IL 2003-16 - Texas Department of Aging and Disability Services
Contents
1. of the claims submission process All attachments are removed from the claim and forwarded to DHS for disposition o Information is entered into CMS exactly as it appears on the claim form No editing or corrections are performed 4 When a claim is transmitted CMS tests the claim for validity and acceptance requirements The claim is paid denied or suspended according to the long term care LTC business requirements Paper claims are mailed to National Heritage Insurance Company PO Box 200105 Austin TX 78720 0105 Contact customer service for assistance at 1 800 626 4117 All LTC providers are provided an original copy of Form 1290 The original should be saved and submissions made from a photocopied form Direct questions to the provider s state contract manager Form Retention Submit the original Form 1290 to NHIC Retain a copy according to the LTC program s retention requirements DETAILED INSTRUCTIONS Claims Claims must contain the provider s complete name address and nine digit provider number A claim that does not have a provider name address or provider number will not be processed Each claim form must have an original signature The following instructions describe what information must be entered in each item of Form 1290 A new claim cannot be processed without the required information Section A Header Information 1 Provider No This item is required except for In Home and Family Support cl2. one hour of service enter the unit in 25 increments 15 minutes Example 25 hours and 30 minutes of service were provided Enter 25 50 in the number of units field 38 Unit Rate This item is required Enter the unit rate for the service provided The line item should include two digits after the decimal point Example 33 00 39 Line Item Total This item is required Enter the line item total by calculating the information entered in items 37 and 38 and if appropriate item 12 Billed Applied Income Co Pay 40 Claim Total Enter the claim total The claim total is the sum of each line item 41 Signature This item is required Sign the form Every claim form must have an original signature 42 Date Enter the date the claim is submitted Billing for Dates of Service Before October 16 2003 When billing for dates of service before October 16 2003 and the claim is submitted on or after 10 16 2003 the local code bill code must be used When using the local code the ZZ qualifier must be used When billing for dates of service on or after October 16 2003 the appropriate HCPCS code must be used unless the service has been identified as Atypical Example of a claim submitted on or after 10 16 2003 for SG 17 Date of Service Service Code Bill Code HCPCS Qualifier 09 01 2003 LVN Nursing SC 13A G0302 ZZ 10 18 2003 LVN Nursing SC 13A HC 9124 or HC T1003 Exc
3. 003 29 End Date This item is required Enter the eight digit end date mm dd yyyy for the line item Example 10 31 2003 30 Rev Code Revenue Code This item is required for some services The Rev Code is used to describe a package of services provided in a 24 hour facility setting e g nursing facility services or Assisted Living Residential Care Refer to the Revenue Code column of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters to determine if a Rev Code is required for the service you are billing Below are examples of when a Rev Code may be required Service Revenue Code Nursing Facility Daily Care 100 Assisted Living Residential Care 240 31 Proc Code Qual Procedure Code Qualifier This item is required The Proc Code Qual describes the source of the Procedure Item Code that you will be entering in item 32 Procedure Item Code There are three types of procedure code qualifiers 1 ZZ Texas LTC Local Codes hereinafter referred to as Bill Code 2 HC Healthcare Common Procedural Coding System HCPCS and Current Procedural Terminology CPT 3 AD American Dental Codes Refer to the Procedure Code Qualifier column of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters to determine the procedure code qualifier you will be entermg when billing for a particular service 32 Proc Item Code Proced
4. 17 or 512 335 4729 in Austin Sincerely signature on file Becky Beechinor Assistant Deputy Commissioner Long Term Care Services BB mgm zl SECTION A Header Information 1 Provider No 2 Provider Name LONG TERM CARE CLAIM 3 Address DHS Form 1290 October 2003 4 Telephone No 5 Client Medicaid No 6 Patient Account No 7 Client Last Name 8 Client First Name 9 Client MI 10 Client Suffix Name This infor mation is for a VA client residing in a VA facility This information is for a client requiring Al Co Pay 11 VA Indicator 12 Billed Applied Income Co Pay SECTION B Nurse Aide Training 18 NAT SSN 19 SERVICE GROUP 20 BILL CODE BEGIN DATE j MEDICAID MEDICARE PRIVATE mm dd yyyy 31 PROC 32 PROC BEGIN DATE END DATE CODE ITEM CODE mm dd yyyy mm dd yyyy QUAL I certify that this information is true accurate and complete to the best of my knowledge understand that claiming for services not actually provided constitutes fraud 21 PATIENT DAYS THIS INFORMATION IS FOR EXPEDITED PAS USE ONLY 13 Service Group 14 Service Code 15 Fund Code 16 Billed Amount 17 Billing Month Year 22 41 Signature 23 END DATE mm dd yyyy 24 TRAINING 42 Date 25 NUMBER OF UNITS NUMBER OF UNITS 27 LINE ITEM LINE ITEM FORM 1290 Instructions LONG TERM CARE CLAIM 10 2003 PURPOSE For long term care providers to submit claims to National Heritag
