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Commonwealth of Kentucky

KyHealth Choices Provider Billing Instructions

For Qualified Medicare Beneficiary

Provider Types 82, 87, 88, 89, 91, and 95

Version 1.8

September 22, 2006

Revision History Document Version

Date Name Comments

1.0 10/14/2005 EDS Initial creation of DRAFT Home Health Services Provider Type – 34

1.2 01/19/2006 EDS Updated Provider Rep list

1.3 02/16/2006 Carolyn Stearman Updated with revisions requested by Commonwealth.

1.4 03/28/2006 Lize Deane Updated with revisions requested by Commonwealth.

1.5 05/01/2006 Tammy Delk Updated with revisions requested by Commonwealth.

1.6 8/18/2006 Ron Chandler Updated with revisions sent by Stayce Towles.

1.7 08/28/2006 Ann Murray Updated with revisions submitted by Vicky Hicks.

1.8 09/18/2006 Ann Murray Replaced Provider Representative table.

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TABLE OF CONTENTS

NUMBER DESCRIPTION PAGE

1 General ................................................................................................................................................. 1 1.1 Member Eligibility.......................................................................................................................... 1 1.2 Plastic Swipe KyHealth Card ........................................................................................................ 2 1.3 Member Eligibility Categories ....................................................................................................... 3

1.3.1 Lock-In ............................................................................................................................. 3 1.3.2 KenPAC ........................................................................................................................... 3 1.3.3 QMB and SLMB............................................................................................................... 3 1.3.4 Managed Care Partnerships............................................................................................ 3 1.3.5 KCHIP .............................................................................................................................. 3 1.3.6 Presumptive Eligibility...................................................................................................... 4 1.3.7 Breast & Cervical Cancer Program.................................................................................. 5

1.4 Verification of Member Eligibility................................................................................................... 6 1.4.1 Obtaining Eligibility and Benefit Information .................................................................... 6

2 General Billing Instructions ............................................................................................................... 9 2.1 General Instructions...................................................................................................................... 9 2.2 Imaging ......................................................................................................................................... 9 2.3 Optical Character Recognition...................................................................................................... 9

3 Electronic Data Interchange (EDI) ................................................................................................... 11 3.1 Means Of Electronic Submission................................................................................................ 11 3.2 How To Get Started .................................................................................................................... 11 3.3 Format and Testing..................................................................................................................... 11 3.4 ECS Help .................................................................................................................................... 11

4 Additional Information and Forms .................................................................................................. 13 4.1 Claims with Service Dates Over One Year Old .......................................................................... 13 4.2 Retroactive Eligibility (Back-Dated) Card.................................................................................... 13 4.3 Unacceptable Documentation..................................................................................................... 13 4.4 Third Party Coverage Information............................................................................................... 14

4.4.1 (Excluding Medicare) ..................................................................................................... 14 4.4.2 Documentation That May Prevent A Claim From Denying............................................ 14 4.4.3 For Accident And Work Related Claims ........................................................................ 15

4.5 Provider Inquiry Form ................................................................................................................. 17 4.6 Prior Authorization Information ................................................................................................... 19 4.7 Adjustments And Claim Credit Request ..................................................................................... 20 4.8 Cash Refund Documentation Form ............................................................................................ 22 4.9 Return To Provider Letter ........................................................................................................... 24 4.10 Provider Representative List....................................................................................................... 26

4.10.1 Phone Numbers and Assigned Counties....................................................................... 26 5 HIPAA Information for Billing .......................................................................................................... 29 6 Completion of UB-92 Billing Form .................................................................................................. 33

6.1 Detailed UB-92 Billing Instructions ............................................................................................. 35 7 Completion of CMS-1500 (12/90) Paper Claim Form ..................................................................... 38

7.1 Completion of Invoice CMS-1500 (12/90) .................................................................................. 39 7.1.1 Crossover (Medicare/Medicaid)..................................................................................... 39

7.2 Completed CMS-1500 (12/90) Claim Form ................................................................................ 40 7.3 Completion of CMS-1500 (12/90) Paper Claim Form................................................................. 41

7.3.1 Detailed Instructions ...................................................................................................... 41 7.4 New Completed CMS-1500 (08/05) Claim Form........................................................................ 43 7.5 Completion of New CMS-1500 (08/05) Paper Claim Form ........................................................ 44

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7.5.1 Detailed Instructions ...................................................................................................... 44 8 Appendix A ........................................................................................................................................ 47

8.1 Internal Control Number (ICN).................................................................................................... 47 9 Appendix B ........................................................................................................................................ 48

9.1 Remittance Advice...................................................................................................................... 48 9.1.1 Examples Of Remittance Advice Pages........................................................................ 49

9.2 Title ............................................................................................................................................. 50 9.3 Banner Page............................................................................................................................... 50 9.4 Paid Claims Page ....................................................................................................................... 54 9.5 Denied Claims Page ................................................................................................................... 57 9.6 Claims in Process Page.............................................................................................................. 61 9.7 Returned Claim........................................................................................................................... 63 9.8 Adjusted Claims Page ................................................................................................................ 65 9.9 Accounts Receivable Summary Page ........................................................................................ 69 9.10 Summary of Benefits Page ......................................................................................................... 76

10 Appendix C ........................................................................................................................................ 79 10.1 Remittance Advice Location Codes (LOC CD)........................................................................... 79

11 Appendix D ........................................................................................................................................ 80 11.1 Remittance Advice Reason Code (ADJ RSN CD or RSN CD) .................................................. 80

12 Appendix E......................................................................................................................................... 82 12.1 Remittance Advice Status Code (ST CD)................................................................................... 82

1 General

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1 General

1.1 Member Eligibility KY Members must apply for Medicaid eligibility through their Department for Community Based Services (DCBS) local office. If you have any questions or concerns, you must contact the KY Administrative Agent (KMAA), which is First Health Services Corporation, at 1-800-635-2570, 8:00 a.m. – 6:00 p.m. Eastern Time, Monday through Friday, except Holidays and select the prompt for Member Eligibility.

The primary identification for Medicaid eligible members is the KyHealth Card. It is a permanent plastic card issued when the Member becomes eligible for Medicaid coverage. The name of the member and the Member Identification number is the only data displayed on the card. The provider has the responsibility to check identification and eligibility of each member before providing services.

NOTE: Payment cannot be made for services provided to ineligible members,

and/or,

Possession of a Member Identification card does not guarantee payment for all medical services.

The following is an example of the KyHealth Card:

1 General


1.2 Plastic Swipe KyHealth Card

Through a vendor of your choice, the magnetic strip can be swiped to obtain eligibility information.

Member Name

First, Middle Initial (if available), Last

Ten DIGIT Member Identification Number

Magnetic Strip

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1.3 Member Eligibility Categories

1.3.1 Lock-In KY Medicaid monitors utilization patterns of Medicaid members to ensure that benefits received are at an appropriate frequency and are medically necessary given the condition presented by the member. Referrals regarding suspected over-utilization are investigated by the Department. In those cases where improper utilization can be documented, the member is "locked-in" or assigned to one physician to serve as case manager and/or one pharmacy for supply of prescription drugs. The lock-in member is thereafter limited to use the services of these providers except in cases of emergency or appropriate referrals by the physician case manager. Providers who are not designated as lock-in case managers or pharmacies do not receive payment for services provided unless a medical emergency is documented or an appropriate referral has been made.

1.3.2 KenPAC Kentucky Patient Access Care (KenPAC) is a patient care system which provides Medicaid members with a primary care provider. The primary care provider is responsible for providing or arranging for the member’s primary care and for referral of other medical services. Similar to "lock-in" members, a service provided to a KenPAC member by a medical provider other than the assigned primary care provider is not covered unless an appropriate referral has been made by the KenPAC PCP. Some categories of medical service are exempt from the KenPAC referral requirement. A complete list of these is listed in 907 KAR 1:320. Some of the physician-provided services which do not require a KenPAC referral include a mental health service (if provided by a psychiatrist), a vision service, a maternity care service, an EPSDT service, a family planning service, or a newborn care service.

1.3.3 QMB and SLMB Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs) are Medicare eligible members who also qualify for limited Medicaid assistance. The QMB eligible individual is issued a medical card with a designation indicating the individual is eligible for either QMB and Medicaid benefits or QMB benefits only. QMB benefits entitle the individual to Medicaid coverage of Part A & Part B Medicare premiums, co-pays, and deductibles. An individual who qualifies for SLMB benefits is not eligible for Medicaid benefits other than coverage of their monthly Medicare premium.

1.3.4 Managed Care Partnerships Passport is a Medicaid health care plan serving Medicaid members living in the following counties: Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble, and Washington.

Although medical benefits for individuals whose care is managed by Passport mimic those of KY Medicaid, some billing procedures may differ. A physician having questions regarding Passport coverage should contact Passport Provider Services at 1-800-578-0775.

1.3.5 KCHIP The KY Children's Health Insurance Program (KCHIP) is for children through the age of 18 years who have no other type of insurance and whose family meets specified income criteria. Based upon household income, these children are issued a regular Medicaid card. Children

1 General


having KCHIP III category eligibility are covered for all Medicaid covered services except non-emergency transportation and EPSDT special services.

1.3.6 Presumptive Eligibility Presumptive Eligibility (PE) is a program offering pregnant women temporary medical coverage for prenatal care. A treating physician may issue an Identification Notice to a woman once pregnancy is confirmed. Presumptive eligibility expires 90 days from the date the Identification Notice is issued 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.

1.3.6.1 Presumptive Eligibility Definitions Presumptive Eligibility (PE) is designed to provide coverage for ambulatory prenatal services when these services are provided by approved health care providers.

A. SERVICES COVERED UNDER PE

• Office visits to a Primary Care Provider (see list below) and/or Health Department,

• Anesthesia Services;

• Surgical Services;

• Termination of Pregnancy;

• Laboratory Services;

• Diagnostic radiology services (including ultrasound);

• General dental services;

• Emergency room services;

• Transportation services(emergency and non-emergency); and,

• Prescription drugs (including prenatal vitamins).

B. 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: --Family Practice --Obstetrics/Gynecology --General Practice --Pediatrics --Internal Medicine;

• Physician Assistants;

• Nurse Practitioners/ARNP’s;

• Nurse Midwives;

• Rural Health Clinics;

• Primary Care Centers; and,

• Public Health Departments.

SERVICES NOT COVERED UNDER PE

1 General


• Office visits or other procedures performed by a specialist physician (those practicing in a specialty other than those 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; and,

• Any services provided by a health care provider who is not recognized by the Department for Medicaid Services (DMS) as a participating provider.

1.3.7 Breast & Cervical Cancer Program Breast and Cervical Cancer Program (BCCP) offers Medicaid coverage to individuals who have a confirmed cancerous or pre-cancerous condition of the breast or cervix. In order to qualify for Medicaid eligibility under this program, an individual must be under age 65 and have no other insurance coverage. Eligible individuals receive an Identification Notice. The length of coverage extends through the required treatment period for the breast of cervical cancer condition. Those members receiving Medicaid through the Breast and Cervical Cancer Program are entitled to full Medicaid services.

