable Enter the Pay To NPI number Enter the Pay To Taxonomy number Enter the facility s zip code Enter the Member s name in Form Locators 58 A B and C that relates to KY Medicaid the payer in Form Locators 50 A B and C Enter the Member s name exactly as it appears on the Member Identification card in last name first
36. charge for services provided for the Member PENDDOWN AMOUNT S Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice CLAIMS DENIED ON THISRA total number of denied claims on the Remittance Advice TOTAL BILLED The total dollar amount billed by the Home Health Services for all claims listed on the DENIED CLAIMS page of the Remittance Advice only on final page of section 12 12 2013 Page 60 10 Appendix C REPORT CRA BANN R COMMONWEALTH OF KENTUCKY M1 DATE 01 23 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 1 PROVIDER REMITTANCE ADVICE CMS 1500 CLAIMS IN PROCESS PROVIDER PAYEE ID 99999999 555 ANY STREET NPI ID CITY 55555 0000 CHECK EFT NUMBER 999999999 ISSUE DATE 01 26 2007 ICN SERVICE DATES BILLED TPL PATIENT NUMBER FROM THRU AMOUNT AMOUNT MEMBER NAME JANE DOE MEMBER NO 9999999999 9999999999999 060606 060606 200 00 0 00 9999999XXX SERVICE DATES RENDERING BILLED PL SERV PROC CD MODIFIERS UNITS FROM THRU PROVIDER AMOUNT DETAIL EOBS 22 88304 TC 1 00 060606 060606 MCD 64000000 200 00 TOTAL CMS 1500 CLAIMS IN PROCESS 200 00 0 00 12 12 2013 Page 61 10 Appendix C 10 6 Claims In Process Page FIELD DESCRIPTION PATIENT ACCOUNT The 14 digit alpha numeric Patient Control Number from Form Locator 3 MEMBER NAME The Member s last name and first initial MEMBER NUMBER The Membe
37. coming in the mail The actual claim is returned with a return to provider sheet attached indicating the reason for the claim being returned 12 12 2013 Page 64 10 Appendix C REPORT CRA PRAD R COMMONWEALTH OF KENTUCKY M1 DATE 12 14 2006 RA 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE CMS CLAIM ADJUSTMENTS HEALTH SERVICES PAYEE ID 99999999 ATTN JANE DOE NPI ID 555 ANY STREET CITY KY 55555 0000 ICN SERVICE DATES BILLED ALLOWED TPL SPENDDOWN CO PAY PAID PATIENT NUMBER FROM THRU AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT MEMBER NAME JANE DOE MEMBER 9999999999 9999999999999 031103 031103 20 00 0 00 0 00 99999 20 00 0 00 20 00 9999999999999 031103 031103 20 00 0 00 0 00 99999 20 00 0 00 20 00 SERVICE DATES RENDERING BILLED ALLOWED PL SERV PROC CD MODIFIERS UNITS FROM THRU PROVIDER AMOUNT AMOUNT DETAIL EOBS 99 WP101 1 00 031103 031103 McD 40097065 20 00 20 00 0102 0029 TOTAL NO OF ADJ 1 TOTAL CMS 1500 ADJUSTMENT CLAIMS 0 00 0 00 0 00 0 00 0 00 0 00 Providers have an option of requesting an adjustment as indicated above or requesting a cash refund form and instructions for completion can be found in the Billing Instructions If a cash refund is submitted an adjustment CANNOT be filed If an adjustment is submitted a cash refund CANNOT be filed 12 12 2013 Page 65 10 Appendix C 10 8 Adjusted Claims Page The information on this page reads left to ri
38. ct PstResp Amt Coinsurance snd orCo psy Amt Provider Amt Line Deduct Pst Resp Amt Coinsurance and orCo psy Amt Provider Pay Amt psf Cs Ls 12 12 2013 Page 47 8 1 2 Medicare Coding Sheet Instructions FIELD NUMBER FIELD NAME AND DESCRIPTION Member s Name Enter the Member s last name and first name exactly as it appears on the Member Identification card Member s ID Enter the Member s ID as it appears on the claim form EOMB Date Enter Medicare s EOMB date Line Number Enter the line number The line numbers must be in sequential order Deductible Amount Enter deductible amount from Medicare if applicable Co insurance and or Co pay Amount Enter the total amount of co insurance and or co pay from Medicare if applicable Provider Pay Amount Enter the amount paid from Medicare Patient Responsibility Enter the patient responsibility amount from Medicare 12 12 2013 Page 48 8 2 Medicare Coding for Physical Therapist As of September 29 2008 the Medicare EOMB is no longer needed to be attached to a claim if Medicare pays on the service Instead of the Medicare EOMB providers will utilize the coding sheet on the next page In the event that Medicare denies your service the Medicare EOMB will be required to be attached to the claim The Medicare Coding Sheet may be accessed at www kymmis com You may type in the Medicare information into the PDF and print the cod
39. ction amount owed by the provider TOTAL RECOUPED This amount is the total of the providers checks and recoupment amounts posted to this accounts receivable transaction BALANCE The system generated balance remaining on the accounts receivable transaction REASON CODE A two byte alpha numeric code specifying the reason an accounts receivable was processed against a providers account ANY RECOUPMENT ACTIVITY OR PAYMENTS RECEIVED FROM THE PROVIDER list below the RECOUPMENT PAYMENT SCHEDULE All initial accounts receivable allow 60 days from the setup date to make payment on the accounts receivable After 60 days if the accounts receivable has not been satisfied nor a payment plan initiated monies are recouped from the provider on each Remittance Advice until satisfied This is your only notification of an accounts receivable setup Please keep all Accounts Receivable Summary pages until all monies have been satisfied 12 12 2013 Page 69 10 Appendix C REPORT CRA SUMM R COMMONWEALTH OF KENTUCKY M1 DATE 02 01 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 13 PROVIDER REMITTANCE ADVICE SUMMARY PROVIDER PAYEE ID 99999999 NPI ID 0 BOX 555 CHECK EFT NUMBER 999999999 CITY KY 55555 0000 ISSUE DATE 02 02 2007 CLAIMS DATA CURRENT CURRENT MONTH TD MONTH TD YEAR TD YEAR TD NUMBER AMOUNT NUMBER AMOUNT NUMBER AMOUNT CLAIMS PAID 43 130 784 46 43 130 784 46 1 98
40. dge Bullitt Carroll Grayson Hardin Henry Jefferson Larue Marion Meade Nelson Oldham Shelby Spencer Trimble and Washington were formerly known as Passport members Effective 1 1 2013 members residing in the above counties now have the choice of Passport MCO Humana Caresource or the other MCO s which cover members state wide The other Managed Care Plans servicing Kentucky Medicaid members in these former Passport counties are WellCare of Kentucky and CoventryCares of Kentucky Medical benefits for persons whose care is overseen by an MCO are similar to those of Kentucky Medicaid but billing procedures and coverage of some services may differ Providers with Managed Care plan questions should contact Passport Provider Services at 1 800 578 0775 WellCare of Kentucky at 1 877 389 9457 Humana Caresource at 1 855 852 7005 and CoventryCares of Kentucky at 1 855 300 5528 1 2 2 3 KCHIP The Kentucky Children s Health Insurance Program KCHIP provides coverage to children through age 18 who have no insurance and whose household income meets program guidelines Children with KCHIP III are eligible for all Medicaid covered services except Non Emergency Transportation and EPSDT Special Services Regular KCHIP children are eligible for all Medicaid covered services For more information access the KCHIP website at http kidshealth ky gov en kchip 1 2 2 4 Presumptive Eligibility Presumptive Eligibility PE is a program which off