5. BOARD MEMBERS ii E X AS Chair Cane ens Department of Human Services Abigail Rios Barrera M D San Antonio COMMISSIONER James R Hine Jon M Bradley Dallas August 11 2003 John A Cuellar Dallas To CBA Home and Community Support Services HCSS Agencies Manson B Peal CBA CCAD Adult Foster Care AFC Providers guston CBA CCAD Assisted Living Residential Care AL RC Agencies Terry Durkin Wilkinson CBA CCAD Emergency Response Services ERS Agencies Midland CBA CCAD Home Delivered Meals HDM Agencies CBA CCAD Respite Care Agencies Community Living Assistance and Support Services CLASS Agencies Consolidated Waiver Program CWP Consumer Managed Personal Assistant Services CMPAS Agencies Day Activity and Health Services DAHS Agencies Deaf Blind with Multiple Disabilities DB MD Agencies Hospice Provider Agencies Medically Dependent Children Program MDCP Primary Home Care PHC Agencies Programs of All Inclusive Care for the Elderly PACE Agencies Special Services to Persons with Disabilities SSPD Agencies Nursing Facilities Therapy Providers Subject Long Term Care LTC Information Letter No 03 16 Provider Letter No 03 20 REVISED LTC Claim Form 1290 effective 10 16 2003 The Health Insurance Portability and Accountability Act of 1996 HIPAA is federal legislation that establishes national standards for electronic health care transactions and code sets for billing purposes The Texas Department of Human Services D
6. HS and the Texas Department of Mental Health and Mental Retardation TDMHMR must comply with HIPAA Electronic Data Interchange EDI provisions by October 16 2003 To comply with HIPAA provisions the billing claims format has been changed Who is Impacted by HIPAA Regardless of the method of billing used all Long Term Care LTC provider agencies facilities will be impacted by HIPAA Purpose of Information Letter This information letter includes the revised LTC Claim Form 1290 dated October 2003 and instructions on how to complete the form The form has been revised to include changes as a result of HIPAA implementation and will become effective 10 16 03 You are being provided with one original Form 1290 Please save the original and submit claims from a photocopied form Should you misplace the original form you may contact your regional contract manager for another Form 1290 or you can download the form at www dhs state tx us John H Winters Human Services Complex 701 West 51st Street P O Box 149030 Austin TX 78714 9030 512 438 3011 Call your local DHS office for assistance LTC Information Letter No 03 16 Provider Letter No 03 20 August 11 2003 Page 2 In reviewing the LTC Claim Form 1290 and instructions you will note the following not all inclusive 1 2 5 Form 1290 has been reformatted For example the applied income co pay field has been moved to the Section A Header Nurse Aide Training h
7. aims Enter the nine digit number as it appears on the contract 2 Provider Name This item is required Enter the provider s name as it appears on the contract 3 Address This item is required Enter the provider s address as it appears on the contract 4 Telephone No Enter the provider s telephone number as it appears on the contract 5 Client Medicaid No This item is required for all claims except Nurse Aide Training NAT claims Enter the client s nine digit client Medicaid number 6 Patient Account No Enter the provider s internal client control number 7 Client Last Name This item is required Enter the client s last name For NAT enter the trainee s last name 8 Client First Name Enter the client s first name For NAT enter the trainee s first name 9 Client MI Enter the client s middle initial For NAT enter the trainee s middle initial 10 Client Suffix Name Enter the client s suffix name Example Jr Sr Note Complete item 11 when billing for a Veteran Administrations VA client residing in a VA facility 11 VA Indicator This item is applicable only to SGs 1 and 8 Enter VA if client is residing in a VA facility Note Complete item 12 when billing for a client that requires Applied Income AI Co Pay 12 Billed Applied Income Co Pay Enter the dollar amount of the client s income to be contributed to the claim or the client s asses
