Denial - 0660 Calculated payment equals zero. Other insurance paid more than Medicaid Allowable.
Action: Adjusted the claim (Medicaid write off)
Denial - 2091 Recipient services covered by HMO plan
Action: Claim would be filed to Medicaid HMO's
Denial - 0142 Claim exceeds 12 month filing limit
Action: Claim appealed with Clearing house acceptance report
Denial - 0312 Referring provider required for this procedure in field 17A/19.
Action: Issue raised to calling team regarding the PCP info after that updated the info with dummy#000000100 and refiled the claim.
Denial - 2346 Referring provider number not on file.
Action: Dummy#000000100 updated in 17A and refiled the claim.
Denial - 4888 NDC Missing/Invalid
Action: NDC# updated in claim note and refiled the claim.
Denial - 0721 Recipient ineligible for date of service
Action: After Medicaid eligibility, if the patient have other active insurance claim filed to other carrier. If patient have no other coverage bill to patient.
Denial - 0720 Medicare coverage is present
Action: After Medicare verification claim filed to Medicare.
Denial - 4257 Invalid procedure code modifier
Action: Removed modifier and refiled the claim.
Denial - 4801 These services cannot be billed on this claim form or the provider type listed for this provider number cannot file this type of claim.
Action: Normally G codes denied for this reason. After Medicare payment claim has been adjusted.
Showing posts with label medicaid. Show all posts
Showing posts with label medicaid. Show all posts
Wednesday, December 30, 2009
Tuesday, December 22, 2009
Bill to medicaid patients - how and when
how and when to Bill medicaid patients
Bill patients only in the following situations:
The recipient's Medicaid eligibility status is pending . If you bill the recipient and they are found eligible for Medicaid with a retroactive date that includes the date of service, you must return the entire amount collected from the recipient and then bill Medicaid. For this reason, it is recommended that you hold claims until after eligibility is determined.
Medicaid does not cover the service and the recipient agrees to pay by completing a written, signed agreement that includes the date, type of service, cost, verification that the provider informed the recipient that Medicaid will not pay for the service, and recipient agreement to accept full responsibility for payment. This
agreement must be specific to each incident or arrangement for which the client accepts financial responsibility.
The TPL payment was made directly to the recipient or his/her parent or guardian. You may not bill for more than the TPL paid for services rendered.
The recipient fails to disclose Medicaid eligibility or TPL information. If a recipient does not disclose Medicaid eligibility or TPL information at the time of service or within Medicaid ’ s stale date period, the recipient assumes full responsibility for payment of services.
you cannot bill the patient for:
For co-payment indicated on a private insurance card
For the difference between the amount billed and the amount paid by Medicaid or a TPL
When Medicaid denies the claim because the provider failed to follow Medicaid policy
Medicaid is the payor of last resort and must be billed after all other payment sources.
Bill patients only in the following situations:
The recipient's Medicaid eligibility status is pending . If you bill the recipient and they are found eligible for Medicaid with a retroactive date that includes the date of service, you must return the entire amount collected from the recipient and then bill Medicaid. For this reason, it is recommended that you hold claims until after eligibility is determined.
Medicaid does not cover the service and the recipient agrees to pay by completing a written, signed agreement that includes the date, type of service, cost, verification that the provider informed the recipient that Medicaid will not pay for the service, and recipient agreement to accept full responsibility for payment. This
agreement must be specific to each incident or arrangement for which the client accepts financial responsibility.
The TPL payment was made directly to the recipient or his/her parent or guardian. You may not bill for more than the TPL paid for services rendered.
The recipient fails to disclose Medicaid eligibility or TPL information. If a recipient does not disclose Medicaid eligibility or TPL information at the time of service or within Medicaid ’ s stale date period, the recipient assumes full responsibility for payment of services.
you cannot bill the patient for:
For co-payment indicated on a private insurance card
For the difference between the amount billed and the amount paid by Medicaid or a TPL
When Medicaid denies the claim because the provider failed to follow Medicaid policy
Medicaid is the payor of last resort and must be billed after all other payment sources.
Medicaid
State Insurace Medicaid – An operations study
Medicaid is a federal and state plan, operated by the states, which is an entitlement program under the Social Security Administration of the federal government for patients whose income and resources are insufficient to pay for healthcare.