41. edicaid eligible members is the Kentucky Medicaid card This is a permanent plastic card issued when the Member becomes eligible for Medicaid coverage The name of the member and the member s Medicaid ID number are displayed on the card The provider is responsible for checking identification and verifying eligibility before providing services NOTE Payment cannot be made for services provided to ineligible members and possession of a Member Identification card does not guarantee payment for all medical services 12 12 2013 Page 1 1 General 1 2 1 Plastic Swipe KY Medicaid Card _ KyHealth Choices Member Name entuck 5 First Middle Initial if available Last yY UNBRIDLED SPIRIT 10 DIGIT Member Identification Number CHILD CLAYTON 1234567890 DO NOT THROW AWAY This is your permanent medical card Card Holder Show this card each time you receive any medical services Rules 1 Use this card only for the person listed on the front of this card Magnetic Strip 2 Do not let anyone else use this card to get services 3 Do not give false information or hide information to get medical coverage If vou break the rules vou can be prosecuted for fraud and have to pay money back If you need to replace this card call your local DCBS office If you have questions about your coverage call 800 635 2570 THIS CARD DOES NOT GUARANTEE ELIGIBILITY OR PAYMENT FOR SERVICES Provider You are respons
42. ember s last name and first initial MEMBER NUMBER The Member s ten digit Identification number as it appears on the Member s Identification card ICN The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services CLAIM SERVICE DATES The date or dates the service was provided in month day FROM THRU and year numeric format BILLED AMOUNT The usual and customary charge for services provided for the Member ALLOWED AMOUNT The allowed amount for Medicaid TPL AMOUNT Amount paid if any by private insurance excluding Medicaid and Medicare SPENDDOWN AMOUNT The amount collected from the member COPAY AMOUNT The amount collected from the member PAID AMOUNT The total dollar amount reimbursed by Medicaid for the claim listed Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice CLAIMS PAID ON THIS RA The total number of paid claims on the Remittance Advice TOTAL BILLED The total dollar amount billed by the provider for all claims listed on the PAID CLAIMS page of the Remittance Advice only on final page of section TOTAL PAID The total dollar amount paid by Medicaid for all claims listed on the PAID CLAIMS page of the Remittance Advice only on final page of section 12 12 2013 Page 58 REPORT CRA BANN R RAH 9999999 PROVIDER 555 ANY STREET CITY KY 55555 0000 COMMONWEALTH OF
43. emittance Advice EXPLANATION OF ADJUSTMENT CODE FIELD DESCRIPTION ADJUSTMENT CODE A two digit number denoting the reason for returning the claim ADJUSTMENT CODE Description of the adjustment Code All adjustment codes DESCRIPTION detailed on the Remittance Advice are listed with a description definition COUNT Total number of times an adjustment Code is detailed on the Remittance Advice 12 12 2013 Page 74 10 Appendix C EXPLANATION OF RTP CODES FIELD DESCRIPTION RTP CODE A two digit number denoting the reason for returning the claim RETURN CODE Description of the RTP Code All RTP codes detailed on the DESCRIPTION Remittance Advice are listed with a description definition COUNT Total number of times an RTP Code is detailed on the Remittance Advice 12 12 2013 Page 75 11 Appendix D 11 Appendix D 11 1 Remittance Advice Location Codes LOC CD The following is a code indicating the Department for Medicaid Services branch division or other agency that originated the Accounts Receivable Active Hold Recoup Payment Plan Under Consideration Hold Recoup Other Other Inactive FFP Not Reclaimed Other Inactive FFP Paid in Full nm oou gt Payout Hold Involves Interest Cannot Be Recouped Hold Recoup Refund Inactive Charge off FFP Not Reclaimed Payout Complete Payout Set Up In Error Active Prov End Dated Active Provider A R Transfer HP Ente
44. enial statement from other insurance carrier to the CMS 1500 02 12 claim Insurance Plan Name or Program Name Enter the Member s insurance carrier name Complete only if entry in 9a Diagnosis or Nature of Illness or Injury Enter a 9 in the ICD Indicator field in the upper right corner Enter the required appropriate ICD 9 CM diagnosis code Twelve diagnosis codes may be entered oa Insured s Policy or Group Number 12 12 2013 Page 42 Date of Service Non Shaded Area Enter the date in numeric format MMDDYY Place of Service Non Shaded Area Enter the appropriate two digit place of service code which identifies the location where the service was rendered Procedure Code Non Shaded Area Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the member Modifier Non Shaded Area Modifier 25 should be used only with an evaluation and management E amp M service code and only when a significant separately identifiable evaluation and management service is provided by the same provider to the same patient on the same day of the procedure or service Documentation is not required to be submitted with the claim but appropriate documentation for the procedure and evaluation and management service must be maintained Diagnosis Code Indicator Non Shaded Area Enter the diagnosis pointers A L to refer to a diagnosis code in field 21 Do not enter the actua
45. ers pregnant women temporary medical coverage for prenatal care A treating physician may issue an Identification Notice to a woman after pregnancy is confirmed Presumptive Eligibility expires 90 days from the date the Identification Notice is issued but coverage will not extend beyond three calendar months This short term program is only intended to allow a woman to have access to prenatal care while she is completing the application process for full Medicaid benefits 1 2 2 4 1 Presumptive Eligibility Definitions Presumptive Eligibility PE is designed to provide coverage for ambulatory prenatal services when the following services are provided by approved health care providers A SERVICES COVERED UNDER PE e Office visits to a Primary Care Provider see list below and or Health Department 12 12 2013 Page 3 1 General Laboratory Services Diagnostic radiology services including ultrasound General dental services Emergency room services Transportation services emergency and non emergency Prescription drugs including prenatal vitamins DEFINITION OF PRIMARY CARE PROVIDER Any health care provider who is enrolled as a KY Medicaid provider in one of the following programs Physician osteopaths practicing in the following medical specialties e Family Practice e Obstetrics Gynecology e General Practice e Pediatrics e Internal Medicine Physician Assistants Nurse Practitioners ARNP s Nurse Midwives Rura