8. as been assigned its own section New fields terms have been added and will be required for proper billing e g Rev Revenue Code Modifiers Place of Service POS Code etc Some fields or terms have been deleted and are no longer required for billing e g Service Group SG In most instances you are required to use national bill codes For example bill code G0701 personal assistance services PAS will be billed using the national bill code S5125 The process for claims adjustment will change Effective Date of LTC Claim Form 1290 For claims reviewed by NHIC on or after October 14 2003 revised Form 1290 dated 10 03 must be used Claims received by NHIC on the Form 1290 dated 9 99 on or after October 14 2003 will be returned for resubmission on the revised Form 1290 Claims received by NHIC on the revised Form 1290 dated 10 03 on or after October 14 2003 will be held and processed after 10 16 2003 Claims received by NHIC on the revised Form 1290 dated 10 03 prior to October 14 2003 will be returned for resubmission on the new form after October 14 2003 Additional Information for using the revised LTC Claim Form 1290 Training sessions will be provided during September for both electronic users and paper submitter provider agencies facilities The Paper Submitter User Manual dated 2003 will be mailed to every provider in August The LTC User Manual is being sent to you by the National Heritage Insuranc
9. c modifiers apply to the service billed Modifier 1 Complete Modifier 1 if your contract includes more than one SG Examples SG3 CBA AL RC and SG7 CCAD RC Enter the appropriate U modifier in Modifier 1 Column from the list below Leave blank if your contract includes only one service group U3 SG 3 U7 SG7 Note Hospice providers must enter a modifier in the Modifier 1 column to indicate if the provider is billing for an SG4 5 or 6 MHMR client Modifier 2 Complete Modifier 2 if your contract requires a budget Examples PAS ERS Meals Enter the appropriate U modifier in Modifier 2 column from the list below U1 Budget 1 U2 Budget 2 34 POS Place of Service Code This item is required The POS Code identifies the location e g nursing facility client s home assisted living residential care facility dentist office where the service e g daily care PAS ERS assisted living residential care dental service being billed was provided Enter the appropriate POS code that identifies where the service was provided to the client Refer to Appendix C Place of Service found in the Long Term Care Manual for Paper Submitters to identify the code to use when billing for a particular service Examples Nursing Facility Dental Care Office or Other POS Assisted Living Residential Care Assisted Living Facility Other POS 35 TID Tooth ID Complete this item if you are billing for ser
10. e Company NHIC If you do not receive the user manual by September 6 2003 contact NHIC for a copy The manual was revised to complement changes made to the Form 1290 The LTC User Manual provides detailed instructions on how to complete the form and must be used as a resource when completing the Form 1290 The manual provides a copy of the Bill Code Crosswalk and instructions on its use The information from the Bill Code Crosswalk must be used when billing for services on or after October 16 2003 To summarize All LTC provider agencies facilities will be impacted by HIPAA changes The 2003 LTC User Manual for Paper Submitters and the revised Form 1290 dated 10 03 become effective October 16 2003 LTC Information Letter No 03 16 Provider Letter No 03 20 August 11 2003 Page 3 e To learn more about how to complete the Form 1290 attend a training or workshop in August or September 2003 Please check the NHIC website for trainings workshops in your area e Review the Bill Code Crosswalk to familiarize yourself with new fields that will be required by October 16 Still have questions about this information letter e For community care providers contact your regional CMS Coordinator e For nursing facility and therapy providers contact the Provider Claims Services Help Desk at 512 490 4666 For all providers if you have questions about general billing or the user manual contact the NHIC LTC Help Desk at 1 800 626 41
11. e Insurance Company NHIC for processing in the Claims Management System CMS Note Form 1290 becomes effective October 16 2003 Form 1290 dated 10 03 must be used for claims received by NHIC on or after October 14 2003 e Claims received on old Form 1290 dated 9 99 on or after October 14 2003 Claims received by NHIC on the old Form 1290 on or after October 14 2003 will be returned to providers for resubmission on the revised Form 1290 e Claims received on revised Form 1290 dated 10 03 before October 14 2003 o Claims received by NHIC on the revised Form 1290 before October 14 2003 will be returned for resubmission on the revised Form 1290 o Claims received by NHIC between October 14 and October 16 will be held and processed on October 16 2003 PROCEDURES One or more claims may be submitted in one mailing Form 1290 is used to bill for new claims adjustment claims dental claims nurse aide training NAT claims and expedited claims A paper claim allows one client per claim form A single claim form may contain up to 17 line items for that one client Claims requiring more than 17 line items per billing must be submitted on multiple claim forms Claims submitted on paper are sorted and imaged before being data entered into CMS Process 1 NHIC receives claim form s requests 2 Claims are imaged for tracking and archiving purposes 3 Claims are keyed into CMS o Attachments are not accepted as part