1 General


1.4 Verification of Member Eligibility This section discusses:

1. Methods for verifying eligibility;

2. How to verify eligibility through an automated 800 number function;

3. How to use other proofs to determine eligibility; and,

4. What to do when a proof of eligibility is not available.

1.4.1 Obtaining Eligibility and Benefit Information Eligibility and benefit information is available to providers via the following:

5. Voice Response Eligibility Verification (VREV) available 24 hours/7 days a week at 1-800-807-1301;

6. Access KyHealth-Net at http://www.chfs.ky.gov/dms/KyHealth.htm; and,

• Contacting the First Health Services Corporation, the fiscal agent for KMAA, Call Center Customer Representative at 1-800-635-2570 Monday through Friday 8:00 a.m. – 6:00 p.m., except Holidays.

1.4.1.1 Voice Response Eligibility Verification (VREV) EDS maintains a Voice Response Eligibility Verification (VREV) system that provides member eligibility verification, third party liability (TPL) information, KenPAC, Lock-in, 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, or etc.).

3. Prompt the caller for the dates of service (enter four digit year, for example, MMDDCCYY).

4. Respond by providing the appropriate information for the requested inquiry.

5. Prompt for another inquiry.

6. Conclude the call.

This system provides a fast-path mode that permits a provider to take a short path to information. By simply keying the appropriate responses to prompts such as provider ID or Member Identification number as soon as each prompt begins. This greatly increases the speed of the inquiry. The number of inquiries is limited to 5 per call. The VREV spells the member name and announces the dates of service to ensure accuracy of responses. The check amount data is accessed through the VREV voice menu. The provider file is accessed to obtain up to the last three (3) processing check dates and check amounts.

The telephone number (for use by touch-tone phones only) for the VREV is 1-800-807-1301. If you have a rotary telephone, the VREV is not available.

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1.4.1.2 VREV Conversion Chart If you have the Member name and Date of Birth, dial 1-800-807-1301, then choose from the following prompts:

1# to access VREV

Enter the eight digit Medicaid provider ID number followed by the #

1# for Eligibility Verification

5# for Standard Eligibility Verification

2# to access using the Member’s First Name and Last Name

Enter first 5 digits of LAST NAME: *22*72*63*91*62# (*B*R*O*W*N#)

1# to Confirm the LAST NAME

2# to Change the LAST NAME

Enter first 4 digits of FIRST NAME: *51*21*62*32# (J*A*N*E#)

1# to Confirm the LAST NAME

2# to Change the LAST NAME

Using the following conversion chart for the letters of the alphabet, with a * before each letter and a # after the last character of the name:

A 21 H 42 O 63 V 83

B 22 I 43 P 71 W 91

C 23 J 51 Q 11 X 92

D 31 K 52 R 72 Y 93

E 32 L 53 S 73 Z 12

F 33 M 61 T 81 SP *

G 41 N 62 U 82 END #

1# to verify eligibility by the member’s social security number (SSN)

2# to verify eligibility by the member’s DATE OF BIRTH

Enter the Member’s DATE OF BIRTH: MMDDCCYY#

Enter 1# = Male or 2# = Female,

Enter the FROM DATE OF SERVICE#

Enter the TO DATE OF SERVICE#

Or Enter # for today’s date

The system gives the entire name and member Medicaid identification number as well as stating if the member is eligible or ineligible for the DATE OF SERVICE requested.

1 General


1.4.1.3 KyHealth-Net Online Member Verification

KYHEALTH-NET ONLINE ACCESS CAN BE OBTAINED AT:

http://www.chfs.ky.gov/dms/

Click on KYHEALTH-NET

This web-based system is designed to allow Medicaid Providers instant access to pertinent member information. A User Manual is available for downloading and is designed to assist you in navigating through the system. If at any time you have suggestions, comments, or questions, please contact us through the assistance email address located at the bottom of each primary web page ([email protected]).

Please keep in mind information contained on the KyHealth-Net is highly confidential and access should be strictly limited to those with valid reasons. It is the responsibility of the provider and the system administrator to ensure all persons with access understand the appropriate use of this data. We highly recommend the creation and implementation of guidelines within your office outlining appropriate and inappropriate uses of this data.

2 General Billing Instructions



2.1 General Instructions The Department for Medicaid Services is mandated by the Centers for Medicare and Medicaid Services (CMS) to use the UB92 form for the reimbursement of services. You may bill on paper or electronically.

2.2 Imaging All paper claims are imaged. Imaging is taking a picture of the claim and using that picture during claims processing. The major objectives of the imaging technology are: increased accuracy in claims processing; improved customer and provider service; and, reduced storage requirements. This state of the art technology streamlines Medicaid claims processing and provide efficient tools for claim resolution, inquiries, and attendant claim related matters. Considerable gains in productivity and data accuracy are achieved with the EDS Imaging Solution implemented. Listed are a few guidelines for original claims, as well as claims that are being resubmitted, to ensure accurate readability:

• USE BLACK INK ONLY;

• Do not use glue;

• Do not use more than one staple per claim;

• Press hard to guarantee strong print density if claim is not typed or computer generated;

• Do not use white-out or shiny correction tape; and,

• Do not send attachments smaller than the accompanying claim form.

2.3 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 in order for the text to be properly read by the scanner.



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3 Electronic Data Interchange (EDI)



Healthcare organizations have traditionally conducted business by trading information on preprinted paper forms. The variety and volume of paper-based exchanges has grown. This has forced healthcare organizations to seek more efficient ways of communicating. Electronic Data Interchange (EDI) is structured business-to-business communications using electronic media rather than paper.

3.1 Means Of Electronic Submission EDS processes electronic transactions on either soft or hard media as defined below.

Soft Media • Asynchronous Modem transmission • Mainframe Communications (contact the EDS EDI Technical Support Help Desk for

constraints)

Hard Media • CD • 3 1/2 inch diskette

3.2 How To Get Started All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner contact the EDS Electronic Data Interchange Technical Support Help Desk at:

EDS 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.

3.3 Format and Testing All EDI Trading Partners must test successfully with EDS 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.

3.4 ECS Help If you are already billing electronically, or have questions of a technical communications nature contact the EDI Technical Support Help Desk at 1-800-205-4696. Help Desk hours are 7:00 a.m. to 6:00 p.m. Monday through Friday except holidays.

4 Additional Information and Forms



4.1 Claims with Service Dates Over One Year Old In accordance with federal regulations, claims must be received by Medicaid within 12 months from the date of service or six months from the Medicare 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.”

For KY, the date received is included 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.

To consider claims 12 months past the date of service for processing, the provider must attach documentation showing timely receipt by DMS or EDS 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 your 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 your claims for processing for possible payment is:

• A Screen Print from KyHealth-Net verifying eligibility issuance date and eligibility dates must be attached behind the claim.

• A Screen Print from KyHealth-Net to verify timely filing within each 12 months from date of service, such as the appropriate section of the Remittance Advice or from the Main Menu’s Claims Inquiry selection; and,

• A copy of the Medicare Explanation of Medicare Benefits received twelve months after service date, but less than six months after the Medicare adjudication date.

4.2 Retroactive Eligibility (Back-Dated) Card Aged claims for Members whose eligibility for medical assistance or a specific service is determined retroactively may be considered for payment if filed within one year from the issuance date noted on the Member Identification card. A copy of the Member’s Identification card covering the services dates must be attached behind the claim. Claim submission must be within 12 months of the issuance date.

• Paper Cards are obsolete as of July 1, 2005. Providers who are billing for services prior to this may use a copy of the paper card. After July 1, 2005 a copy of the KyHealth-Net card issuance screen is also acceptable documentation.

4.3 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 “timely” by EDS.



4.4 Third Party Coverage Information

4.4.1 (Excluding 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.

4.4.2 Documentation That May Prevent A Claim From Denying

• For Other Insurance The following forms of documentation prevent your claim from denying for other health insurance when attached to the claim.

1. Remittance statement from the insurance carrier that includes:

a. Member name; b. Date(s) of service; c. Billed information that matches the billed information on the claim submitted to Medicaid;

and, d. An indication of denial or 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:

a. Member name; b. Date(s) of service(s); c. Termination or effective date of coverage (if applicable); d. Statement of benefits available (if applicable); and, e. Signature of insurance representative or the letter must 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:

a. Member name; b. Date(s) of service; c. Name of insurance carrier; d. Name of insurance representative spoken to and the phone number of the insurance

carrier or notation indicating a voice automated response system was reached; e. Termination or effective date of coverage; and, f. Statement of benefits available (if applicable).

4. A copy of a prior remittance statement from an insurance company may be considered an acceptable form of documentation if it is:

a. For the same Member;

b. For the same or related service being billed on the claim; and,

c. 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 EDS 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:

a. Member name;

b. Date of insurance or employee termination or effective date (if applicable); and,

c. Employer letterhead or signature of company representative.

6. No response within 120 days from the insurance carrier

a. 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 EDS. EDS overrides the other health insurance edits and forward a copy of the TPL Lead form to the TPL Unit. The TPL staff contact the insurance carrier to see why they have not paid their portion of liability.

4.4.3 For Accident And Work Related Claims For claims related to an accident or work related incident, the provider should pursue information relating to the event. If an employer, individual, or an insurance carrier is a liable party, but the liability has not been determined, you may submit your claim to EDS with an attached letter containing any relevant information, that is, names of attorneys, other involved parties and/or the Member’s employer to:

EDS P.O. Box 2107 ATTN: TPL Unit Frankfort, KY 40602-2107



EDS EDS Corporation Attention: TPL Unit P.O. Box 2107 Frankfort, KY 40602

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: _________________________



4.5 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:

EDS Corporation P.O. Box 2100 Provider Services Frankfort, KY 40602-2100

Please keep the following points in mind when using this form:

• Send the two-part completed form to EDS. The yellow copy is returned to you with a response;

• When resubmitting a corrected claim, do not attach a Provider Inquiry Form;

• A toll free EDS number 1-800-807-1232 is available in lieu of using this form; and,

• To check claim status, call the EDS Voice Response on 1-800-807-1301.



PROVIDER INQUIRY FORM EDS P.O. Box 2100 Please remit both copiesFrankfort, KY 40602-2100 of the Inquiry Form to EDS1. Provider ID 3. Member Name (first, last) 2. Provider Name and Address 4. Medical Assistance Number 5. Billed Amount 6. Claim Service Date 7. RA 8. Internal Control Number 9. Provider’s Message 10. Signature Date

EDS Response: ______This claim has been resubmitted for possible payment. ______EDS can find no record of receipt of this claim as indicated above. Please resubmit. ______This claim paid on __________________in the amount of ______________________________ ______This claim was denied on ________________with EOB code____________________________ ______This claim denied on _______________with EOB 00294 “KenPAC Member. Referring provider ID is missing or is

not the KenPAC primary physician/clinic ID for the date(s) of service.” ______This claim denied on _______________with EOB 00295 “KenPAC Member. Billing and/or referring provider ID is

not the KenPAC primary physician/clinic for date(s) of service.” ______This claim denied on _______________with EOB 00467 “Member has other medical coverage. Bill other

insurance first or attach documentation of denial from the insurance carrier.” ______Aged claim. Please see attached documentation concerning services submitted past the 12 month filing limit. Other: ______________________________________________________________________________ ____________________________________________________________________________________ Signature Date



4.6 Prior Authorization Information • The prior authorization process does NOT verify anything except medical necessity.

• The process does not verify eligibility.