46. ght and does not follow the general headings DESCRIPTION 14 digit Patient Control Number from Form Locator 3 The Member s last name and first initial The Member s ten digit Identification number as it appears on the Member s Identification card The 12 digit unique system generated identification number assigned to each claim by HP Enterprise Services The date or dates the service was provided in month day and year numeric format The usual and customary charge for services provided for the Member The amount allowed for this service Amount paid if any by private insurance excluding Medicaid and Medicare Copay amount to be collected from member The amount to be collected from the member The total dollar amount reimbursed by Medicaid for the claim listed Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice Note The ORIGINAL claim information appears first followed by the NEW adjusted claim information 12 12 2013 Page 66 10 Appendix C REPORT CRA TRAN R COMMONWEALTH OF KENTUCKY DATE 12 26 2006 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE FINANCIAL TRANSACTIONS PROVIDER 5 PAYEE ID 99999999 PO BOX 5555 NPI ID 99999999 CITY KY 55555 5555 TRANSACTION PAYOUT REASON RENDERING SVC DATE NUMBER CCN AMOUNT CODE PRO
47. h insurance when attached to the claim 1 Remittance statement from the insurance carrier that includes e Member name e Date s of service e Billed information that matches the billed information on the claim submitted to Medicaid and e indication of denial or that the billed amount was applied to the deductible NOTE Rejections from insurance carriers stating additional information necessary to process claim is not acceptable 2 Letter from the insurance carrier that includes e Member name e Date s of service s e Termination or effective date of coverage if applicable e Statement of benefits available if applicable and e The letter must have a signature of an insurance representative or be on the insurance company s letterhead 3 Letter from a provider that states they have contacted the insurance company via telephone The letter must include the following information e Member name e Date s of service e Name of insurance carrier e Name of and phone number of insurance representative spoken to or a notation indicating a voice automated response system was reached e Termination or effective date of coverage and e Statement of benefits available if applicable 4 prior remittance statement from an insurance company may be considered an acceptable form of documentation if it is 12 12 2013 Page 11 5 Additional Information and Forms e For the same Member e
48. he guidelines below providers can ensure claims are processed as they intend e USE BLACK INK ONLY e Do not use glue e Donot use more than one staple per claim e Press hard to guarantee strong print density if claim is not typed or computer generated e Do not use white out or shiny correction tape and Do send attachments smaller than the accompanying claim form 4 3 Optical Character Recognition Optical Character Recognition OCR eliminates human intervention by sending the information on the claim directly to the processing system bypassing data entry OCR is used for computer generated or typed claims only Information obtained mechanically during the imaging stage does not have to be manually typed thus reducing claim processing time Information on the claim must be contained within the fields using font 10 as the recommended font size in order for the text to be properly read by the scanner 12 12 2013 Page 9 5 Additional Information and Forms 5 Additional Information and Forms 5 1 Claims with Dates of Service More than One Year Old In accordance with federal regulations claims must be received by Medicaid no more than 12 months from the date of service or six months from the Medicare or other insurance payment date whichever is later Received is defined in 42 CFR 447 45 d 5 as The date the agency received the claim as indicated by its date stamp on the claim Kentucky Medicaid includes
49. hn Hoffman 4 4 02 22 2012 Brenda Orberson Global updates made to remove all references to Ann Murray KenPAC and Lockin DMS Approved 03 09 2012 John Hoffman 4 5 04 05 2012 Stayce Towles Updated provider rep listing Ann Murray DMS Approved 04 11 2012 John Hoffman 4 6 08 20 2012 Stayce Towles Section 7 Changed Taxonomy Qualifier from PXC Patti George to ZZ in form locators 24l and 33B per CO18459 Update of Provider Inquiry form approved by John Hoffman on 08 30 12 10 25 2012 Towles Appendix A Updated CMS 1500 Crossover Berryman Form and Instructions DMS Approved 10 29 2012 Jennifer L Smith 01 31 2013 Hicks Update section 1 2 2 2 to reflect former Passport Patti George Members having a choice of MCOs as of 1 1 2013 DMS Approved 02 27 2013 John Hoffman 0 08 12 2013 Stayce Towles Update to section 5 10 Provider Rep listing Patti George 12 06 2013 Hicks Updates to section 6 added new CMS 1500 Stayce Towles 02 12 form Sandy Berryman DMS approved 12 12 2013 John Hoffmann 4 9 7 01 2013 Wicky Hicks Updates to NET PAYMENT and NET EARNINGS Patti George descriptions in Section 10 10 1 DMS Approved 07 09 2013 John Hoffman TABLE OF CONTENTS NUMBER DESCRIPTION PAGE 1 1 uice EE De debe 1 1 2 Member Egib
50. ible for verifying the identity eligibility and status of the cardholder Eligibility information may be obtained at at or by calling 800 807 1301 Pharmacy information may be obtained by calling 800 432 7005 To report fraud 800 372 2970 Commonwealth of Kentucky f 2 Department for Community Based Services If found please drop this card in any U S mailbox 275 East Main Stroet 3W A sten Frankfort K Y 40621 0001 Through a vendor of your choice the magnetic strip can be swiped to obtain eligibility information Providers who wish to utilize the card s magnetic strip to access eligibility information may do so by contracting with one of several vendors 12 12 2013 Page 2 1 General 1 2 2 Member Eligibility Categories 1 2 2 1 and SLMB Qualified Medicare Beneficiaries QMB and Specified Low Income Medicare Beneficiaries SLMB are Members who qualify for both Medicare and Medicaid In some cases Medicaid may be limited A QMB Member s card shows QMB or QMB Only QMB Members have Medicare and full Medicaid coverage as well QMB only Members have Medicare and Medicaid serves as a Medicare supplement only A Member with SLMB does not have Medicaid coverage Kentucky Medicaid pays a buy in premium for SLMB Members to have Medicare but offers no claims coverage 1 2 2 2 Managed Care Partnership Kentucky Medicaid members who live in the following counties Breckinri
