SECTION 15 - BILLING INSTRUCTIONS 15.1 ELECTRONIC DATA INTERCHANGE... 2 15.2 INTERNET ELECTRONIC CLAIM SUBMISSION... 2 15.3 DENTAL CLAIM FORM... 3 15.4 PROVIDER RELATIONS COMMUNICATION UNIT... 3 15.5 RESUBMISSION OF CLAIMS... 3 15.6 BILLING PROCEDURES FOR MEDICARE/MEDICAID... 3 15.7 DENTAL CLAIM FILING INSTRUCTIONS... 4 15.8 INSURANCE COVERAGE CODES... 8 1
SECTION 15-BILLING INSTRUCTIONS 15.1 ELECTRONIC DATA INTERCHANGE Billing providers who want to exchange electronic transactions with Missouri Medicaid should access the ASC X12N Implementation Guides, adopted under HIPAA, at www.wpc-edi.com. For Missouri specific information, including connection methods, the biller s responsibilities, forms to be completed prior to submitting electronic information, as well as supplemental information, reference the X12N Version 4010A1 and NCPDP Telecommunication V.5.1 & Batch Transaction Standard V.1.1 Companion Guides found through this web site. To access the Companion Guides, select: Missouri Medicaid Electronic Billing Layout Manuals System Manuals Electronic Claims Layout Manuals X12N Version 4010A1 or NCPDP Telecommunication V.5.1 & Batch Transaction Standard V.1.1 Companion Guide. 15.2 INTERNET ELECTRONIC CLAIM SUBMISSION Providers may submit claims via the Internet. The web site address is www.emomed.com. Providers are required to complete the on-line Application for Missouri Medicaid Internet Access Account. Please reference http://dss.missouri.gov/dms/ and click on the Apply for Internet Access link. Providers are unable to access www.emomed.com without proper authorization. An authorization is required for each individual user. For full functionality of the Internet application, either the Internet Explorer 5.0 or higher web browser or the Netscape 4.7 or higher web browser is recommended. The features of the Internet application include claim submissions, claim credits and eligibility verification. The following claim types can be used in Internet applications: Medical (NSF), Inpatient and Outpatient (UB-04), Dental (2002, 2004 American Dental Association), Nursing Home and Pharmacy. For convenience, some of the input fields are set as indicators or accepted values in dropdown boxes. Providers have the option to input and submit claims individually or in a batch submission. A confirmation file is returned for each transmission. 2
15.3 DENTAL CLAIM FORM The Dental Claim Form, American Dental Association (ADA), 2002, 2004 American Dental Association is used to bill Missouri Medicaid for dental services unless a provider bills those services electronically. Instructions on how to complete the Dental Claim Form are on the following pages. 15.4 PROVIDER RELATIONS COMMUNICATION UNIT It is the responsibility of the Provider Relations Communication Unit to assist providers in filing claims. For questions, providers may call (573) 751-2896. Section 3 of this manual has a detailed explanation of this unit. If assistance is needed regarding establishing required electronic claim formats for claims submissions, accessibility to electronic claim submission via the Internet, network communications, or ongoing operations, the provider should contact the Infocrossing Healthcare Services Help Desk at (573) 635-3559. 15.5 RESUBMISSION OF CLAIMS Any line item on a claim that resulted in a zero payment can be resubmitted if it denied due to a correctable error. The error that caused the claim to deny must be corrected before resubmitting the claim. The provider may resubmit electronically or on a Dental Claim Form. An example of a correctable error is the use of an invalid procedure code. If a line item on a claim paid but the payment was incorrect do not resubmit that line item. For instance, if the dental provider received $2.00 instead of $20.00, that claim cannot be resubmitted. It will deny as a suspect duplicate. In order to correct that payment, the provider must submit an Individual Adjustment Request. Section 6 of this manual explains the adjustment request process. 15.6 BILLING PROCEDURES FOR MEDICARE/MEDICAID When a recipient has both Medicare Part B and Medicaid coverage, a claim must be filed with Medicare first as primary payor. If the patient has Medicare Part B but the service is not covered or the limits of coverage have been reached previously, a paper claim must be submitted to Medicaid with the Medicare Remittance Advice attached indicating the denial. Reference Section 16.5 of this manual for instructions for submission of claims to Medicaid. If a claim was submitted to Medicare indicating that the recipient also had Medicaid and disposition of the claim is not received from Medicaid within 60 days of the Medicare remittance advice date (a reasonable period for transmission for Medicare and Medicaid processing), a paper crossover claim must be submitted to Medicaid. Reference Section 16 for billing instructions. 3
15.7 DENTAL CLAIM FILING INSTRUCTIONS The American Dental Association, 2002, 2004, Dental Claim Form should be typed or legibly printed. It may be duplicated if the copy is legible. Medicaid claims should be submitted electronically to www.emomed.com or mailed to: Infocrossing Healthcare Services P.O. Box 5300 Jefferson City, MO 65102 Information about ordering claim forms and provider labels is in Section 3. NOTE: An asterisk (*) beside field numbers indicates required fields. These fields must be completed or the claim is denied. All other fields should be completed as applicable. Two asterisks (**) beside the field number indicate a field is required in specific situations. FIELD NUMBER & NAME 1-2 Not required. INSTRUCTIONS FOR COMPLETION *3. Primary Payer Information Enter name, address, city, state and zip code for the insurance company or third-party payer. **4-11. Other Coverage Required only if recipient has second dental policy. Leave blank if there is not other dental coverage.(1) **12-17. Primary Insured Information When verifying the recipient's eligibility, verify if there is other insurance coverage. If applicable, enter the name of the dental insurance, address, and policy number. 18-19. Not required. If the other insurance pays, the amount paid should be entered in field #32, section :"Other Fees." Leave blank if there are no other dental coverage. *20. Patient Name Enter the recipients last name, first name and middle initial as shown on the recipient's ID card. Enter the recipient's street address, city of residence and state. 21. Date of Birth Not required. 22. Sex Not required. 4