Eligibility
The Medicaid program, jointly funded by the State and Federal governments, provides medical benefits to individuals with low income and resources. It is run by the individual States under broad Federal guidelines. Each state
a) Establishes its own eligibility standards
b) Determines the type, amount, duration, and scope of services
c) Sets the rate of payment for services
d) Administers its own program
Consequently, the Medicaid program differs widely from state to state. It even differs from region to region within a State, since local bodies are also involved in the funding and implementation of the program. Coverage, billing and reimbursement rules also change over time.
Though each state has discretionary powers to set its own eligibility standards, States are required to provide Medicaid coverage to most individuals receiving federally assisted income maintenance benefits, and for related groups not receiving such cash assistance.
Aid to Families with Dependent Children (AFDC)
Recipients of AFDC and Supplemental Security Income (SSI) are all eligible for Medicaid. They receive federal cash assistance. Besides, other disadvantaged groups, who satisfy the AFDC and SSI program criteria, but who do not receive cash assistance are also eligible. Poor children and low-income pregnant women, both of whom are some of the largest beneficiaries of Medicaid, are examples. Some states also include non-disabled adults without children in the Medicaid eligible groups.
Medically Needy Eligibility Groups
Some groups may not satisfy the low-income standard. That is, their income may make them ineligible for Medicaid. But they can still become eligible by "spending down". This means that a person may have an income above the poverty level indicated by the state's Medicaid program. But high medical expenses may offset this margin. When the medical expenses are reduced from the person’s income that person may fall below the poverty level. This is called spending down and thus the person become eligible.
Another way a person becomes part of the medically needy group and qualifies for Medicaid is by paying the state an amount equal to the difference between family income and the income eligibility standard.
Suppose a person's income is $100.00 above the income eligibility level. The person does not qualify. But by paying $100.00 to the state, after deducting any medical expenses he/she has incurred, he/she becomes eligible. The amount, which keeps him/her above the poverty level, is surrendered to the state. Only Medically needy individuals resort to this method. Their incomes will not be low enough to qualify for Medicaid, and not high enough to help them meet their medical needs.
Different states apply different income and resources methodologies to decide on the poverty level i.e. the methods they adopt to measure income/resources level and thus decide on Medicaid eligibility differ widely.
Medicaid Benefits for Medicare Beneficiaries
For certain poor Medicare beneficiaries, called "Qualified Medicare Beneficiaries" (QMB) with incomes below the Federal poverty level and with resources below twice the standard allowed under the SSI program, Medicaid will pay the Part A and Part B Medicare premiums and co-insurance.
"Specified Low-Income Medicare Beneficiaries" (SLBM), those that have marginally higher incomes than the QMBs, Medicaid will pay the Medicare Part B premium only.
Claims Submission & Payment
Federal Law requires Medicaid to accept CMS 1500 for claims processing in states where optical scanning facility is not available. Some states like New York and Georgia have special forms developed exclusively for claims processing by their state and which has optical scanning facilities. Though the Health Care Financing Administration (CMS) of the Department of Human Services of the US Government is responsible for administering Medicaid, each State Government has its own requirements and they append to what CMS determines. Hence claims submission in some states may go directly to Department of Human Services, while in some states it goes to county department of welfare and so on.
Medicaid carriers in almost all states have the facility of receiving claims electronically.
Filing Limit – This is the period within which claims need to be submitted failing which claims would be denied for lapse of time. Some Medicaid carriers have this as 1 year from date of service while some have this as 90 days from date of service and so on.
Other insurance plan – It is to be ensured that the patient has no other coverage other than Medicaid. If he has one and it is still valid, then we need to submit it to that coverage first.
Crossover – Crossover is a process wherein claims are automatically being sent to the supplemental carriers by Medicare after Medicare processes the primary claims and makes payment to the providers. The supplemental carriers processes and make payment to the providers. Some Medicaid carriers would have this facility. Here the provider need not have to submit a fresh claim to the secondary carrier.
Medicaid is a federal and state plan, operated by the states, which is an entitlement program under the Social Security Administration of the federal government for patients whose income and resources are insufficient to pay for healthcare.