51. ice requires a two digit code and e Field 24E Diagnosis Code Indicator is a one digit only field e insurance other than Medicare KY Medicaid makes a payment on services you are billing complete Fields 9 9A 9D and 29 on the CMS 1500 02 12 claim form e insurance does not make a payment on services you are billing attach the private insurance denial to the CMS 1500 claim form Do not complete Fields 9 9A 9D and 29 on the CMS 1500 02 12 claim form e When billing the same procedure code for the same date of service you must bill on one line indicating the appropriate units of service e f you are submitting a copy of a previously submitted claim on which some line items have paid and some have denied mark through or delete any line s on the claim already paid If you mark through any lines be sure to recompute your total charge in Field 28 to reflect the new total charge billed 12 12 2013 Page 45 8 Appendix A 8 1 Medicare Coding for LCSW Occupational Therapist and Psychologist As of September 29 2008 the Medicare EOMB is no longer needed to be attached to a claim if Medicare pays on the service Instead of the Medicare EOMB providers will utilize the coding sheet on the next page In the event that Medicare denies your service the Medicare EOMB will be required to be attached to the claim The Medicare Coding Sheet may be accessed at www kymmis com You may type in the Medicare informati
52. ier is a liable party but the liability has not been determined claims may be submitted to HP Enterprise Services with an attached letter containing any relevant information such as names of attorneys other involved parties and or the Member s employer to HP Enterprise Services ATTN TPL Unit P O Box 2107 Frankfort KY 40602 2107 12 12 2013 Page 12 5 Additional Information and Forms 5 4 4 1 TPL Lead Form HP Enterprise Services HP Enterprise Services Attention TPL Unit Box 2107 Frankfort KY 40602 2107 Third Party Liability Lead Form Provider Name Provider Member Name Member Address Date of Birth From Date of Service To Date of Service Date of Admission Date of Discharge Insurance Carrier Name Address Policy Number Start Date End Date Date Claim Was Filed with Insurance Carrier Please check the one that applies No Response in Over 120 Days Policy Termination Date Other Please explain in the space provided below Contact Name Contact Telephone Signature Date DMS Approved January 10 2011 12 12 2013 Page 13 5 Additional Information and Forms 5 5 Provider Inquiry Form Provider Inquiry Forms may be used for any unique questions concerning claim status paid or denied claims and billing concerns The mailing address for the Provider Inquiry Form is HP Enterprise Services Provider Services P O Box 2100 Frankfort KY 406
53. il lines exceed the limit for claim type 04 _ UNABLE TO IMAGE OR KEY Claim form EOMB must be legible Highlighted forms cannot be accepted Please resubmit on a new form Print too light Printtoo dark Highlighted data fields Dark copy 05 Medicaid does not make payment when Medicare has paid the amount in full 06 The Recipient s Medicaid MAID number is missing CES E 07 ___ Medicare Coding Sheet does not match the claim ___ Dates of Service Member Number Charges Balance due in Block 30 08 _ Other Reason Claims are being returned to you for correction for the reasons noted above Helpful Hints When Billing for Services Provided to a Medicaid Member The Member s Medicaid number on the CMS 1500 08 05 must be entered Field 9A The Member s Medicaid number on the CMS 1500 02 12 must be entered Field 1A The Member s Medicaid number on the UB04 must be entered in Block 60 Medicare numbers are not valid Medicaid numbers Please refer to your billing manual if you have any concerns about billing the Medicaid program correctly Please make the necessary corrections and resubmit for processing If you have any questions please feel free to contact our Provider Relations Group open Monday through Friday 8 00 a m until 6 00 p m eastern standard daylight savings time at 1 800 807 1232 If you are interested in billing Medicaid electronically please contact HP Enterpri
54. in aeiaai aas aaia entente enne en 47 8 1 2 Medicare Coding Sheet 1 eene 48 8 2 Medicare Coding for Physical Therapist nnne 49 8 2 1 Medicare Coding entree entere sinistre 50 8 2 2 Medicare Coding Sheet Instructions 51 Appendix B erede a a Ra RUE UR 52 9 1 Internal Control Number 52 Appendix tee de eh aurae aci ce dee aeu 53 10 1 Remittance Advice aeg ee Dese to eed e a DR Lee RR as oci aee did 53 10 1 1 Examples Of Pages In Remittance Advice sse 53 10 2 Title tn ties pee Pep d 55 10 3 Banner Page ceinen i ep d Pe HE ELE RR Dur Hd Me ipa 55 10 4 Paid Claims Page eie ee ee es HE iur api tie Pep ode d Ded dus 58 10 5 Denied Claims Page eie c Eng e He qu dues 60 10 6 1 amp 585 entrent nennen nnns inten ensis 62 10 7 Returned Glaim eit Ep ede bd Maedche dd dative MET d doe ERE I RUP e dnas 64 10 8 Adjusted Glaims Page e eee bnt dere fb re e 66 10 9 Financial Transaction aet fne e ek epe ted 68 10 9 1 Non Claim Specific Payouts To Providers sse 68 10 9 2 Non Claim Specific Refunds From 68 10
55. ind when refunding e Attach the Cash Refund Documentation Form to a check made payable to the KY State Treasurer e Attach applicable documentation such as a copy of the remittance advice showing the claim for which a refund is being issued e f refunding all claims on an RA the check amount must match the total payment amount on the RA If refunding multiple RAs a separate check must be issued for each RA 12 12 2013 Page 19 5 Additional Information and Forms HP Enterprise Services Mail To HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 ATTN Financial Services CASH REFUND DOCUMENTATION 1 Check Number 2 Check Amount 3 Provider Name ID Address 4 Member Name 5 Member Number 6 From Date of Service 7 To Date of Service 8 RA Date 9 Internal Control Number If several ICNs attach RAs edle La b Eb ade Research for Refund Check appropriate blank a Payment from other source Check the category and list name attach copy of EOB Health Insurance Auto Insurance Medicare Paid Other b Billed in error c Duplicate payment attach a copy of both RAs If RAs are paid to two different providers specify to which provider ID the check is to be applied d Processing error OR overpayment explain why e Paid to wrong provider f Money has been requested date of the letter attach a copy of letter requesting money g Other Contact Name Phone DMS App
56. ing sheet so you don t have to hand write the required information The PDF will not save your changes in the coding sheet Please follow the guidelines below so your Medicare Coding Sheet may process accurately Black ink only No colored ink pencils or highlighters e No white out Correction tape is allowed e f a service is paid in by Medicare those services do not need to be billed to Kentucky Medicaid The allowed amount and paid amount from Medicare would be the same e The billed amount on the claim form should equal the allowed amount on the Medicare EOMB e Take the coinsurance and or deductible and divide it by the of detail lines being billed That will give you the amount to list on each coding line Must make sure that all of the coinsurance and or deductible is totaled to the Medicare EOMB e The coinsurance and or deductible can not exceed the allowed amount on the coding sheet e When billing a multiple page CMS 1500 the total charge is put on the last claim On the previous page put continued in the billed amount e When using the coding sheet you will put the line in sequential order When using two coding sheets the second coding sheet will begin with line 7 e When writing zero s do not put a line through the zero and e The documents must be listed in the following order e Claim form e Coding sheet and e Any other attachments that may be needed Medicare EOMB is not required t