• The process does not verify age.

• The prior authorization letter does not guarantee payment. It only indicates that the service is approved based on medical necessity.

• If the Member loses KyHealth Choices or if the member ages out of the program eligibility, services are not reimbursed even though they have been authorized based on medical necessity and a prior authorization letter had been issued.

• Services should only be post authorized in case of:

• Retro-active Member eligibility

• Retro-active provider number

• Providers should always completely review prior to providing services or billing.

If you determine that the services you are providing require prior authorization (based upon Department for Medicaid Services policies and regulations or from the Fee Schedule for your procedure/revenue code), you may contact:

SHPS 9200 Shelbyville Road, Suite 100 Louisville, KY 40222 Telephone: 1-800-292-2392 Fax: 1-800-807-7840 Hours: 8:00 a.m. through 6:00 p.m.

Or you may access the KYHealth Net website to obtain blank Prior Authorization forms.

http://www.chfs.ky.gov/dms/kyhealth

http://www.chfs.ky.gov/dms/kyhealth



4.7 Adjustments And Claim Credit Request An adjustment is a change to be made to a “PAID” claim. The mailing address for the Adjustment Request form is:

EDS Corporation 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 your adjustment form. For a Medicaid/Medicare crossover, attach an EOMB (Explanation of Medicare Benefits) with 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; and, • 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.



EDS

ADJUSTMENT AND CLAIM CREDIT REQUEST FORM MAIL TO: EDS CORPORATION

P.O. BOX 2108 FRANKFORT, KY 40602-2108 1-800-807-1232

ATTN: FINANCIAL SERVICES NOTE: A CLAIM CREDIT VOIDS THE CLAIM ICN FROM THE SYSTEM -- A “NEW DAY” CLAIM MAY BE SUBMITTED, IF NECESSARY. THIS FORM WILL BE RETURNED TO YOU IF THE REQUIRED INFORMATION AND DOCUMENTATION FOR PROCESSING ARE NOT PRESENT. PLEASE ATTACH A CORRECTED CLAIM AND REMITTANCE ADVICE TO ADJUST A CLAIM.

CHECK APPROPRIATE BOX: CLAIM CLAIM ADJUSTMENT CREDIT

1. Original Internal Control Number (ICN)

2. Member Name 3. Member Medicaid Number

4. Provider Name and Address

5. Provider 6. From Date of Service

7. To Date of Service

8. Original Billed Amount

9. Original Paid Amount

10. Remittance 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



4.8 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:

EDS Corporation P.O. Box 2108 Frankfort, KY 40602-2108 Attn: Financial Services

Please keep the following points in mind when refunding:

• Attach to the Cash Refund Documentation Form a check for the refund amount made payable to the KY State Treasurer.

• Attach applicable documentation, such as a copy of the remittance advice showing the claim for which a refund is being issued.



EDS Mail To: EDS 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)

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



4.9 Return To Provider Letter Claims and attached documentation received by EDS 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:

• Provider ID;

• Original provider or authorized representative signature;

• Member Identification number;

• Member first and last names; and,

• EOMB for Medicare/Medicaid crossover claims.

Other reasons for return may include:

• Illegible claim date of service or other pertinent data.

• Claim lines completed exceed the limit. and,

• Unable to image.



EDS

RETURN TO PROVIDER LETTER Date: _______ - _______ - _______ 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 8-digit provider number must be on the claim form in the appropriate field.

___ Missing ___ Not a valid provider number _________________________________________________________________________________________________ 02) ___ PROVIDER SIGNATURE – All claims require an original signature in the provider signature block.

The Provider signature cannot be stamped or typed on the claim. ___ Missing ___ Typed signature not valid ___ Stamped signature not valid.

_________________________________________________________________________________________________ 03) ___ Detail lines exceed the limit for claim type. _________________________________________________________________________________________________ 04) ___ UNABLE TO IMAGE OR KEY – Claim form/EOMB must be legible. Highlighted forms cannot be accepted. Please resubmit on a

new form. ___ Print too light ___ Print too dark ___ Highlighted data fields ___ Not legible ___ Dark copy _________________________________________________________________________________________________ 05) ___ Medicaid does not make payment when Medicare has paid the amount in full. _________________________________________________________________________________________________ 06) ___ The Member’s Medicaid Identification number is missing _________________________________________________________________________________________________ 07) ___ Medicare EOMB 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 Identification number on the CMS must be entered Field 9A • The Member’s Medicaid Identification number on the UB92 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, 8:00 a.m. until 6:00 p.m. eastern time, at 1-800-807-1232, Monday through Friday, except Holidays. If you are interested in billing Medicaid electronically, please contact the EDS helpdesk at 1-800-205-4696 7:00 a.m. to 6:00 p.m. eastern time, Monday through Friday except holidays. Initials of clerk ____________ Provider Name ____________________________________________________________________________________ Provider Number _______________________________ Reason Code __________



4.10 Provider Representative List

4.10.1 Phone Numbers and Assigned Counties VICKY HICKS

502-209-3050

MICHELLE GOINS

502-209-3071

STAYCE TOWLES

502-209-3052

BRENDA ORBERSON

502-209-3053

JANET SPERRY

502-209-3051

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ANDERSON BOONE BATH ADAIR BALLARD

BOURBON CARROLL BELL ALLEN BRECKINRIDGE

CAMPBELL GALLATIN BOYD BARREN BULLITT

CLARK GRANT BRACKEN BOYLE BUTLER

FAYETTE HENRY BREATHITT CASEY CALDWELL

FRANKLIN JEFFERSON CARTER CLINTON CALLOWAY

GARRARD OLDHAM CLAY CUMBERLAND CARLISLE

HARRISON OWEN ELLIOTT EDMONSON CHRISTIAN

JESSAMINE SHELBY ESTILL GREEN CRITTENDEN

KENTON SPENCER FLEMING HART DAVIESS

MADISON TRIMBLE FLOYD LARUE FULTON

MERCER GREENUP LINCOLN GRAVES

PENDLETON HARLAN MARION GRAYSON

SCOTT JACKSON MCCREARY HANCOCK

WOODFORD JOHNSON METCALFE HARDIN

KNOTT MONROE HENDERSON

KNOX PULASKI HICKMAN

LAUREL ROCKCASTLE HOPKINS

LAWRENCE RUSSELL LIVINGSTON

LEE SIMPSON LOGAN

LESLIE TAYLOR LYON

LETCHER WARREN MARSHALL

LEWIS WAYNE MCCRACKEN

MAGOFFIN MCLEAN

MARTIN MEADE

MASON MUHLENBERG

MENIFEE NELSON



MONTGOMERY OHIO

MORGAN TODD

NICHOLAS TRIGG

OWSLEY UNION

PERRY WASHINGTON

PIKE WEBSTER

POWELL

ROBERTSON

ROWAN

WHITLEY

WOLFE

PROVIDER RELATIONS 1-800-807-1232

5 HIPAA Information for Billing



The Health Insurance Portability and Accountability Act (HIPAA)

Information for Billing

Standard Transaction Formats for Billing KY Medicaid To simplify the electronic exchange of financial and administrative health care transactions, the Health Insurance Portability and Accountability Act (HIPAA) transactions standards require all health plans, health care clearinghouses and health care providers to use or accept the following electronic transactions. Prior to the passage of HIPAA in 1996, Congress determined that to improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (that is, medical practices, hospitals, and health care plans) it was necessary to have national standards for the electronic exchange of health care transactions. The following formats replace the hundreds of proprietary and local formats used throughout the health insurance industry. The transaction standards took effect for KY Medicaid on October 16, 2003:

Code Sets The regulation also requires the use of standardized procedure/diagnosis coding to represent the data to be transmitted. Code Sets include at a minimum:

1. Current Procedure Terminology (CPT-4);

2. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM);

3. HCFA Common Procedure Coding System (HCPCS);

4. ADA Codes on Dental Procedures and Nomenclature, 2nd Edition (CDT-2); and,

5. Revenue Codes

NOTE: Please be aware that no Medicaid local codes are accepted after October 16, 2003.



HIPAA Transaction Standards The HIPAA transactions and code set standards are rules to standardize the electronic exchange of patient-identifiable, health-related information. They are based on electronic data interchange (EDI) standards, which allow the electronic exchange of information from computer to computer without human involvement. These standards apply to nine types of administrative and financial health care transactions used by payers, physicians and other providers, including claims submission, claims status reporting, referral certification and authorization, and coordination of benefits.

HIPAA EDI Transactions Health Care Eligibility Inquiry and Response (270 & 271)

Health Care Claim Status Inquiry / Response (276 & 277)

Unsolicited (277)

Health Care Service Review (278)

Health Care Claim (837 & NCPDP Standard)

Health Care Claim Payment and Remittance Advice (835)

NOTE: The standard transaction for the Coordination of Benefits using the 837 is not HIPAA mandated and therefore not currently a requirement for HIPAA compliance.

Health Care Eligibility Inquiry and Response (270 & 271) A provider uses the 270-benefit inquiry transaction to inquire about Medicaid eligibility for a Member. Effective October 16, 2003 this replaces the Medicaid Eligibility Verification Systems (MEVS) transaction. It can also be used to check benefits, deductibles, and copays of the patient's health plan and verify that the patient is on file and currently covered by the plan. The 271 is a response from KY Medicaid to the inquiry. The response is conditional. It is not a guarantee of payment.

Health Care Claim Status Inquiry and Response (276 & 277) A provider uses the 276 claim status inquiry to ask about the status of processing for a particular claim or claims that remain outstanding within its accounts receivable system. The 277 is the response from KY Medicaid.

Unsolicited (277) KY Medicaid is using this transaction to transmit the status of a suspended or pended claim back to the provider.



Health Care Service Review (278) This transaction is used to transmit referral information between providers and between provider and payer. Note: A referral from provider to provider is one of the most attractive transactions for providers.

Health Care Claims (837 & NCPDP Standard) Effective October 16, 2003 health care claims for pharmaceuticals use the NCPDP v5.1 standard to bill KY Medicaid. Other claims use the X12 837 format. There are separate Implementation Guides (the official standard) for institutional claims, professional and dental claims. The 837 replaces electronic versions of the uniform billing claim and the CMS 1500. It can carry HMO medical encounter accounting information as well as billing claims. A key consideration for coordination with payer claim systems is a requirement for systems to retain all of the information received on the claim.

Health Care Claim Payment and Remittance Advice (835) The Payment and Remittance Advice transaction is frequently used in separate functions. In the payment role, it is a payment order directing a bank to effect payment to a provider; in this role, the remittance advice is primarily payment reference information to enable the provider's systems to match up the payment with claims paid. Payments are frequently made in aggregate to cover several claims. In the electronic remittance advice role, it explains payment, partial payment, or denial, item by item for each claim. The remittance advice is intended to support automatic reconciliation of claims in provider accounts receivable systems and is one of the most attractive transactions from a provider's viewpoint.