Eligibility
The Medicaid program, jointly funded by the State and Federal governments, provides medical benefits to individuals with low income and resources. It is run by the individual States under broad Federal guidelines. Each state
a) Establishes its own eligibility standards
b) Determines the type, amount, duration, and scope of services
c) Sets the rate of payment for services
d) Administers its own program
Consequently, the Medicaid program differs widely from state to state. It even differs from region to region within a State, since local bodies are also involved in the funding and implementation of the program. Coverage, billing and reimbursement rules also change over time.
Though each state has discretionary powers to set its own eligibility standards, States are required to provide Medicaid coverage to most individuals receiving federally assisted income maintenance benefits, and for related groups not receiving such cash assistance.
Aid to Families with Dependent Children (AFDC)
Recipients of AFDC and Supplemental Security Income (SSI) are all eligible for Medicaid. They receive federal cash assistance. Besides, other disadvantaged groups, who satisfy the AFDC and SSI program criteria, but who do not receive cash assistance are also eligible. Poor children and low-income pregnant women, both of whom are some of the largest beneficiaries of Medicaid, are examples. Some states also include non-disabled adults without children in the Medicaid eligible groups.
Medically Needy Eligibility Groups
Some groups may not satisfy the low-income standard. That is, their income may make them ineligible for Medicaid. But they can still become eligible by "spending down". This means that a person may have an income above the poverty level indicated by the state's Medicaid program. But high medical expenses may offset this margin. When the medical expenses are reduced from the person’s income that person may fall below the poverty level. This is called spending down and thus the person become eligible.
Another way a person becomes part of the medically needy group and qualifies for Medicaid is by paying the state an amount equal to the difference between family income and the income eligibility standard.
Suppose a person's income is $100.00 above the income eligibility level. The person does not qualify. But by paying $100.00 to the state, after deducting any medical expenses he/she has incurred, he/she becomes eligible. The amount, which keeps him/her above the poverty level, is surrendered to the state. Only Medically needy individuals resort to this method. Their incomes will not be low enough to qualify for Medicaid, and not high enough to help them meet their medical needs.
Different states apply different income and resources methodologies to decide on the poverty level i.e. the methods they adopt to measure income/resources level and thus decide on Medicaid eligibility differ widely.
Medicaid Benefits for Medicare Beneficiaries
For certain poor Medicare beneficiaries, called "Qualified Medicare Beneficiaries" (QMB) with incomes below the Federal poverty level and with resources below twice the standard allowed under the SSI program, Medicaid will pay the Part A and Part B Medicare premiums and co-insurance.
"Specified Low-Income Medicare Beneficiaries" (SLBM), those that have marginally higher incomes than the QMBs, Medicaid will pay the Medicare Part B premium only.
Claims Submission & Payment
Federal Law requires Medicaid to accept CMS 1500 for claims processing in states where optical scanning facility is not available. Some states like New York and Georgia have special forms developed exclusively for claims processing by their state and which has optical scanning facilities. Though the Health Care Financing Administration (CMS) of the Department of Human Services of the US Government is responsible for administering Medicaid, each State Government has its own requirements and they append to what CMS determines. Hence claims submission in some states may go directly to Department of Human Services, while in some states it goes to county department of welfare and so on.
Medicaid carriers in almost all states have the facility of receiving claims electronically.
Filing Limit – This is the period within which claims need to be submitted failing which claims would be denied for lapse of time. Some Medicaid carriers have this as 1 year from date of service while some have this as 90 days from date of service and so on.
Other insurance plan – It is to be ensured that the patient has no other coverage other than Medicaid. If he has one and it is still valid, then we need to submit it to that coverage first.
Crossover – Crossover is a process wherein claims are automatically being sent to the supplemental carriers by Medicare after Medicare processes the primary claims and makes payment to the providers. The supplemental carriers processes and make payment to the providers. Some Medicaid carriers would have this facility. Here the provider need not have to submit a fresh claim to the secondary carrier.
Medicaid addresses and phone numbers of different states
Medicaid of Arizona
P. O. Box 1700, Phoenix, AZ 85002
1-800-962-6690
Medical of California
P.O. Box 13029
Sacramento, CA 95813-4029
1-800-952-5294
State of Connecticut Medicaid
P.O. Box 2991.