57. ion MASS ADJUSTED CLAIMS page but are formatted the same as the ADJUSTED CLAIMS page CLAIMS DENIED These figures correspond with the summary line of the last page of the DENIED CLAIMS section CLAIMS IN PROCESS The number of claims processed that suspended along with the amount billed of the suspended claims These figures correspond with the summary line of the last page of the CLAIMS IN PROCESS section 10 10 1 Payments FIELD DESCRIPTION The number of claims paid CLAIMS PAYMENT Any money owed to providers SYSTEM PAYOUTS Total check amount NET PAYMENT mms MY money refunded to Medicaid by a provider 12 12 2013 Page 72 10 Appendix C The 1099 amount NET EARNINGS 12 12 2013 Fage 79 10 Appendix C EXPLANATION OF BENEFITS DESCRIPTION A five digit number denoting the EXPLANATION OF BENEFITS detailed on the Remittance Advice EOB CODE DESCRIPTION Description of the EOB Code All EOB Codes detailed on the Remittance Advice are listed with a description definition COUNT Total number of times an EOB Code is detailed on the Remittance Advice EXPLANATION OF REMARKS FELD a five cci number denoting the remark identified on the Remittance Advice REMARK CODE Description of the Remark Code All remark codes detailed on DESCRIPTION the Remittance Advice are listed with a description definition COUNT Total number of times a Remark Code is detailed on the R
58. is Companion 20Guides index aspx 12 12 2013 Page 7 3 KyHealth Net 3 KyHealth Net The KyHealth Net website allows providers to submit claims online via a secure direct data entry function Providers with internet access may utilize the user friendly claims wizard to submit claims in addition to checking eligibility and other helpful functions 3 4 How To Get Started All Providers are encouraged to utilize KyHealth Net rather than paper claims submission To become a KyHealthNet user contact our EDI helpdesk at 1 800 205 4696 or click the link below http www chfs ky gov dms kyhealth htm 3 2 KyHealth Net Companion Guides Field by field instructions for KyHealth Net claims submission are available at http www kymmis com kymmis Provider 20Relations KY HealthNetManuals aspx 12 12 2013 Page 8 4 General Billing Instructions for Paper Claim Forms 4 General Billing Instructions for Paper Claim Forms 4 1 General Instructions The Department for Medicaid Services is mandated by the Centers for Medicare and Medicaid Services CMS to use the appropriate form for the reimbursement of services Claims may be submitted on paper or electronically 4 2 Imaging All paper claims are imaged which means a digital photograph of the claim form is used during claims processing This streamlines claims processing and provide efficient tools for claim resolution inquiries and attendant claim related matters By following t
59. ity e Retro active provider number Providers should always completely review the Prior Authorization Letter prior to providing services or billing Access the KYHealth Net website to obtain blank Prior Authorization forms http www kymmis com kymmis Provider e20Relations PriorAuthorizationForms aspx Access to Electronic Prior Authorization request EPA https home kymmis com 12 12 2013 Page 16 5 Additional Information and Forms 5 7 Adjustments And Claim Credit Requests An adjustment is a change to be made to a PAID claim The mailing address for the Adjustment Request form is HP Enterprise Services P O Box 2108 Frankfort KY 40602 2108 Attn Financial Services Please keep the following points in mind when filing an adjustment request Attach a copy of the corrected claim and the paid remittance advice page to the adjustment form For a Medicaid Medicare crossover attach an EOMB Explanation of Medicare Benefits to the claim Do not send refunds on claims for which an adjustment has been filed Be specific Explain exactly what is to be changed on the claim Claims showing paid zero dollar amounts are considered paid claims by Medicaid If the paid amount of zero is incorrect the claim requires an adjustment and An adjustment is a change to a paid claim a claim credit simply voids the claim entirely 12 12 2013 Page 17 5 Additional Information and Forms HP Enterprise Services ADJ
60. ive FFP Paid in Full Payout on Hold Involves Interest Cannot Recouped Hold Recoup Refund Inactive Charge off FFP Not Reclaimed Payout Complete Payout Set Up In Error Active Prov End Dated Active Provider A R Transfer HP Enterprise Services On Hold Hold Recoup Further Review Hold Recoup Bankruptcy Hold Recoup Appeal Hold Recoup Resolution Hearing 12 12 2013 Page 80
61. l Health Clinics Primary Care Centers Public Health Departments C SERVICES NOT COVERED UNDER PE Office visits or procedures performed by a specialist physician those practicing ina specialty other than what is listed in Section B above even if that visit procedure is determined by a qualified PE primary care provider to be medically necessary Inpatient hospital services including labor delivery and newborn nursery services Mental health substance abuse services Any other service not specifically listed in Section A as being covered under PE Any services provided by a health care provider who is not recognized by the Department for Medicaid Services DMS as a participating provider 12 12 2013 Page 4 1 General 1 2 2 5 Breast amp Cervical Cancer Treatment Program Breast and Cervical Cancer Treatment Program BCCTP offers Medicaid coverage to women who have a confirmed cancerous or pre cancerous condition of the breast or cervix In order to qualify women must be screened and diagnosed with cancer by the Kentucky Women s Cancer Screening Program be between the ages of 21 to 65 have no other insurance coverage and not reside in a public institution The length of coverage extends through active treatment for the breast or cervical cancer condition Those members receiving Medicaid through the Breast and Cervical Cancer Program are entitled to full Medicaid services Women who are eligible through PE or BCCTP do not re
62. l ICD 9 CM diagnosis code Charges Non Shaded Area Enter the usual and customary charge for the service provided to the Member Days or Units Non Shaded Area Enter the number of units provided for the Member on this date of service ID Qualifier Shaded Area Enter a ZZ to indicate Taxonomy NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim 12 12 2013 Page 43 Rendering Provider ID Shaded Area Enter the Rendering Provider s Taxonomy Number NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the number corresponds to more than one Medicaid provider number Taxonomy will be a requirement on the claim Non Shaded Area Enter the Rendering Provider s NPI Number Patient s Account No Enter the patient account number HP Enterprise Services keys the first 14 or fewer digits This number appears on the remittance statement as the invoice number Total Charge Enter the total of all individual charges entered in Field 24F Total each claim separately Enter the amount paid if any by other insurance NOTE Do not enter Medic