12. eptions Nursing Facility Hospice ICF MR For dates of service before 10 16 03 and the claim is submitted on or after 10 16 03 both the revenue code and the local bill code must be used For dates of service on or after 10 16 03 and the claim is submitted on or after 10 16 03 only the revenue code should be used Example of a claim submitted on or after 10 16 2003 for SG 1 Date of Service Service Code Revenue Code and Bill Qualifier Code HCPCS 09 01 2003 Daily Care SC1 100 N0201 ZZ 10 18 2003 Daily Care SC1 100 Hospice Physician Services Regardless of the dates of service hospice physician services submitted on or after 10 16 03 must be billed using the revenue code and the appropriate CPT code Adaptive Aids Durable Medical Equipment DME Medical Supplies Regardless of the dates of service Adaptive Aids DME Medical Supplies Local Code G0500 submitted on or after 10 16 03 must be billed using the appropriate national code Dental Regardless of the dates of service dental service claims submitted on or after 10 16 03 must be billed using the appropriate national code Line Item Adjustments Line item adjustments are submitted to make a change to a previously paid claim Line items must contain all of the original claims information exactly as shown in the R amp S report Line item information is matched to the original claim detail line item using data that includes but is not limited
13. evenue code POS codes The Bill Code Crosswalk includes detailed procedures about using the Crosswalk Section B Complete for Nurse Aide Training NAT ONLY 18 NAT SSN This item is required Enter the trainee s nine digit social security number 19 Service Group This item is required Enter up to five characters for the service group identification as it appears on the provider s service authorization Refer to the Service Group column of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters for a list of service groups 20 Bill Code This item is required Enter the five character code for the specific service provided to the client Refer to the Bill Code column of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters for a list of bill codes Note A procedure code qualifier is not required when billing for NAT 21 Patient Days This item is required Complete one or all of the subtypes The sum of all three types must equal 100 0 This percentage should consist of a maximum of three leading digits before and one digit after the decimal point Example 100 0 Medicaid Enter the percentage of filled beds in the facility for Medicaid clients This percentage should consist of a maximum of three leading digits before and one digit after the decimal point Example 30 0 Medicare Enter the percentage of filled beds in
14. sed AI co pay amount Note Complete items 13 through 17 for Expedited PAS Claims only 13 Service Group Enter the service group 14 Service Code Enter the service code 15 Fund Code Enter the fund code 16 Billed Amount Enter the billed amount 17 Billing Month Year Enter the two digit month and four digit year of the billing month year mnyvyyyy Important Note e Bill Code Crosswalk Throughout these form instructions you will be referred to the Bill Code Crosswalk The Bill Code Crosswalk is a cross referenced code set used to match the Texas LTC Local Codes i e bill codes to the National Standard Procedure Codes e g procedure item revenue codes You must use information on the Bill Code Crosswalk associated with the bill code that reflects the service billed when completing Form 1290 The Bill Code Crosswalk includes codes necessary when billing for services e g bill codes Healthcare Common Procedural Coding System HCPCS item codes revenue codes place of sale POS codes The Bill Code Crosswalk is found in Appendix B of the Long Term Care Manual for Paper Submitters e How to Use the Crosswalk 1 Identify the Service Group Service Code SG SC that you are billing 2 Go to the Bill Code Crosswalk and find the same SG SC 3 Continue on the same line Find the corresponding information to complete the applicable items on the form Examples bill code HCPCS item code r