Implementation Guides for the Standards The implementation guides for the ASC X12N standards may be obtained from:

Washington Publishing Company 806 W. Diamond Ave., Suite 400 Gaithersburg, MD, 20878 Telephone: 1-301-949-9740 FAX: 1-301-949-9742. These guides are also available at no cost through the Washington Publishing Company on the Internet at http://www.wpc-edi.com/hipaa/.

The implementation guide for retail pharmacy standards is available from:

National Council for Prescription Drug Programs 4201 North 24th Street, Suite 365 Phoenix, AZ, 85016 Telephone: 1-602-957-9105 FAX: 1-602-955-0749.

It is also available from the NCPDP’s website at http://www.ncpdp.org.



Medicaid Companion Guides EDS and the Department have prepared companion guides for Medicaid Services. The companion guide specifies unique data fields necessary to correctly submit standard transactions for KY Medicaid processing. They are used in conjunction with the implementation guides. Companion guides are available on KY Medicaid’s website located at http://chs.ky.gov/dms.

Attachments At this time, claims requiring attachments must still be billed via paper. Each claim is processed separately; therefore, each individual claim needs the required or supporting documentation. Attachments are handled in the same manner as the current process standard for KY Medicaid.

EOB/Adjustment Reason/Remark Codes The EOB/Adjustment reason/remark codes change to HIPAA compliant codes. These codes are included on ASC X12N835 electronic remit and/or paper remittance advice. The purpose of the EOB/Adjustment Reason/Remark Codes is to communicate the status and disposition of the claim to the provider.

EDS Technical Support All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner, contact the EDS Electronic Data Interchange Technical Support Help Desk at 1-800-205-4696 between the hours of 8:00 a.m. and 6:00 p.m. Monday through Friday except holidays.

If you have a general HIPAA question, please call 1-800 807-1232 between the hours of 8:00 a.m. to 6:00 p.m. EST Monday through Friday except holidays.

Additional Resources HRSA HIPAA Website http://www.bphc.hrsa.gov/hipaa/

DHHS Administrative Simplification Website http://aspe.os.dhhs.gov/admnsimp/

Centers for Medicare and Medicaid Services (CMS) http://cms.hhs.gov/hipaa/http://www.cms.gov/hipaa

Southern HIPAA Administrative Regional Process (SHARP) workgroup http://www.sharpworkgroup.com/

Workgroup for Electronic Data Interchange’s (WEDI) Strategic National Implementation Process (SNIP) http://snip.wedi.org

Washington Publishing Company (Implementation Guides) http://www.wpc-edi.com

6 Completion of UB-92 Billing Form



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-92 billing form. Only the billing instructions required for EDS processing or the Medicaid Program information are included. Instructions for Fields not used by EDS or the Medicaid Program can be found in the UB-92 Training Manual. The UB-92 Training Manual and UB-92 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-92 billing form must be sent to:

EDS P.O. Box 2106 Frankfort, KY 40602-2106


Printed 9/18/2006 Provider Type-82, 87, 88, 89, 91, 95Page 34

2 3 PATIENT CONTROL NO. 4 TYPE OF BILL

Home 12345678910 893 1234 Any Street

5 FED TAX NO

6 STATEMENT COVERS PERIOD FROM THROUGH

7 COV’D. 8 N-C D. 9 C-I D. 10 L-R D. 11

Here, KY. 40000 11012003 11312003 31 12 PATIENT NAME 13 PATIENT ADDRESS JANE DOE 14 BIRTHDATE 15 SEX 16 MS ADMISSION 21 D HR 22 STAT 23 MEDICAL RECORD NO. CONDITION CODES 31 17 DATE 18 HR 19 TYPE 20 SRC 24 25 26 27 28 29 30

1/1/02 12 30 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE 36 OCCURRENCE SPAN 37

CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH A B C

39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT

a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED

CHARGES 49

120 ROOM & BOARD 31 4623 00 300 LABORATORY 36415 11/01/2003 1 10 00 320 XRAY 71010 11/01/2003 1 75 00 410 OXYGEN E1390 11/02/2003 1 300 00 410 OXYGEN-PORTABLE E0431 11/02/2003 1 40 00 420 PHYSICAL THERAPY 97001 11/20/2003 1 50 00 420 PHYSICAL THERAPY 97116 11/20/2003 3 35 00 420 PHYSICAL THERAPY 97530 11/20/2003 6 150 00 440 SPEECH HEARING EVALUATION 92506 11/15/2003 1 50 00 440 SPEECH THERAPY 97110 11/15/2003 6 150 00 440 SPEECH THERAPY 97530 11/15/2003 8 175 00 001 TOTAL 5423 00 50 PAYER 51 PROVIDER NO. 52 REL 53 ASG

INFO BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56

KENTUCKY MEDICAID 12000000 57 DUE FROM PATIENT

58 INSURED’S NAME 59 P. REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. JANE DOE 4000000000 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION Y123456 67 PRIN. DIAG. CD. OTHER DIAG. CODES 76 ADM. DIAG. CD. 77 E-CODE 78 68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE

123.0 123.0 79 P.C. 80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE 82 ATTENDING PHYS.ID CODE DATE CODE DATE CODE DATE C12345 DR. DAN A B OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE 83 OTHER PHYS. ID CODE DATE CODE DATE CODE DATE A C D E 84 REMARKS OTHER PHYS. ID 85 PROVIDER REPRESENTATIVE 86 DATE X 11/31/2003 UB-92 HCFA-1450 OCR/ORIGINAL I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART

HEREOF..

James Biller



6.1 Detailed UB-92 Billing Instructions

FIELD NUMBER FIELD NAME AND DESCRIPTION 1 Provider Name, Address And Telephone

Enter the complete name, address, and telephone number, (including area code) of the facility.

3 Patient Control Number Enter the patient control number. The first 20 digits (alpha/numeric) appear on the remittance advice as the invoice number.

4 Type of Bill Enter the appropriate three-digit codes to indicate the type of bill.

1st Digit (Type of Facility) 7 = Clinic

2nd Digit (Bill Classifications Clinics Only)

4 = Outpatient Rehabilitation Facility (ORF)

5 = Comprehensive Outpatient Rehabilitation Facility (CORF)

3rd Digit (Frequency) 1 = Admit through discharge

2 = Interim, first claim

3 = Interim, continuing claim

4 = Interim, final claim

6 Statement Covers Period FROM Enter the beginning date of the billing period in numeric format (MMDDYY). THROUGH Enter the last date of the billing period in numeric format (MMDDYY).

22 Patient Status Codes Enter the appropriate two digit patient status code indicating the disposition of the member as of the “through” date in Field 6.

Status Codes Accepted by KY Medicaid 01 Discharged to Home or Self Care (Routine Discharge) 02 Discharged or Transferred to Acute Hospital 03 Discharged or Transferred to Skilled Nursing Facility (SNF) or

NF 04 Discharged or Transferred to Intermediate Care Facility (ICF) 05 Discharged or Transferred to Another Type of Institution



FIELD NUMBER FIELD NAME AND DESCRIPTION 06 Discharged or Transferred to Home Under Care of Organized

Home Health Service Organization 07 Left Against Medical Advice 10 Discharged or Transferred to Mental Health Center or Mental

Hospital 20 Expired 30 Still a Member

39-41 Value Codes The appropriate value code(s) for Medicare/Medicaid crossover claims. A1 = Deductible Payer A Enter the amount shown on the EOMB to be applied toward the member’s deductible amount due. Attach EOMB.

A2 = Coinsurance Payer A Enter the amount shown on the EOMB to be applied toward the member’s coinsurance amount due. Attach EOMB. B1 = Deductible Payer B Enter the amount shown on the EOMB to be applied toward the member’s deductible amount due. Attach EOMB. B2 = Coinsurance Payer B Enter the amount shown on the EOMB to be applied toward the member’s coinsurance amount due. Attach EOMB.

50 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. * * Medicaid is payer of last resort.

51 Provider ID Enter the eight digit KY Medicaid provider ID for the payer shown in Field 50 on the corresponding line (A, B, or C).

54 Prior Payments Enter the amount the facility has received toward payment of the claim prior to the billing date. Third party payment shall be entered in this area. Do not enter Medicare payment amounts in this area.

58 Insured’s Name Enter the member’s name in 58 A, B, and C that relates to the payer in 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.



FIELD NUMBER FIELD NAME AND DESCRIPTION 60 Identification Number

Enter the member’s identification number in 60 A, B, or C. Enter the ten digit Member Identification number exactly as it appears on the Member’s card.

82 Attending Physician ID Enter in Field 82B the unique physician identification number (UPIN) followed by the last name, first name, and middle initial for the attending physician. If the physician does not have a UPIN number, enter the appropriate license number in Field 82A.

85 Provider Certification and Signature The actual signature of the provider’s authorized representative is required. Stamped or typed signatures are not accepted.

86 Date Bill Submitted Enter the date in numeric format (MMDDYY) that the UB-92 billing form was completed and signed.

7 Completion of CMS-1500 (12/90) Paper Claim Form



The CMS-1500 (12/90) 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 (12/90) claim form. An original claim form and EOMB must be sent to:

EDS P.O. Box 2101 Frankfort, KY 40602-2101



7.1 Completion of Invoice CMS-1500 (12/90)

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 (12/90) for billing respective plans.

The CMS-1500 (12/90) 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’s Medicare provider ID is on the KY Medicaid cross-reference file, the claim may automatically be forwarded to EDS via magnetic tape 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 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.



7.2 Completed CMS-1500 (12/90) Claim Form

1a. INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1)

HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER HEALTH PLAN BLK LUNG

24. A DATE(S) OF SERVICE FROM TO DD YY MM DD YY

B C D E

Place of Service

Type of Service

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

F G H I J K

DIAGNOSIS CODE $ CHARGES

MM DAYS OR UNITS

EPSDT PLAN CPT/HCPCS MODIFIER

DO NOT STAPLE AREA

(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial

CITY STATE

ZIP CODE TELEPHONE (Include Area Code) ( )

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH SEX MM DD YY

M F c. EMPLOYER’S NAME OR SCHOOL

d. INSURANCE PLAN NAME OR PROGRAM NAME

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

SIGNED DATE

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR

INJURY (Accident) OR PREGNANCY (LMP)

19. RESERVED FOR LOCAL USE

17a. I.D. NUMBER REFERRING PHYSICIAN

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS GIVE FIRST DATE MM DD YY

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE)

25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO.

x YES NO

27. ACCEPT ASSIGNMENT?

STATE

ZIP CODE TELEPHONE (INCLUDE AREA CODE)

( ) 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH MM DD YY SEX

M F

b. EMPLOYER’S NAME OR SCHOOL NAME

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO

If yes , return to and complete item 9 a - d.

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNED

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATIONMM DD YY MM DD YY

FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SEVICES

MM DD YY MM DD YY

FROM TO 20. OUTSIDE LAB? $ CHARGES YES NO 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO.

3. PATIENT’S BIRTH DATE SEX MM DD YY M F

6. PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

8. PATIENT STATUS

Single Married Other

Employed Full-Time Part-Time Student Student

4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No., Street)

EMG COBRESERVED FOR LOCAL USE

10d. RESERVED FOR LOCAL USE

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

SIGNED DATE apply to this bill and are made a part thereof.)