63. lier s Billing Name Address Zip Code and Phone Number Enter the Provider s name address zip code and phone number Enter the appropriate Pay to NPI Number Shaded Area Enter ZZ and the Pay To Taxonomy Number NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the NPI number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim Enter the date in a month day year numeric format MMDDYY This 12 12 2013 Page 40 7 4 New CMS 1500 02 12 Claim Form with NPI and Taxonomy opyo olig HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE NUCC 02 12 T PICA PICA MEDICARE MEDICAID TRICARE CHAMPVA RECA OTHER 1 INSURED S 1 0 NUMBER in 1 T 2 PATIENT S NAME Last Name First Name Middle Initi 3 PATIENT S BIRTH WWE SEX 4 INSURED S NAME Last Name First Name Middle Initial 5 PATIENT S ADDRESS No Street 6 PATIENT RELATIONSHIP TO INSURED 7 INSURED S ADDRESS No Street DT _ e ui ZIP CODE TELEPHONE Include Area Code TELEPHONE Include Area Code 9 OTHER INSURED S NAME Last Name First Name Middle Initial 10 IS PATIENT S CONDITION RELATED TO 11 INSURED S POLICY GROUP OR FECA NUMBER a TACO INSURED S POLICY O
64. m Medicare 12 12 2013 Page 51 9 Appendix B 9 1 Internal Control Number ICN An Internal Control Number ICN is assigned by HP Enterprise Services to each claim During the imaging process a unique control number is assigned to each individual claim for identification efficient retrieval and tracking The ICN consists of 13 digits and contains the following information 11 10 032 123456 1 2 3 4 TI i 0 el E S p pecu _ K eae M 2 Br ADJUSTMENTS VOID CHECK RELATED 2 Year of Receipt 3 Julian Date of Receipt The Julian calendar numbers the days of the year 1 365 For example 001 is January 1 and 032 shown above is February 1 4 Batch Sequence Used Internally 12 12 2013 Page 52 10 Appendix C 10 1 Remittance Advice This section is a step by step guide to reading a Kentucky Medicaid Remittance Advice RA The following sections describe major categories related to processing adjudicating claims To enhance this document s usability detailed descriptions of the fields on each page are included reading the data from left to right top to bottom 10 1 1 Examples Of Pages In Remittance Advice There are several types of pages in a Remittance Advice including separate page types for each type of claim however if a provider does not have activity in that particular category those pages are not included Following
65. name and middle initial format 12 12 2013 Page 28 Identification Number Enter the Member Identification number in Form Locators 60 A B and C that relates to the Member s name in Form Locators 58 A B and C Enter the 10 digit Member Identification number exactly as it appears on the Member Identification card e7 Diagnosis Code Enter the ICD 9 CM Vol 1 and 2 code describing the principal diagnosis 67A Q Other Diagnosis Code Enter the ICD 9 CM Vol 1 and 2 codes that co exist at the time the service is provided Attending Physician ID only Please watch future mailings from KY Medicaid for updates Enter the Attending Physician NPI number Enter a 1G and the unique physician identification number UPIN followed by the last name and first name of the attending physician If the physician does not have a UPIN number enter the appropriate license number NOTE The UPIN number of the Attending Physician can be used for a limited time 12 12 2013 Page 29 6 3 UB 04 Claim Form With NPI Alone NOTE KY Medicaid advises providers to use this method when a single NPI corresponds to a single KY Medicaid provider ID mew wee DI i n Pu s a a 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON COVERED CHARGES 49 m lt r
66. nter the Rendering Provider s Taxonomy Number NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the NPI number corresponds to more than one KY Medicaid provider number Taxonomy will be a requirement on the claim Non Shaded Area Enter the Rendering Provider s NPI Number Enter the usual and customary charge for the service provided to the Member 12 12 2013 Page 39 Patient s Account No Enter the patient account number HP Enterprise Services keys the first 14 or fewer digits This number appears on the remittance statement as the invoice number Total Charge Enter the total of all individual charges entered in Field 24F Total each claim separately Amount Paid Enter the amount paid if any by other insurance NOTE Do not enter Medicare payment For Medicare involved claims attach a copy of the Medicare EOMB indicating either payment or denial Balance Due Required only if other insurance made payment on the claim Subtract the insurance payment entered in Field 29 from the total charge entered in Field 28 and enter the balance due date must be on or after the date s of service billed on the claim Service Facility Location Information If the address in Form Locator 33 is not the address where the service was rendered Form Locator 32 must be completed Physician s Supp
67. o be attached to the claim 12 12 2013 Page 49 8 2 1 Medicare Coding Sheet CMS1500 CROSSOVER EOMB FORM Member 1 Member ID 2 EOMB Date 3 Line 4 Deduct Pst Resp Amt Coinsursnce snd orCo psy Amt Provider Pay Amt oe Line 4 Deduct Pst Resp Amt snd orCo psy Amt Provider Amt Ps Line 4 Deduct Pst Resp Amt Coinsurance and orCo psy Amt Provider Amt Pe Line 4 Deduct Pst Resp Amt Coinsurance snd orCo psy Amt Provider Amt L3 HOD Line 4 Deduct PstResp Amt Coinsurance snd orCo psy Amt Provider Amt Line Deduct Pst Resp Amt Coinsurance and orCo psy Amt Provider Pay Amt psf Cs Ls 12 12 2013 Page 50 8 2 2 Medicare Coding Sheet Instructions FIELD NUMBER FIELD NAME AND DESCRIPTION Member s Name Enter the Member s last name and first name exactly as it appears on the Member Identification card Member s ID Enter the Member s ID as it appears on the claim form EOMB Date Enter Medicare s EOMB date Line Number Enter the line number The line numbers must be in sequential order Deductible Amount Enter deductible amount from Medicare if applicable Co insurance and or Co pay Amount Enter the total amount of co insurance and or co pay from Medicare if applicable Provider Pay Amount Enter the amount paid from Medicare Patient Responsibility Enter the patient responsibility amount fro
68. ode which identifies the location where the service was rendered 11 Insurance Plan Name or Program Name 12 12 2013 Page 38 Procedure Code Non Shaded Area Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the member Modifier Non Shaded Area Modifier 25 should be used only with an evaluation and management E amp M service code and only when a significant separately identifiable evaluation and management service is provided by the same provider to the same patient on the same day of the procedure or service Documentation is not required to be submitted with the claim but appropriate documentation for the procedure and evaluation and management service must be maintained Diagnosis Code Indicator Non Shaded Area Enter 1 2 3 or 4 referencing the specific diagnosis for which the member is being treated as indicated in Field 21 Charges Non Shaded Area Days or Units Non Shaded Area Enter the number of units provided for the Member on this date of service ID Qualifier Shaded Area Enter a ZZ to indicate Taxonomy NOTE Those KY Medicaid providers who have a one to one match between the NPI number and the KY Medicaid provider number do not require the use of the Taxonomy when billing If the number corresponds to more than one Medicaid provider number Taxonomy will be a requirement on the claim Rendering Provider ID Shaded Area E