Hartford, CT 06104
Alabama Medicaid
PO Box 5624
Montgomery, AL
Delaware medicaid
P.O. BOX 906
NEW CASTLE DELAWARE 19
Arkansas Medicaid
P.O. Box 8105.
Little Rock, AR 72203-8105
1-800-482-8988
Alaska Medicaid
P.O. Box 240808.
Anchorage, AK 99524-0808
1-800-211-7470
Florida Medicaid
P. O. Box 2525.
Jacksonville, FL 32231-0019
IDAHO Medicaid
P.O. Box 23
Boise, ID 83707
Illinois Medicaid
P.O. Box 19115.
Springfield, Illinois 62794-9115
402-471-9580
1-800-842-1461
Indiana Medicaid
P.O. Box 441423.
Indianapolis, IN 46244-1423
Iowa Medicaid
P. O. Box 150001.
Des Moines, Iowa 50315
Kansas Medicaid
P.O. Box 3571.
Topeka, KS 66601-3571
Kentucky Medicaid
P.O. Box 2016. Frankfort, KY 40602-2016
800-255-1932
Louisiana Medicaid
P.O. Box 80159.
Baton Rouge, LA 70898-0159
1-888-342-6207
1-800-776-6323
P. O. Box 1700, Phoenix, AZ 85002
1-800-962-6690
Medical of California
P.O. Box 13029
Sacramento, CA 95813-4029
1-800-952-5294
State of Connecticut Medicaid
P.O. Box 2991.
Hartford, CT 06104
Alabama Medicaid
PO Box 5624
Montgomery, AL
Delaware medicaid
P.O. BOX 906
NEW CASTLE DELAWARE 19
Arkansas Medicaid
P.O. Box 8105.
Little Rock, AR 72203-8105
1-800-482-8988
Alaska Medicaid
P.O. Box 240808.
Anchorage, AK 99524-0808
1-800-211-7470
Florida Medicaid
P. O. Box 2525.
Jacksonville, FL 32231-0019
IDAHO Medicaid
P.O. Box 23
Boise, ID 83707
Illinois Medicaid
P.O. Box 19115.
Springfield, Illinois 62794-9115
402-471-9580
1-800-842-1461
Indiana Medicaid
P.O. Box 441423.
Indianapolis, IN 46244-1423
Iowa Medicaid
P. O. Box 150001.
Des Moines, Iowa 50315
Kansas Medicaid
P.O. Box 3571.
Topeka, KS 66601-3571
Kentucky Medicaid
P.O. Box 2016. Frankfort, KY 40602-2016
800-255-1932
Louisiana Medicaid
P.O. Box 80159.
Baton Rouge, LA 70898-0159
1-888-342-6207
1-800-776-6323
medicaid claim submission address list
Maryland Medicaid
P.O. Box 1935. Baltimore, MD 21203
Michigan Medicaid
PO BOX 30238. LANSING MI 48909
Minnesota Medicaid claim
P.O. Box 64166. St. Paul, MN 55164
Mississippi Medicaid claim
P. O. Box 23076. Jackson, MS 39225-3076
Montana Medicaid claim
P. O. Box 5865. Helena, MT 59604
Nebraska Medicaid claim
PO BOX 95026. Lincoln, NE 68509-5026
Nevada Medicaid claim mailing address
P.O. Box 30042. Reno NV 89520-3042
New Hampshire Medicaid claim mailing
PO Box 2001. Concord, NH 03302-2001
P.O. Box 1935. Baltimore, MD 21203
Michigan Medicaid
PO BOX 30238. LANSING MI 48909
Minnesota Medicaid claim
P.O. Box 64166. St. Paul, MN 55164
Mississippi Medicaid claim
P. O. Box 23076. Jackson, MS 39225-3076
Montana Medicaid claim
P. O. Box 5865. Helena, MT 59604
Nebraska Medicaid claim
PO BOX 95026. Lincoln, NE 68509-5026
Nevada Medicaid claim mailing address
P.O. Box 30042. Reno NV 89520-3042
New Hampshire Medicaid claim mailing
PO Box 2001. Concord, NH 03302-2001
Subscribe to:
Posts (Atom)