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office)

33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE#

PIN# QMB Provider ID #

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

3. 24.

5. PATIENT’S ADDRESS (No., Street) Case, Marlene

10. IS PATIENT’S CONDITION RELATED TO:

IF APPLICABLE a. EMPLOYMENT? (CURRENT OR PREVIOUS)

YES NO

b. AUTO ACCIDENT? PLACE (State)

YES NO

c. OTHER ACCIDENT?

YES NO

May use up to20 digits

Doctors Place100 Easy St.Anytown , KY 40601

x

12345617890

v222

110503 99214

50 00

12-1-03

1 50 00 1 11

Betty Lou



7.3 Completion of CMS-1500 (12/90) Paper Claim Form

7.3.1 Detailed Instructions Claims are returned or rejected if required information is incorrect or omitted. The following fields must be completed:

FIELD NUMBER FIELD NAME AND DESCRIPTION 2 Patient’s Name Enter the member’s last name, first name, and middle initial

exactly as it appears on the Member Identification card. 9a Other Insured’s Policy Group Number Enter the member’s ten-digit Member Identification number

exactly as it appears on the current card. 11 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.

11c Insurance Plan Name or Program Name 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.

24A Date of Service Enter the date in numeric format (MMDDYY). 24B Place of Service Enter the appropriate two-digit place of service code, which

identifies the location where the service was rendered. 24D Procedure Code

Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the member.

24E Diagnosis Code Indicator Enter 1, 2, 3, or 4, referencing the specific diagnosis for which

the member is being treated as indicated in Field 21. 24F Charges Enter the usual and customary charge for the service provided to

the Member. 24G Days or Units Enter the number of units provided for the Member on this date

of service. 26 Patient’s Account No. Enter the patient account number. EDS keys the first 20 or

fewer digits. This number appears on the remittance statement as the invoice number.

28 Total Charge Enter the total of all individual charges entered in Field 24F.

Total each claim separately. 29 Amount Paid



FIELD NUMBER FIELD NAME AND DESCRIPTION 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.

30 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.

31 Signature of Physician or Supplier Including Degrees or Credentials

The signature of the provider’s authorized representative is required. Stamped signatures are not acceptable.

Date 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.

33 Physician’s, Supplier’s Billing Name, Address, Zip Code, and Phone Number

Enter the provider’s name, address, zip code and phone number above PIN.

Enter the eight-digit KY Medicaid providers ID beside the PIN. Group ID Enter the eight-digit KY Medicaid group providers ID if

applicable.



7.4 New Completed CMS-1500 (08/05) Claim Form



7.5 Completion of New CMS-1500 (08/05) Paper Claim Form

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 2 Patient’s Name

Enter the member’s last name, first name and middle initial exactly as it appears on the Member Identification card.

9a Other Insured’s Policy Group Number

Enter the member’s 10-digit Member Identification number exactly as it appears on the current card.

11 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.

11c Insurance Plan Name or Program Name

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.

24A Date of Service (Non Shaded Area)

Enter the date in numeric format (MMDDYY).

24B Place of Service (Non Shaded Area)

Enter the appropriate two digit place of service code, which identifies the location where the service was rendered.

24D Procedure Code (Non Shaded Area)

Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the member.

24E 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.

24F Charges (Non Shaded Area)

Enter the usual and customary charge for the service provided to the Member.



FIELD NUMBER FIELD NAME AND DESCRIPTION 24G Days or Units (Non Shaded Area)

Enter the number of units provided for the Member on this date of service.

24I ID Qualifier (Shaded Area)

Enter a 1D to indicate Medicaid Provider.

24J Rendering Provider ID# (Shaded Area)

Enter the eight digit KY Medicaid assigned provider ID.

26 Patient’s Account No.

Enter the patient account number. EDS keys the first 14 or fewer digits. This number appears on the remittance statement as the invoice number.

28 Total Charge

Enter the total of all individual charges entered in Field 24F. Total each claim separately.

29 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.

30 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.

31 Signature of Physician or Supplier Including Degrees or Credentials

The signature of the provider’s authorized representative is required. Stamped signatures are not acceptable.

Date

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.

33 Physician’s, Supplier’s Billing Name, Address, Zip Code and Phone Number

Enter the provider’s name, address, zip code and phone number above PIN.



FIELD NUMBER FIELD NAME AND DESCRIPTION 33b 33b (Shaded Area)

Enter a 1D plus the eight digit KY Medicaid assigned provider ID.

8 Appendix A


8 Appendix A

8.1 Internal Control Number (ICN) An Internal Control Number (ICN) is assigned by EDS 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 17 digits and contains the following information:

0 - 06005 - 0 - 0 - 600 - 0 - 001 - 00

1 2 3 4 5 6 7 8 1. Claim Input Indicator

0 = Exam-entered 1 = Typed 2 = Accounts Receivable 3 = Electronic Claims Submission (ECS) 4 = Beginning 12/1/95, any claim that generates a credit and sufficient money isn’t

available to satisfy the amount due, the claim credit ICN reflects a (4) for financial reporting.

5 = No Pay 6 = Electronic Point of Service (POS) 7 = Capitation 8 = Encounter 9 = Mass Adjustments - Mass Adjusted/Credit Claims

2. Date of Receipt (Calendar Year and Julian Date; 2006, 005 = January 5, 2006).

3. Not used.

4. Not used.

5. Batch Number (Batch Range).

6. Type of Document: 0 = New Day Claim 1 = Credit 2 = Adjustment/Debit 3 = Unit Dose Return 4 = Electronic Denied adjustments Effective 4/15/05 5 = N/A

7. Document Number within the Batch.

8. Line Number within the Claim.

9 Appendix B


9 Appendix B

9.1 Remittance Advice This packet is intended as a step-by-step guide in reading your EDS Remittance Advice (RA). The sections following are organized to describe all major categories related to processing/adjudicating claims. To enhance this document’s usability, detailed descriptions of the fields on each page are discussed, reading the data from left to right, top to bottom.

9 Appendix B


9.1.1 Examples Of Remittance Advice Pages There are several types of pages, including separate corresponding pages for Medicare/Medicaid (Crossover Claims) for each type, contained in a Remittance Advice. If a provider does not have activity during the cycle for a particular category, these pages will not be included (see attached). Following are examples of pages which may appear in your Remittance Advice:

Field Description Returned Claims This section lists all claims that have been returned to the

provider (RTP) via an RTP letter. The RTP letter explains why the claim is being returned. These claims are returned because they are missing information pertinent to 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 in

current and previous cycles. 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 do nothing with 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).

Accounts Receivable Summary

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.

Summary of Benefits Page

This section details all categories contained in the Remittance Advice for the current cycle, month to date, and year to date. Explanation of Benefit (EOB) codes listed throughout the Remittance Advice are defined in this section.

NOTE: FOR YOUR OWN RECONCILIATION OF CLAIMS PAYMENTS AND CLAIMS RESUBMISSION OF DENIED CLAIMS, IT IS HIGHLY RECOMMENDED YOU KEEP ALL REMITTANCE ADVICES FOR AT LEAST ONE YEAR.

9 Appendix B


9.2 Title The header information that follows is contained on every page of the Remittance Advice.

Field Description KY Department for Medicaid Services Medicaid Management Information System Remittance Advice

Title

Page The number of the page within each Remittance Advice.

AS OF The date the payment cycle was adjudicated. RUN DATE The date the Remittance Advice was printed. RA NUMBER A system generated number for the Remittance

Advice PROVIDER NAME The name of the provider that billed. (The type of

provider is listed directly below the name of provider.) CLAIM TYPE The type of claims listed on the Remittance Advice. PROVIDER ID The eight-digit Medicaid assigned provider ID 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.

9.3 Banner Page All Remittance Advices have a “banner page” 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. It is imperative that you pay close attention to this page.

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 1

AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004

REMITTANCE ADVICE

---- NEWSLETTER UPDATE ----

*********************ATTENTION PROVIDER********************************

THE CENTERS FOR MEDICARE AND MEDICAID SERVICES, CMS,SHARP AND HAWK HAVE

DEVELOPED A SERIES OF FREE WORKSHOPS, PRODUCTS AND SERVICES TO PROVIDE

PRACTICAL INFORMATION ON HOW HIPAA WILL AFFECT MEDICAL PRACTICES. FOR

DATES, TIMES AND LOCATIONS OF A WORKSHOP NEAR YOU, GO TO

HTTP://WWW.KYMA.ORG/HIPAA_CMS_FLYER.PDF HAVE HIPAA QUESTIONS? SEND YOUR

EMAILS TO [email protected]. INDIVIDUALS CAN SUBSCRIBE TO A

LIST OR CHANGE THEIR NAME IF ALREADY SUBSCRIBED BY SENDING AND EMAIL

FROM YOUR EXISTING ADDRESS TO [email protected] AND

ENTERING THE FOLLOWING IN BODY OF EMAIL(DO NOT ENTER SUBJECT) SUBSCRIBE

HAWK YOURFIRSTNAME YOURLASTNAME IF YOU HAVE FURTHER QUESTIONS, GO TO

HTTP://WWW.ARCHIMEDES-COMMUNITY.ORG/SIGS/LISTSERVS/LISTSERVS.HTM.

9 Appendix B


KENTUCKY DEPARTMENT OF MEDICAID SERVICES PAGE: 2

AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/19/2004

REMITTANCE ADVICE

RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY

QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES

CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 86000000

P A I D C L A I M S

AMT. FROM

INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED OTHER CLAIM PMT

NUMBER NAME NUMBER ICN FROM THRU CHARGES SOURCES AMOUNT EOB

91096400DRS DONN S 4049999999 39626101403018300 09/06/2004-09/06/2004 1150.00 0.00 206.16 00379

01 PS: 99 PROC: 73721 MOD: QTY: 1 09/06/2004-09/06/2004 1150.00 0.00 206.16 00365

91096200DRS HAMPTON M 2749999999 39626101403018200 09/06/2004-09/06/2004 1150.00 0.00 206.16 00379

01 PS: 99 PROC: 73721 MOD: QTY: 1 09/06/2004-09/06/2004 1150.00 0.00 206.16 00365

92004800DRS HENSLEY D 3659999999 39626401405026700 09/13/2004-09/13/2004 1150.00 0.00 219.78 00379

01 PS: 99 PROC: 70551 MOD: QTY: 1 09/13/2004-09/13/2004 1150.00 0.00 219.78 00365

92004300DRS ROLA T 4019999999 39626401405026600 09/13/2004-09/13/2004 1150.00 0.00 206.16 00379

01 PS: 99 PROC: 73721 MOD: QTY: 1 09/13/2004-09/13/2004 1150.00 0.00 206.16 00365

216600DRS STEM T 2959999999 39626200405023900 08/02/2004-08/02/2004 1150.00 0.00 239.79 00379

01 PS: 99 PROC: 72148 MOD: QTY: 1 08/02/2004-08/02/2004 1150.00 0.00 239.79 00365

CLAIMS PAID ON THIS RA: 5 TOTAL BILLED: 5,750.00 TOTAL PAID: 1,078.05

9 Appendix B


KENTUCKY DEPARTMENT OF MEDICAID SERVICES PAGE: 3

AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 03/19/2004

REMITTANCE ADVICE




* P A I D C L A I M S *

INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED DEDUCTIBLE COINSURANCE CLAIM PMT