15. the facility for Medicare clients This percentage should consist of a maximum of three leading digits before and one digit after the decimal point Example 30 0 Private Enter the percentage of filled beds in the facility for private clients This percentage should consist of a maximum of three leading digits before and one digit after the decimal point Example 40 0 22 Begin Date This item is required Enter the eight digit begin date mm dd yyyy for the line item Example 10 01 2003 23 End Date This item is required Enter the eight digit end date mm dd yyyy for the line item Example 10 31 2003 24 Training Hours This item is required Enter the number of training hours completed Include one digit after the decimal point Example 79 5 25 Number of Units This item is required Enter the number of units of service provided to the client The line item should include one digit after the decimal point Example 139 0 26 Unit Rate This item is required Enter the unit rate for the service provided The line item should include two digits after the decimal point Example 33 00 27 Line Item Total This item is required Enter the line item total by calculating the information entered in items 24 25 and 26 Section C Line Item Information 28 Begin Date This item is required Enter the eight digit begin date mm dd yyyy for the line item Example 10 01 2
16. to service dates codes revenue bill procedure item and units The line item adjustments must contain one or more negative line items The negative line items cancel out the applicable line items listed on the original claim that is to be adjusted Enter the line item s to be adjusted as they appear on the original claim in Section B of Form 1290 except that the number of units and line item total are entered in negative amounts Many line items for a claim may be adjusted Each line item adjusted must be credited back before any and all correct changes are made The credit appears on the adjusted line item as a negative number of units on the R amp S report Not all negative line items credited line items have a corresponding positive line item adjusted charge adjustment associated with it Line item adjustments for dates of service before 10 16 03 You must use the ZZ qualifier and the appropriate local bill code originally used when the original claim was processed Line item adjustments for dates of service after 10 16 03 You must use the appropriate local national code or Revenue Code used when the original clatm was processed
17. ure Item Code This item is required for some services The Proc Item Code describes the service provided to the client Services provided are described by codes There are four types of procedure item codes 1 Bill Codes 2 HCPCS 3 CPT 4 AD Refer to the Bill Code HCPCS or CPT Codes columns of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters to determine the Procedure Item Code you need to enter when billing for a particular service Complete this item as follows e If you entered the code ZZ in item 31 Proc Item Code enter a Bill Code e If you entered the code HC in item 31 Proc Item Code enter a HCPCS or CPT e If you entered the code AD in item 31 Proc Item Code enter a Dental Code 33 Modifiers Leave blank if this item is not applicable to the service billed The modifiers are used to further define a service and or assist in determining what to pay during the claims adjudication process Refer to Modifier columns 2 3 and 4 of the Bill Code Crosswalk found in Appendix B of the Long Term Care Manual for Paper Submitters to determine if a modifier and or more than one modifier is required when billing for a particular service Note about Modifiers 1 and 2 Modifiers 1 and 2 used to provide contract specific information are not included in the Bill Code Crosswalk e g service group budget number Use the modifier information below to determine if contract specifi
18. vices for a client receiving dental services treatment by a licensed dentist Enter up to a two digit number that identifies the tooth on which the service was performed Refer to the Tooth ID chart of the Bill Code Crosswalk found in Appendix C of the Long Term Care Manual for Paper Submitters to identify the tooth ID 36 Rendering Provider Name This item is required if the service being billed is a skilled professional service and was provided by someone other than the provider agency i e dentist therapist other licensed professional The rendering provider name identifies the name of the person that provided the service to the client This does not apply to unskilled nonprofessional services delivered by the provider agency examples meals attendant services day activity and health services Enter the name of the skilled professional person etc that provided the service to the client You do not need to include the person s credentials See examples below Examples Skilled Professional Service Provided Name of Rendering Provider Dental Services David Dental Physical Therapy Patty Therapist Nursing Services Nadine Service 37 Number of Units This item is required Enter the number of units of service provided to the client The line item should include two digits after the decimal point Example 139 00 Note If the unit rate for the service you are billing is hourly and you are billing for less than
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