69. on into the PDF and print the coding sheet so you don t have to hand write the required information The PDF will not save your changes in the coding sheet Please follow the guidelines below so your Medicare Coding Sheet may process accurately e Black ink only No colored ink pencils or highlighters e No white out Correction tape is allowed e service is paid in by Medicare those services do not need to be billed to Kentucky Medicaid The allowed amount and paid amount from Medicare would be the same e When writing zeros do not put a line through the zero e When billing a claim with multiple detail lines be sure that Medicare has allowed a payment on those services If Medicare has denied a detail line that detail must be ona separate claim with the Medicare EOMB attached and e The documents must be listed in the following order e Claim form e Coding sheet and e Any other attachments that may be needed 12 12 2013 Page 46 8 1 1 Medicare Coding Sheet CMS1500 CROSSOVER EOMB FORM Member 1 Member ID 2 EOMB Date 3 Line 4 Deduct Pst Resp Amt Coinsursnce snd orCo psy Amt Provider Pay Amt oe Line 4 Deduct Pst Resp Amt snd orCo psy Amt Provider Amt Ps Line 4 Deduct Pst Resp Amt Coinsurance and orCo psy Amt Provider Amt Pe Line 4 Deduct Pst Resp Amt Coinsurance snd orCo psy Amt Provider Amt L3 HOD Line 4 Dedu
70. r s ten digit Identification number as it appears on the Member s Identification card ICN The 13 digit unique system generated identification number assigned to each claim by HP Enterprise Services CLAIM SERVICE DATE The date or dates the service was provided in month day FROM THRU and year numeric format BILLED AMOUNT The usual and customary charge for services provided for the Member TPL AMOUNT Amount paid if any by private insurance excluding Medicaid and Medicare Explanation of Benefits All EOBs detailed on the Remittance Advice are listed with a description definition at the end of the Remittance Advice 12 12 2013 Page 62 10 Appendix C REPORT CRA IPPD R COMMONWEALTH OF KENTUCKY M1 DATE 01 30 2007 RA 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 2 PROVIDER REMITTANCE ADVICE CMS CLAIMS RETURNED PROVIDER PAYEE ID 99999999 5555 ANY STREET NPI ID CITY KY 55555 5555 CHECK EFT NUMBER 999999999 ISSUE DATE 02 02 2007 ICN REASON CODE 9999999999999 01 CLAIMS RETURNED 01 12 12 2013 Page 63 10 Appendix C 10 7 Returned Claim FIELD DESCRIPTION ICN 13 digit unique system generated identification number assigned to each claim by HP Enterprise Services REASON CODE A code denoting the reason for returning the claim CLAIMS RETURNED ON THIS The total number of returned claims on the Remittance Advice Note Claims appearing on the returned claim page are forth
71. rning services submitted past the 12 month filing limit Other Signature Date HIPAA Privacy Notification This message and accompanying documents are covered by the Communications Privacy Act 18 U S C 2510 2521 and contain information intended for the specified individual s only This information is confidential If you are not the intended recipient or an agent responsible for delivering it to the intended recipient you are hereby notified that you have received this document in error and that any review dissemination copying or the taking of any action based on the contents of this information is strictly prohibited If you have received this communication in error please notify us immediately and delete the original message 12 12 2013 Page 15 5 Additional Information and Forms 5 6 Prior Authorization Information The prior authorization process does NOT verify anything except medical necessity It does not verify eligibility nor age The prior authorization letter does not guarantee payment It only indicates that the service is approved based on medical necessity If the individual does not become eligible for Kentucky Medicaid loses Kentucky Medicaid eligibility or ages out of the program eligibility services will not be reimbursed despite having been deemed medically necessary Prior Authorization should be requested prior to the provision of services except in cases of e Retro active Member eligibil
72. roved January 10 2011 12 12 2013 Page 20 5 Additional Information and Forms 5 9 Return To Provider Letter Claims and attached documentation received by HP Enterprise Services are screened for required information listed below If the required information is not complete the claim is returned to the provider with a Return to Provider Letter attached explaining why the claim is being returned A claim is returned before processing if the following information is missing e Provider ID e Member Identification number e Member first and last names and for Medicare Medicaid crossover claims Other reasons for return may include e lllegible claim date of service or other pertinent data e Claim lines completed exceed the limit and e Unable to image 12 12 2013 Page 21 5 Additional Information and Forms HP RETURN TO PROVIDER LETTER Dear Provider The attached claim is being returned for the following reason s These items require correction before the claim can be processed 01 PROVIDER NUMBER A valid NPI or provider number must be on the claim form in the appropriate field Missing _ Not a valid provider number 02 PROVIDER SIGNATURE All claims require an original signature in the provider signature block The Provider signature cannot be stamped or typed on the claim ___ Missing ___ Typed signature not valid ___ Stamped signature not valid 03 ___ Deta
73. rprise Services On Hold Hold Recoup Further Review Hold Recoup Bankruptcy Hold Recoup Appeal N x 0 DAS Hold Recoup Resolution Hearing 12 12 2013 Page 76 12 Appendix E 12 Appendix E 12 1 Remittance Advice Reason Code ADJ RSN CD or RSN CD The following is a two byte alpha numeric code specifying the reason an accounts receivable was processed against a provider s account 12 12 2013 Page 77 12 Appendix E 01 Prov Refund Health Insur Paid 32 Payout Advance to be Recouped 02 Prov Refund Member Rel Paid 33 Payout Error on Refund 03 Prov Refund Casualty Insu Paid 34 Payout RTP 04 Prov Refund Paid Wrong Vender 35 Payout Cost Settlement 05 Prov Refund Apply to Acct Recv 36 Payout Other 06 Prov Refund Processing Error 37 Payout Medicare Paid TPL 07 Prov Refund Billing Error 38 Recoupment Medicare Paid TPL 08 Prov Refund Fraud 39 Recoupment DEDCO 09 Prov Refund Abuse 40 Provider Refund Other Rsn 10 Prov Refund Duplicate Payment 41 Acct Recv Patient Assessment 11 Prov Refund Cost Settlement 42 Acct Recv Orthodontic Fee 12 Prov Refund Other Unknown 43 Acct Receivable KENPAC 13 Acct Receivable Fraud 44 Acct Recv Other DMS Branch 14 Acct Receivable Abuse 45 Acct Receivable Other 15 Acct Receivable TPL 46 Acct Receivable CDR HOSP Audit 16 Acct Recv Cost Settlement 47 Act Rec Demand