NUMBER NAME NUMBER ICN FROM THRU CHARGES AMOUNT AMOUNT AMOUNT EOB

CRANE J 4069999999 39626401906005900 06/12/2004-06/25/2004 86.23 0.00 86.23 86.25 00379

01 PS: 21 PROC: 90844 MOD: AH QTY: 1 06/12/2004-06/12/2004 90.00 0.00 17.25 17.25 00365

02 PS: 21 PROC: 90844 MOD: AH QTY: 1 06/14/2004-06/14/2004 90.00 0.00 17.25 17.25 00365

03 PS: 21 PROC: 90844 MOD: AH QTY: 1 06/18/2004-06/18/2004 90.00 0.00 17.25 17.25 00365

04 PS: 21 PROC: 90844 MOD: AH QTY: 1 06/20/2004-06/20/2004 90.00 0.00 17.25 17.25 00365

05 PS: 21 PROC: 90844 MOD: AH QTY: 1 06/25/2004-06/25/2004 90.00 0.00 17.25 17.25 00365

MEDICARE PAID DATE: 09/09/2004 MEDICARE APPROVED AMOUNT 431.15

MEDICARE PAID AMOUNT 344.92

HEADY J 4059999999 39626401916029200 07/30/2004-07/30/2004 34.96 0.00 34.96 34.96 00379

01 PS: 21 PROC: 96117 MOD: QTY: 3 07/30/2004-07/30/2004 180.00 0.00 34.96 34.96 00365



CLAIMS PAID ON THIS RA: 2 TOTAL BILLED: 121.19 TOTAL PAID: 121.21

9 Appendix B


9.4 Paid Claims Page FIELD DESCRIPTION INVOICE NUMBER The office account number the provider has assigned to

this member, if applicable. MEMBER NAME The member’s last name and first initial. IDENTIFICATION NUMBER The member’s ten-digit Identification number as it appears

on the Member’s Medicaid card. ICN The 17-digit unique system generated identification

number assigned to each claim by EDS. CLAIM SERVICE DATES FROM THRU

The date(s) the service was provided in month, day, and year numeric format.

BILLED CHARGES The provider’s charge for services provided. AMT FROM OTHER SOURCES Amount paid, if any, by private insurance (excluding

Medicaid and Medicare). CLAIM PMT AMOUNT The total dollar amount reimbursed by Medicaid for the

claim listed. EOB Explanation of Benefit. All EOB’s detailed on the

Remittance Advice are listed with a description/definition on the SUMMARY OF BENEFITS PAGE of the Remittance Advice.

01,02, ETC The detail number billed on the claim. PS The place of service code billed per detail. PROC The procedure code billed per detail. MOD The modifier billed per detail. QTY The number of times the service was performed per detail. DOS The date of service billed per detail. BILLED CHARGES The provider’s charge per detail. AMT FROM OTHER SERVICES The amount paid per detail from a private insurance

company. CLAIM PMT AMT The amount paid per detail. 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.

TOTAL PAID The total dollar amount paid by Medicaid for all claims listed on the PAID CLAIMS page of the Remittance Advice.

NOTE: IF THE CLAIM TYPE IS FOR CROSSOVER SERVICES, THE MEDICARE PAID DATE, APPROVED AMOUNT, AND PAID AMOUNT IS LISTED IN THE DETAIL AREA.

9 Appendix B




REMITTANCE ADVICE




* D E N I E D C L A I M S *

AMT. FROM



1775 DEAN C 4039999999 19625401240002600 04/05/2004-04/05/2004 2550.00 0.00 0.00 00121

01 PS: 11 PROC: 72156 MOD: QTY: 1 04/05/2004-04/05/2004 1275.00 0.00 0.00

02 PS: 11 PROC: 72157 MOD: QTY: 1 04/05/2004-04/05/2004 1275.00 0.00 0.00

REMARK CODES: 00 00121

CLAIMS DENIED ON THIS RA: 1 TOTAL BILLED: 2,550.00 TOTAL PAID: 0.00

9 Appendix B




REMITTANCE ADVICE

RA NUMBER: 229999 PROVIDER NAME: FRAZIER REHAB CENTER EAST

CORF

CLAIM TYPE: OUTPATIENT CROSSOVERS PROVIDER ID: 91000000

* D E N I E D C L A I M S *

INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED COINSURANCE DEDUCTIBLE CLAIM PAID


1010278812 FOWLER III W 4069999999 19615001806001300 12/07/1994-12/14/1994 98.23 98.23 0.00 0.00 00228



REMARK CODES: 00 00977 00 00008 00 00228

CLAIMS DENIED ON THIS RA: 1 TOTAL BILLED: 98.23 TOTAL PAID: 0.00

9 Appendix B


9.5 Denied Claims Page FIELD DESCRIPTION INVOICE NUMBER The office account number the provider has assigned

to this member, if applicable. MEMBER NAME The member’s last name and first initial. IDENTIFICATION NUMBER The member’s ten-digit Identification number (as it

appears on the member’s Medicaid card.) ICN The 17-digit unique system generated identification



BILLED CHARGES The provider’s charge for services provided. AMT. FROM OTHER SOURCES

Amount paid, if any, by private insurance (excluding Medicaid and Medicare).

CLAIM PAID AMOUNT The total dollar amount reimbursed by Medicaid for the claim listed.

EOB Explanation of Benefit. All EOB’s detailed on the Remittance Advice are listed with a description/definition on the SUMMARY OF BENEFITS PAGE of the Remittance Advice.

01,02, ETC The detail number billed on the claim. PS The place of service code billed per detail. PROC The procedure code billed per detail. QTY The number of times the service was performed per

detail. DOS The date of service billed per detail. BILLED CHARGE The provider’s charge per detail. AMT FROM OTHER SOURCES

The amount paid per detail from a private insurance company.

CLAIM PMT AMT The amount paid per detail. REMARK CODES Any remark status code the claim may deny for will

be listed with the detail affected. NOTE: GMIS CLAIMCHECK® DENIALS LIST THE

PROCEDURE CODE BEING DENIED AND THE GMIS DENIAL REASON. ANY RELATED HISTORY ASSOCIATED WITH THE DENIAL WILL BE PRINTED.

NOTE: WHEN THE CLAIM TYPE INDICATES “PROFESSIONAL CROSSOVERS”, THE MEDICARE PAID DATE, APPROVED AMOUNT, AND PAID AMOUNT WILL APPEAR UNDER THE DETAIL INFORMATION.

9 Appendix B


CLAIMS DENIED ON THIS RA The total number of denied claims on the Remittance Advice.

TOTAL BILLED The total dollar amount billed by the provider for all claims listed on the DENIED CLAIMS page of the Remittance Advice.

TOTAL PAID There will not be a total paid amount on the denied pages of the remittance advice.

9 Appendix B




REMITTANCE ADVICE




* C L A I M S I N P R O C E S S *

AMT. FROM



184370 POWEL D 3129999999 19625301225000700 07/29/2004-07/31/2004 118.00 0.00 0.00 00241

184370 POWEL D 3129999999 19625301225000800 07/26/2004-07/29/2004 126.00 0.00 0.00 00241

CLAIMS SUSPENDED ON THIS RA: 2 TOTAL BILLED: 244.00 TOTAL PAID: 0.00

9 Appendix B




REMITTANCE ADVICE

RA NUMBER: 229999 PROVIDER NAME: PINNACLE REHABILITATION

CORF

CLAIM TYPE: OUTPATIENT CROSSOVERS PROVIDER ID: 91000000

* C L A I M S I N P R O C E S S *

INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED COINSURANCE DEDUCTIBLE CLAIM PAID


W131196005 BOGGE E 4049999999 19614101804008400 02/23/2004-02/28/2004 124.85 83.79 41.06 0.00 00290

361195076 CASSETTY O 4109999999 19602201807000100 - 812.00 812.00 0.00 0.00 00110

C442196012 HAFLE A 4029999999 19615501807004500 04/18/2004-04/30/2004 260.00 260.00 0.00 0.00 00290

C422195046 JOLLY L 4009999999 19616901801006500 12/05/2004-12/15/2004 196.00 196.00 0.00 0.00 00110

0611950225 KIRBY M 4019999999 19613401801003900 12/01/2004-12/22/2004 136.80 136.80 0.00 0.00 00110

W151196005 PETTY K 4059999999 19609201806004900 - 92.00 92.00 0.00 0.00 00110

C441196051 POWELL E 3179999999 19614201802004900 01/31/2004-01/31/2004 116.00 16.00 100.00 0.00 00290

61196004 STEWART M 2689999999 19610601804007600 02/01/2004- 1540.00 1540.00 0.00 0.00 00110

C462195041 WOLFE D 4059999999 19613101805009700 09/05/2004-09/15/2004 532.00 532.00 0.00 0.00 00290

CLAIMS SUSPENDED ON THIS RA: 9 TOTAL BILLED: 3,809.65 TOTAL PAID: 0.00

9 Appendix B


9.6 Claims in Process Page FIELD DESCRIPTION INVOICE NUMBER The office account number the provider has assigned

to this member, if applicable. MEMBER NAME The member’s last name and first initial. IDENTIFICATION NUMBER The member’s ten-digit Member Identification number

as it appears on the member’s Medicaid card. ICN The 17-digit unique system generated identification



BILLED CHARGES The provider’s charge for services provided. AMT. FROM OTHER SOURCES


CLAIM PMT AMOUNT The “Claims in Process” page does not reflect payment amounts.


CLAIMS SUSPENDED ON THIS RA

The total number of suspended claims on the Remittance Advice.

TOTAL BILLED The total dollar amount billed by the Qualified Medicare Beneficiary for all claims listed on the CLAIMS IN PROCESS page of the Remittance Advice.

TOTAL PAID The “Claims in Process” page does not reflect payment amounts.

9 Appendix B




REMITTANCE ADVICE




* C L A I M S R E T U R N E D *

ICN REASON CODE

19612401563015000 02

19612401563015000 02

19612401563016200 07

19612401563016200 07

19612401500010900 07

CLAIMS RETURNED ON THIS RA: 5

9 Appendix B


9.7 Returned Claim FIELD DESCRIPTION ICN The 17-digit unique system generated identification

number assigned to each claim by EDS. REASON CODE A code denoting the reason for returning the claim. CLAIMS RETURNED ON THIS RA

The total number of returned claims on the Remittance Advice.

NOTE: CLAIMS APPEARING ON THE “RETURNED CLAIM” PAGE WILL BE FORTHCOMING IN THE MAIL. THE ACTUAL CLAIM WILL BE RETURNED WITH A “RETURN TO PROVIDER” SHEET ATTACHED INDICATING THE REASON FOR THE CLAIM BEING RETURNED.