*23. Patient ID# Enter the Medicaid number exactly as shown on the recipient's ID card. *24. Date Enter the actual date services were rendered in month/day/year numeric format. **25. Oral Cavity Report the area of the oral cavity. In any of the following instances, leave this field blank. 26. Tooth system Not required. a. the procedure identified in #29 requires the identification of a tooth or a range of teeth. b. the procedure identified in #29 incorporates a specific area of the oral cavity in its nomenclature. c. the procedure identified in #29 does not relate to any portion of the oral cavity. *27. Tooth Number or Letter Enter the appropriate tooth number or letter for services performed on each line item of the claim. If a particular tooth number or letter does not apply, this field may be left blank.the valid fields are: A-T Deciduous teeth 1-32 Permanent teeth AS-TS Deciduous supernumerary teeth 51-82 Permanent supernumerary teeth When billing for partial dentures, enter the tooth number for one of the teeth being replaced in this field. Alveoplasties should be billed using the correct oral cavity code 10 for upper right quadrant, 20 for upper left quadrant, 30 for lower left quadrant and 40 for lower right quadrant. *28. Tooth Surface Enter the appropriate surface code, if 5
applicable, otherwise leave blank. The valid values are: M Mesial D Distal O Occlusal L Lingual I Incisal F Facial B Buccal *29. Procedure Code Enter the five-digit code for the service performed, as well as any applicable modifiers. **30. Description Only required in specific situations as described in Section 13. *31. Fee Enter the usual and customary fee for the procedures(s) performed. Do not subtract the copay or coinsurance amounts from the charge. 32. Other fees When other charges are applicable to dental services provided, this field must be reported. Enter the amount here. *33. Total Fee Enter the total of the charges shown. 34. Missing Teeth Not required. **35. Remarks For timely filing purposes, if this is a resubmitted claim, enter the Internal Control Number (ICN) of the previous related claim or attach a copy of the original Remittance Advice indicating the claim was initially submitted timely. 36-38. Not required. **39. Number of Enclosures Complete whether or not radiographs, oral images, or study models are submitted with the claim. If no enclosures are submitted, enter 00 in each of the boxes to verify that 6
nothing has been sent and therefore no possible attachments are missing. 40. Is treatment for Orthodontics? If no, skip to #43. If yes, answer #41 and 42. 41. Date Appliance placed. Enter the date orthodontic appliance was placed, if the answer to #40 is yes. Otherwise leave blank. 42. Months of Treatment Remaining Enter the months of orthodontic treatment remaining, if the answer to #40 is yes. Otherwise leave blank. 43. Replacement of Prosthesis. This item applies to crowns and all fixed or removable prostheses. a. If claim does not involve a prosthetic restoration, check "no" and proceed to #45. b. If claim is for the initial placement of a crown or fixed or removable prosthesis, check "no" and go to #45. c. The patient has previously had these teeth replaced by a crown, check "yes" and go to #44. 44. Date of Prior Placement. Enter the date of the initial placement of the prosthesis, if the answer to #43 is yes. Otherwise leave blank. 45. Treatment Resulting From If the dental treatment listed on the claim was provided as a result of an accident or injury, check the appropriate box and proceed to items #46 & 47. If services are not the result of an accident, skip to field #48. The valid values are: AA Auto Accident EM Employment Related OA Other Accident 46. Accident Date Enter the date on which the accident in #45 occurred. Otherwise leave blank. 7
47. Auto Accident State Enter the state in which the auto accident in #45 occurred. Otherwise leave blank. 48. Name, Address, City, State Enter the name and complete address of dentist or dental entity. 49. Provider ID# This number is the NPI number assigned to the billing dentist or dental entity. 50. Dentist License # Not required. 51. Dentist SS# or T.I.N Not required. 52. Phone Number Enter provider's phone number. *53. Signature & Date Signature of treating dentist and the date form is signed. *54. Provider ID# (Performing Provider) 55. License # Not required. This number is the NPI number assigned to the treating dentist. *56. Address, City, State, MO Enter the name and complete address of dentist or dental entity. 57. Phone Number Enter treating dentist phone number 58. Treating Provider Specialty Not required. * These fields are mandatory on all Dental Claim Form. ** These fields are mandatory only in specific situations as described. (1) NOTE: This field is for private insurance information only. If no private insurance is involved LEAVE BLANK. If Medicare, Medicaid, employers name or other information appears in this field, the claim will deny. See Section 5 for further TPL information. 15.8 INSURANCE COVERAGE CODES Type of insurance coverage codes identified on the interactive voice response (IVR) system, a point of service (POS) terminal, or eligibility files accessed via the Internet are listed in Section 5, Third Party. While providers are verifying the patient s eligibility, they can obtain the TPL information contained on the Division of Medical Services recipient file. Eligibility may be verified by calling the Interactive Voice Response (IVR) system at (573) 635-8908, which allows the provider to inquire on third party resources. The provider may also use a point of service (POS) terminal or the Internet at 8
www.emomed.com to verify eligibility and inquire on third party resources. Reference Sections 1 and 3 for more information. Recipients must always be asked if they have third party insurance regardless of the TPL information given by the IVR, POS terminal or Internet. IT IS THE PROVIDER S RESPONSIBILITY TO OBTAIN FROM THE RECIPIENT THE NAME AND ADDRESS OF THE INSURANCE COMPANY, THE POLICY NUMBER, AND THE TYPE OF COVERAGE. Reference Section 5 of this manual, Third Party Liability. END OF SECTION TOP OF PAGE 9