74. se Services at 1 800 205 4696 7 30 AM to 6PM Monday through Friday except holidays Initials of clerk ____ LL Provider Number Reason Code ___ 12 12 2013 Page 22 5 10 Provider Representative List 5 10 1 Phone Numbers and Assigned Counties 5 Additional Information and Forms KELLY GREGORY VICKY HICKS 502 209 3100 502 209 3100 Extension 2021273 Extension 2021263 Kelly dio gregory hp com vicky hicks hp com Assigned Counties Assigned Counties ADAIR GREEN MCCREARY ANDERSON GARRARD MENIFEE ALLEN HART MCLEAN BATH GRANT MERCER BALLARD HARLAN METCALFE BOONE GRAYSON MONTGOMERY BARREN HENDERSON MONROE BOURBON GREENUP MORGAN BELL HICKMAN MUHLENBERG BOYD HANCOCK NELSON BOYLE HOPKINS OWSLEY BRACKEN HARDIN NICHOLAS BREATHITT JACKSON PERRY BRECKINRIDGE HARRISON OHIO CALDWELL KNOX PIKE BULLITT HENRY OLDHAM CALLOWAY KNOTT PULASKI BUTLER JEFFERSON OWEN CARLISLE LARUE ROCKCASTLE CAMPBELL JESSAMINE PENDLETON CASEY LAUREL RUSSELL CARROLL JOHNSON POWELL CHRISTIAN LESLIE SIMPSON CARTER KENTON ROBERTSON CLAY LETCHER TAYLOR CLARK LAWRENCE ROWAN CLINTON LINCOLN TODD DAVIESS LEE SCOTT CRITTENDEN LIVINGSTON TRIGG ELLIOTT LEWIS SHELBY CUMBERLAND LOGAN UNION ESTILL MADISON SPENCER EDMONSON LYON WARREN FAYETTE MAGOFFIN TRIMBLE FLOYD MARION WAYNE FLEMING MARTIN WASHINGTON FULTON MARSHALL WEBSTER FRANKLIN MASON WOLFE GRAVES MCCRACKEN
75. this bill and are made a part thereof NUCC Instruction Manual available at www nucc org 12 12 2013 Page 37 7 3 Completion of CMS 1500 08 05 Claim Form With NPI and Taxonomy 7 3 1 Detailed Instructions Claims are returned or rejected if required information is incorrect or omitted Handwritten claims must be completed in black ink ONLY The following fields must be completed FIELD NUMBER FIELD NAME AND DESCRIPTION Patient s Name Enter the member s last name first name and middle initial exactly as it appears on the Member Identification card Date of Birth Enter the date of birth for the member Other Insured s Policy Group Number Enter the member s 10 digit Member Identification number exactly as it appears on the current card Insured s Policy Group or FECA Number Required if the member has insurance other than Medicare or Medicaid and the other insurance made a payment on the claim Enter the policy number of the other insurance Required if the member has insurance other than Medicaid or Medicare and the other insurance has made a payment on the claim Enter the name of the other insurance company Diagnosis or Nature of Illness Enter the required appropriate ICD 9 CM diagnosis code Four diagnosis codes may be entered Date of Service Non Shaded Area Enter the date in numeric format MMDDYY Place of Service Non Shaded Area Enter the appropriate two digit place of service c
76. tient Rehabilitation Facility ORF 5 Comprehensive Outpatient Rehabilitation Facility CORF 4th Digit Frequency 1 Admit through discharge 2 Interim first claim 3 Interim continuing claim 4 Interim final claim Statement Covers Period FROM Enter the beginning date of the billing period covered by this invoice in numeric format MMDDYY THROUGH Enter the last date of the billing period covered by this invoice in numeric format MMDDYY Discharge Code and Date 12 12 2013 Page 31 Enter 42 and the actual discharge date when the THROUGH date Form Locator 6 is not the actual discharge date and Form Locator 4 indicates Final Bill Date of Birth Enter the Member s date of birth Enter the code for the time of admission to the facility Admission hour is required for both inpatient and outpatient services Enter the appropriate two digit patient status code indicating the disposition of the patient as of the through date in Form Locator 6 3 22 Medicare EOMB Date Enter the EOMB date from Medicare if applicable 39 41 Value Codes Enter the appropriate value code s for Medicare Medicaid crossover claims A1 Deductible Payer A Enter the amount as shown on the EOMB to be applied to the Member s deductible amount due Attach EOMB A2 Coinsurance Payer A Enter the amount as shown on the EOMB to be applied toward Member s coinsurance amount due Attach EOMB
77. ttention to this page 12 12 2013 Page 55 10 Appendix C REPORT CRA BANN R COMMONWEALTH OF KENTUCKY M1 DATE 01 23 2007 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 1 PROVIDER REMITTANCE ADVICE PROVIDER BANNER MESSAGES PROVIDER PAYEE ID 99999999 555 ANY STREET NPI ID 99999999 CITY KY 55555 0000 CHECK EFT NUMBER 999999999 ISSUE DATE 01 26 2007 Commonwealth of Kentucky 12 12 2013 Page 56 10 Appendix C REPORT CRA BANN R COMMONWEALTH OF KENTUCKY M1 DATE 01 23 2007 RA 9999999 MEDICAID MANAGEMENT INFORMATION SYSTEM PAGE 1 PROVIDER REMITTANCE ADVICE CMS 1500 CLAIMS PAID PROVIDER PAYEE ID 99999999 555 ANY STREET NPI ID CITY 55555 0000 CHECK EFT NUMBER 999999999 ISSUE DATE 01 26 2007 ICN SERVICE DATES BILLED ALLOWED TPL SPENDDOWN CO PAY PAID PATIENT NUMBER FROM THRU AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT MEMBER NAME JANE DOE MEMBER NO 9999999999 9999999999999 060606 060606 200 00 0 00 0 00 9999999XXX 18 05 0 00 2 00 16 05 SERVICE DATES RENDERING BILLED ALLOWED PL SERV PROC CD MODIFIERS UNITS FROM THRU PROVIDER AMOUNT AMOUNT DETAIL EOBS 22 88304 TC 1 00 060606 060606 MCD 64000000 200 00 18 05 5001 0018 9918 00A2 TOTAL CMS 1500 CLAIMS PAID 200 00 0 00 0 00 18 05 0 00 16 05 12 12 2013 Page 57 10 Appendix C 10 4 Paid Claims Page FIELD DESCRIPTION PATIENT ACCOUNT The 14 digit Patient Account Number from Form Locator 3 MEMBER NAME The M
78. unt Enter the paid amount from Medicare if applicable Enter the Pay To NPI number NOTE KY Medicaid advises providers to use this method when a single NPI corresponds to multiple KY Medicaid provider ID s or if more than one NPI was obtained for one KY Medicaid provider ID This method is for a limited time only Please watch future mailings from KY Medicaid for updates Insured s Name Enter the Member s name in Form Locators 58 A B and C that relates to KY Medicaid the payer in Form Locators 50 A B and C Enter the Member s name exactly as it appears on the Member Identification card in last name first name and middle initial format Enter the names of payer organizations from which the provider expects payment For Medicaid use KY Medicaid All other liable payers including Medicare must be billed first 12 12 2013 Page 33 Identification Number Enter the Member Identification number in Form Locators 60 A B and C that relates to the Member s name in Form Locators 58 A B and C Enter the 10 digit Member Identification number exactly as it appears on the Member Identification card e7 Diagnosis Code Enter the ICD 9 CM Vol 1 and 2 code describing the principal diagnosis 67A Q Other Diagnosis Code Enter the ICD 9 CM Vol 1 and 2 codes that co exist at the time the service is provided Attending Physician ID only Please watch future mailings from KY Medicaid for updates Enter the

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