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 7 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 * A D J U S T E D C L A I M S * AMT. FROM INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED OTHER CLAIM PMT NUMBER NAME NUMBER ICN FROM THRU CHARGES SOURCES AMOUNT EOB 1 *** ADJUSTMENT TO CLAIM 19529601073082000 ORIGINALLY PAID ON 06/21/2004 FOR MEMBER MUNCIE COLLEE MEMBER MAID # 4029999999 PROVIDED 07/09/2004 BILLED AMOUNT: 66.00 PAID AMOUNT: 21.93 ADJ RSN CODE: 60 *** NEW CLAIM 09533200770202300 MUN024 MUNCIE C 4029999999 09533201770202300 07/09/2004-07/09/2004 66.00 0.00 43.86 00311 01 PS: 22 PROC: 72220 MOD: QTY: 2 07/09/2004-07/09/2004 66.00 0.00 43.86 00311 THE NET EFFECT OF THIS ADJUSTMENT IS 21.93 THE TOTAL NET EFFECT ON THIS RA IS 21.93 CLAIMS ADJUST/CREDIT ON THIS RA: 2 TOTAL BILLED: 0.00 TOTAL PAID: 21.93

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 Qualified Medicare Beneficiary Billing Instructions).

If a cash refund is submitted, an adjustment CANNOT be filed.

If an adjustment is submitted, a cash refund CANNOT be filed.

9 Appendix B


9.8 Adjusted Claims Page The information on this page will read left to right and will not follow the general headings until *** NEW CLAIM information begins.

FIELD DESCRIPTION INVOICE NUMBER The office account number the provider has assigned

to this member, if applicable. MEMBER NAME The member’s last name and first initial. IDENTIFICATION NUMBER The member’s ten-digit Identification number as it

appears on the Member Identification card. ICN The 17-digit unique system generated identification


The date or dates the service was provided in month, day, and year numeric format.

BILLED CHARGES The usual and customary charge for services provided for the member.

AMOUNT FROM OTHER SOURCES


CLAIM PMT AMOUNT The total dollar amount reimbursed by Medicaid for the claim listed.


1 *** ADJUSTMENT TO CLAIM

This begins the information for the original claim data to be adjusted/credited. The number to the left of the asterisks indicates the item number of the adjustment transaction being detailed. In this example it is “1”, indicating the first adjustment/credit transaction listed. The ICN of the original claim being adjusted/credited follows.

ORIGINALLY PAID ON The date the original claim being adjusted/credited was paid by Medicaid.

FOR MEMBER The member’s last and first name. MEMBER IDENTIFICATION NUMBER

The Member Identification number for the member.

PROVIDED The date the service was provided in month, day, and year numeric format.

BILLED AMOUNT The amount that was billed on the original claim being adjusted/credited.

PAID AMOUNT The original amount paid by Medicaid.

9 Appendix B


FIELD DESCRIPTION ADJ RSN CODE Denotes the reason for the adjustment/credit. All

reason codes detailed on the Remittance Advice are listed with a description/definition on the SUMMARY OF BENEFITS PAGE of the Remittance Advice.

*** NEW CLAIM This begins the new information of the adjusted claim and is followed by a 17-digit ICN assigned to the adjustment/ credit that is listed. The new ICN notifies the provider if the transaction is a credit or an adjustment. The sixth digit from the right indicates a claim credit if it is a “1” and an adjustment if it is a “2”.

At this point, the information follows the general headings of the Remittance Advice indicating the adjusted transaction results.

INVOICE NUMBER The office account number the provider has assigned to this member, if applicable.

MEMBER NAME The member’s last name and first initial. IDENTIFICATION NUMBER The member’s ten-digit Identification number as it

appears on the member’s Identification card. ICN The 17-digit unique system generated identification


The date or dates the service was provided in month, day, and year numeric format.

BILLED CHARGES The usual and customary charge for services provided for the member.

AMOUNT FROM OTHER SOURCES


CLAIM PMT AMOUNT The total dollar amount reimbursed by MEDICAID for the claim listed.


THE NET EFFECT OF THIS ADJUSTMENT IS

This is the sum of the specific transaction detailed for this adjustment and its effect on the total transaction.

THE TOTAL NET EFFECT OF THIS RA IS

This is the sum of all transactions detailed for adjustments/ credits on the Remittance Advice and the total effect on the transactions.

CLAIMS ADJUST/CREDIT ON THIS RA

The number of transactions (adjustments and/or claim credits) on the Remittance Advice.

TOTAL BILLED The total dollar amount billed on the ADJUSTED CLAIMS page of the Remittance Advice.

9 Appendix B


FIELD DESCRIPTION TOTAL PAID The total dollar amount paid on the ADJUSTED

CLAIMS page of the Remittance Advice.

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 9 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 * ACCOUNT RECEIVABLE SUMMARY * LOC RSN SETUP AGE COST SETT AMT A/R AMOUNT UNPAID ST PP PAYOUT INT INT BALANCE CD CD DATE (DAYS) FYE REQUESTED INC/DEC RECD/RECP BALANCE CD IND AMOUNT CALC RECD A/R ICN: 29602010807003627 A/R XREF ICN: 29602001707003627 ADJ REASON - RECOUPMENT - OTHER U 55 01202004 0071 00000000 417.22 0.00 417.22 0.00 F R 0.00 0.00 0.00 0.00 RECOUPMENT/PAYMENT SCHEDULE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE 03142004 417.22 55 03312004 131.74 ADJ REASON: RECOUPMENT - OTHER A/R ICN: 29603601809003974 A/R XREF ICN: 29603601709003974 ADJ REASON - RECOUPMENT - OTHER U 55 02042004 0056 00000000 288.84 0.00 173.47 115.37 A R 0.00 0.00 0.00 115.37 RECOUPMENT/PAYMENT SCHEDULE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE 03142004 288.84 55 03312004 173.47 ADJ REASON: RECOUPMENT - OTHER

NOTE: YOUR REFUND MUST BE RECEIVED BY EDS PRIOR TO THE SCHEDULED DUE DATE. IF YOUR REFUND IS NOT RECEIVED IN SUFFICIENT TIME, THE AMOUNT DUE WILL BE RECOUPED ON YOUR NEXT AVAILABLE REMITTANCE ADVICE.

FOR FURTHER EXPLANATION ON A SPECIFIC ACCOUNT RECEIVABLE ITEM, PLEASE CONTACT THE PROVIDER RELATIONS UNIT AT 800-807-1232. WHEN MAKING AN INQUIRY, PLEASE HAVE AVAILABLE THE A/R ICN AND YOUR PROVIDER ID. THIS WILL ASSIST THE PROVIDER RELATIONS SPECIALIST IN EXPEDITING YOUR REQUEST.

9 Appendix B


9.9 Accounts Receivable Summary Page FIELD DESCRIPTION LOC CD A two character code indicating the Department for Medicaid

Services branch/division or other agency that originated the Accounts Receivable. See Appendix C for values.

RSN CD A two byte alpha/numeric code specifying the reason an accounts receivable was processed against a provider’s account. See Appendix D for values.

SETUP DATE The date entered on the accounts receivable transaction in MMDDCCYY format. This date identifies the beginning of the accounts receivable event.

AGE (DAYS) The system generated number of days the accounts receivable transaction has been in “active” or “hold” status from setup date to current date.

COST SETT FYE The eight-digit date entered on the accounts receivable transaction in MMDDCCYY format. This date is defined by the provider as the administrative business year end.

AMT REQUESTED The original accounts receivable transaction amount when the adjustment reason indicates monies are owed from the provider.

A/R INC/DEC This amount is the net amount of adjustments to increase or decrease the original amount requested.

AMOUNT RECD/RECP This amount is the total of the provider checks and recoupment amounts posted to this accounts receivable transaction.

UNPAID BALANCE The system generated balance remaining on the accounts receivable transaction (does not include interest balance).

ST CD A one-character code indicating the status of the accounts receivable transaction. The valid values are: A Active B Hold recoupment payment plan under consideration C Hold recoupment - other F Paid in full P Payout complete

PP IND A one-digit code indicating a recoupment payment plan schedule. Valid values are: X DMS has approved the provider to be on a payment plan. R The provider is not on a payment plan. M DMS has approved the provider to be on a payment plan (more than 12 payments)

9 Appendix B


FIELD DESCRIPTION PAYOUT AMOUNT This is the amount paid to the provider when the adjustment

reason indicates money is owed to the provider. INT CALC This is the amount of interest calculated for an approved

payment. INT RECD This is the total amount posted to the interest calculated. BALANCE The system generates the net balance of this accounts

receivable transaction which includes the original amount plus interested calculated minus adjustments, payments and recoupment.

FIELD DESCRIPTION A/R ICN This is the 17 digit Internal Control Number used to identify

and relate records for one accounts receivable transaction. This number must be referenced when inquiring on any accounts receivable.

A/R X/REF ICN This is the 17 digit Internal Control Number used to identify and relate one accounts receivable transaction to another accounts receivable transaction.

ADJ REASON The definition of the two-digit reason code..

Any recoupment activity or payments received from the provider will list below the ‘”RECOUPMENT PAYMENT SCHEDULE.” All initial accounts receivable will allow sixty (60) days from the “setup date” to make payment on the accounts receivable. After sixty (60) days, if the accounts receivable has not been satisfied nor a payment plan initiated, monies will be recouped from the provider on each Remittance Advice until satisfied.

This will be your only notification of an accounts receivable setup. Please keep all Accounts Receivable Summary pages until all monies have been satisfied.

FIELD DESCRIPTION DUE DATE The date that monies are due to EDS to satisfy the

accounts receivable (60 days from setup date). If a payment plan has been established, several due dates are shown.

AMOUNT DUE The amount due for each due date listed. If a payment plan has not been setup, the entire amount appears in the first AMOUNT DUE column.

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 10 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 * SUMMARY OF BENEFITS PAGE * CLAIMS REMITTANCE SUMMARY CHECK NUMBER 0000000 NUMBER BILLED NET PAY PROCESSED AMOUNT AMOUNT PAID CLAIMS 0 0.00 0.00 PAID ADJ. CLAIMS 0 0.00 0.00 PAID MASS ADJ. CLAIMS 0 0.00 0.00 DENIED CLAIMS 0 0.00 CLAIMS IN PROCESS 9 3809.65 RETURNED CLAIMS 0 BEGINNING CLAIM CREDIT BALANCE 0.00 ENDING CLAIM CREDIT BALANCE 0.00 A/R TRANSACTIONS DEBIT 0.00 A/R TRANSACTIONS CREDIT 0.00 TOTAL PROVIDER CREDIT BALANCE 0.00 SUBTOTAL CHECK AMOUNT 0.00 BEGINNING POS/ELIG CREDIT BALANCE 0.00 MINUS POINT OF SALE FEES 0.00 MINUS ELIGIBILITY TRANSACTIONS 0.00 ENDING POS/ELIG CREDIT BALANCE 0.00 NET CHECK AMOUNT 0.00 MONTH-TO-DATE PAID CLAIMS 0 0.00 0.00 MONTH-TO-DATE PAID ADJ/FINANCIAL 0 0.00 0.00 MONTH-TO-DATE DENIED CLAIMS 0 0.00 YEAR-TO-DATE PAID CLAIMS 513 147737.00 147737.00 YEAR-TO-DATE PAID ADJ/FINANCIAL 9 2110.00- 2110.00- YEAR-TO-DATE DENIED CLAIMS 82 22734.15 NET 1099 AMOUNT 145627.00

9 Appendix B




REMITTANCE ADVICE




EOB THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT

00110 CLAIM SUSPENDED FOR REVIEW. 5

00290 PENDING CONFIRMATION OF MEMBER ELIGIBILITY. 4

* END OF RA *

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 12 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 REMARK THE FOLLOWING IS A DESCRIPTION OF THE REMARK CODES THAT APPEAR ABOVE: COUNT 00008 CROSSOVER LATE BILLING (MORE THAN 6 MONTHS SINCE MCARE PAID) 1 00228 BILLING PROVIDER INELIGIBLE FOR FROM-DATE-OF-SERVICE. 1 00977 TYPE OF BILL INVALID FOR PROVIDER TYPE 1

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 13 AS OF 03/17/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 RSN THE FOLLOWING IS A DESCRIPTION OF THE ADJUSTMENT REASONS THAT APPEAR ABOVE: COUNT: 60 PROVIDER INITIATED ADJUSTMENT 1 * END OF RA *

9 Appendix B


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 14 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER 000456 PROVIDER NAME: DRUGS R. US COMPANY QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES CLAIM TYPE: QUALIFIED MEDICARE BENEFICIARY (QMB) SERVICES PROVIDER ID: 91000000 RTP CODE RETURN CODE DESCRIPTION COUNT 05 CLAIM FORM/EOMB NOT LEGIBLE 2 07 MEMBER ID NUMBER MISSING 1 * END OF RA *

9 Appendix B


9.10 Summary of Benefits Page FIELD DESCRIPTION CLAIMS REMITTANCE SUMMARY

Page identification.

CHECK NUMBER The number of the Warrant Check associated with the Remittance Advice.

NUMBER PROCESSED The number of claims processed under each individual heading (listed on the left of page), where applicable.

BILLED AMOUNT The total billed dollar amount for services billed by the provider on the Remittance Advice.

NET PAY AMOUNT The total dollar amount reimbursed by the Department for Medicaid Services under each individual heading (listed on the left of page), where applicable.

PAID CLAIMS The number of paid claims processed, amount billed, and amount paid by Medicaid. These figures correspond with the summary line of the last page of PAID CLAIMS section.

PAID ADJ CLAIMS 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 EDS for issues that effect a large number of claims or providers. These adjustments will have their own section “MASS ADJUSTED CLAIMS” page, but will be formatted the same as the ADJUSTED CLAIMS page.

DENIED CLAIMS These figures correspond with the summary line of the last page of the DENIED CLAIMS section.

9 Appendix B


FIELD DESCRIPTION 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.

BEGINNING CLAIM CREDIT BALANCE

The amount of money the provider owes Medicaid as a result of a claim adjustment, claim credit, or mass adjustment that could not be satisfied from the previous Remittance Advice.

ENDING CLAIM CREDIT BALANCE

The balance of money owed to Medicaid after monies received during the current Remittance Advice have been applied.

A/R TRANSACTION DEBIT The total dollar amount paid out to a provider once a request has been received from Medicaid.

A/R TRANSACTION CREDIT The total dollar amount recouped to satisfy outstanding claim credit balances or accounts receivable.

TOTAL PROVIDER CREDIT BALANCE

The total dollar amount the provider owes Medicaid as a result of a claim adjustments, claim credits, mass adjustments, and/or an accounts receivable balance unsatisfied pertaining to the current Remittance Advice.

SUBTOTAL CHECK AMOUNT The total of the provider warrant check after the above figures have been calculated.

BEGINNING POS/ELIG CREDIT BALANCE

Not Applicable.

NET CHECK AMOUNT The total of the provider check after the POS fees and eligibility transactions have been subtracted from the SUBTOTAL CHECK AMOUNT.

MONTH-TO-DATE PAID CLAIMS

A month to date number and total billed and reimbursed of paid claims.

MONTH-TO-DATE PAID ADJ/FINANCIAL

A month to date number and total billed and reimbursed of adjusted claims and financial transactions.

MONTH-TO-DATE DENIED CLAIMS

A month to date number and total billed of denied claims.

YEAR-TO-DATE PAID CLAIMS

A year to date number and total billed and reimbursed of paid claims.

YEAR-TO-DATE ADJ/FINANCIAL

A year to date number and total billed and reimbursed of adjusted claims and financial transactions.

YEAR-TO-DATE DENIED CLAIMS

A year to date number and total billed of denied claims.

NET 1099 AMOUNT The total year to date taxable income received from Medicaid.

9 Appendix B


EXPLANATION OF BENEFITS

FIELD DESCRIPTION EOB 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 ERRORS

FIELD DESCRIPTION REMARK A five-digit number denoting the remark identified on

the Remittance Advice. REMARK CODE DESCRIPTION

Description of the Remark Code. All remark codes detailed on the Remittance Advice are listed with a description/definition.

COUNT Total number of times an Remark Code is detailed on the Remittance Advice

EXPLANATION OF ADJUSTMENT CODES

FIELD DESCRIPTION ADJUSTMENT CODE A two-digit number denoting the reason for returning

the claim. ADJUSTMENT CODE DESCRIPTION

Description of the adjustment Code. All adjustment codes 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.

EXPLANATION OF RTP CODES

FIELD DESCRIPTION RTP CODE A two-digit number denoting the reason for returning

the claim. RETURN CODE DESCRIPTION

Description of the RTP Code. All RTP codes detailed on the Remittance Advice are listed with a description/ definition.

COUNT Total number of times an RTP Code is detailed on the Remittance Advice.

10 Appendix C


10 Appendix C

10.1 Remittance Advice Location Codes (LOC CD) The following is a two-character code indicating the Department for Medicaid Services branch/division or other agency that originated the Accounts Receivable:

A Long Term Care B Hospital/Clinical C SURS D Patient Access Branch E Orthodontic F Office of Inspector General G Attorney General H KENPAC I Individual and Group Services J Fraud K Facility Services L Pharmacy M HMS N DMS Commissioner O Other P Program Integrity S Sapient U EDS AA Facilities Service Branch AB Community-Based Service AC Mental Health/Mental Retardation AD Hospital & Outpatient Facilities Services AE Physicians Branch AF Specialty Services Branch AG Utilization Review Branch AH Recovery Operations AI KENPAC AJ Pharmacy AK KCHIP AL Children’s Program Branch AM Healthwatch AN PRO

11 Appendix D


11 Appendix D

11.1 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:

01 Prov Refund – Health Insur Paid 02 Prov Refund – Member/Rel Paid 03 Prov Refund – Casualty Insu Paid 04 Prov Refund – Paid Wrong Vender 05 Prov Refund – Apply to Acct Recv 06 Prov Refund – Processing Error 07 Prov Refund-Billing Error 08 Prov Refund – Fraud 09 Prov Refund – Abuse 10 Prov Refund – Duplicate Payment 11 Prov Refund – Cost Settlement 12 Prov Refund – Other/Unknown 13 Acct Receivable – Fraud 14 Acct Receivable – Abuse 15 Acct Receivable – TPL 16 Acct Recv – Cost Settlement 17 Acct Receivable – EDS Request 18 Recoupment – Warrant Refund 19 Act Receivable-SURS Other 20 Acct Receivable – Dup Payt 21 Recoupment – Fraud 22 Civil Money Penalty 23 Recoupment – Health Insur TPL 24 Recoupment – Casualty Insur TPL 25 Recoupment – Member Paid TPL 26 Recoupment – Processing Error 27 Recoupment – Billing Error 28 Recoupment – Cost Settlement 29 Recoupment – Duplicate Payment 30 Recoupment – Paid Wrong Vendor 31 Recoupment – SURS 32 Payout – Advance to be Recouped 33 Payout – Error on Refund 34 Payout – RTP 35 Payout – Cost Settlement 36 Payout – Other

37 Payout – Medicare Paid TPL 38 Recoupment – Medicare Paid TPL 39 Recoupment – DEDCO 40 Provider Refund – Other TLP Rsn 41 Acct Recv – Patient Assessment 42 Acct Recv – Orthodontic Fee 43 Acct Receivable – KENPAC 44 Acct Recv – Other DMS Branch 45 Acct Receivable – Other 46 Acct Receivable – CDR-HOSP-Audit 47 Act Rec – Demand Paymt Updt 1099 48 Act Rec – Demand Paymt No 1099 49 PCG 50 Recoupment – Cold Check 51 Recoupment – Program Integrity Post Payment Review Contractor A 52 Recoupment – Program Integrity Post Payment Review Contractor B 53 Claim Credit Balance 54 Recoupment – Other St Branch 55 Recoupment – Other 56 Recoupment – TPL Contractor 57 Acct Recv – Advance Payment 58 Recoupment – Advance Payment 59 Non Claim Related Overage 60 Provider Initiated Adjustment 61 Provider Initiated CLM Credit 62 CLM CR-Paid Medicaid VS Xover 63 CLM CR-Paid Xover VS Medicaid 64 CLM CR-Paid Inpatient VS Outp 65 CLM CR-Paid Outpatient VS Inp 66 CLS Credit-Prov Number Changed 67 TPL CLM Not Found on History 68 FIN CLM Not Found on History 69 Payout-Withhold Release 71 Withhold-Encounter Data Unacceptable

11 Appendix D


72 Overage .99 or Less 73 No Medicaid/Partnership Enrollment 74 Withhold-Provider Data Unacceptable 75 Withhold-PCP Data Unacceptable 76 Withhold-Other 77 A/R Member IPV 78 CAP Adjustment-Other 79 Member Not Eligible for DOS 80 Adhoc Adjustment Request 81 Adj Due to System Corrections 82 Converted Adjustment 83 Mass Adj Warr 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 95 Beginning Recoupment Balance 96 Ending Recoupment Balance 97 Begin Dummy Rec Bal 98 End Dummy Recoup Balance 99 Drug Unit Dose Adjustment AA PCG 2 Part A Recoveries BB PCG 2 Part B Recoveries CB PCG 2 AR CDR Hosp DG DRG Retro Review DR Deceased Member Recoupment IP Impact Plus IR Interest Payment CC Converted Claim Credit Balance MS Prog Intre Post Pay Rev Cont C OR On Demand Recoupment Refund RP Recoupment Payout RR Recoupment Refund SS State Share Only UA EDS Medicare Part A Recoup XO Reg. Psych. Crossover Refund

12 Appendix E


12 Appendix E

12.1 Remittance Advice Status Code (ST CD) The following is a one-character code indicating the status of the accounts receivable transaction:

A Active

B Hold Recoup - Payment Plan Under Consideration

C Hold Recoup - Other

D Other-Inactive-FFP-Not Reclaimed

E Other – Inactive - FFP

F Paid in Full

H Payout on Hold

I Involves Interest – Cannot Be Recouped

J Hold Recoup Refund

K Inactive-Charge off – FFP Not Reclaimed

P Payout – Complete

Q Payout – Set Up In Error

S Active - Prov End Dated

T Active Provider A/R Transfer

U EDS On Hold

W Hold Recoup - Further Review

X Hold Recoup - Bankruptcy

Y Hold Recoup - Appeal

Z Hold Recoup - Resolution Hearing

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