Va. DMAS Hospice Provider Manual ch. V, Negative Balance Information – Fee For Service

Negative balances occur when one or more of the following situations have occurred:

• Provider submitted adjustment/void request

• DMAS completed adjustment/void

• Audits

• Cost settlements

• Repayment of advance payments made to the provider by DMAS

In the remittance process the amount of the negative balance may be either off set by

the total of the approved claims for payment leaving a reduced payment amount or may

result in a negative balance to be carried forward. The remittance will show the amount

as, “less the negative balance” and it may also show “the negative balance to be carried

forward”.

The negative balance will appear on subsequent remittances until it is satisfied. An

example is if the claims processed during the week resulted in approved allowances of

$1000.00 and the provider has a negative balance of $2000.00 a check will not be issued,

and the remaining $1000.00 outstanding to DMAS will carry forward to the next

remittance.

INSTRUCTIONS FOR COMPLETING THE PAPER CMS-1500 (02-12) FORM FOR

MEDICARE AND MEDICARE ADVANTAGE PLAN DEDUCTIBLE,

COINSURANCE AND COPAY PAYMENTS FOR PROFESSIONAL SERVICES

The Direct Data Entry (DDE) Crossover Part B claim form can be located through the

MES Provider Portal. Please note that providers are encouraged to use DDE for

submission of claims that cannot be submitted electronically to DMAS. Registration with

MES is required to access and use DDE within the MES Provider Portal.

Once logged on to MES, choose Provider Resources and then select Claims. Providers

have the ability to create a new initial claim, as well as a claim adjustment or a void

through the DDE process. The status of the claim(s) submitted can be checked the next

business day if claims were submitted by 5pm. DDE is provided at no cost to providers.

Paper claim submissions should only be submitted when requested specifically by DMAS.

Purpose: A method of billing Medicare’s deductible, coinsurance and copay for

professional Providers typically use Direct Data Entry (DDE), however, the CMS-1500

(02-12) form must be used in those instances where DMAS has requested the use of the

paper form. The following instructions have numbered items corresponding to fields on

the CMS-1500 (02-12).

NOTE: Note changes in locator 11c and 24A lines 1-6 red shaded area. These changes

are specific to Medicare Part B billing only.

Locator

Instructions

1

REQUIRED

Enter an "X" in the MEDICAID box for the Medicaid

Program. Enter an “X” in the OTHER box for

Temporary Detention Order (TDO) or Emergency

Custody Order (ECO).

1a

REQUIRED

Insured's I.D. Number - Enter the 12-digit

Virginia Medicaid Identification number for the member

receiving the service.

2

REQUIRED

Patient's Name - Enter the name of the member

receiving the service.

3

NOT REQUIRED Patient's Birth Date

4

NOT REQUIRED Insured's Name

5

NOT REQUIRED Patient's Address

6

NOT REQUIRED Patient Relationship to Insured

7

NOT REQUIRED Insured's Address

8

NOT REQUIRED Reserved for NUCC Use

9

NOT REQUIRED Other Insured's Name

9a

NOT REQUIRED Other Insured's Policy or Group Number

9b

NOT REQUIRED Reserved for NUCC Use

9c

NOT REQUIRED Reserved for NUCC Use

9d

NOT REQUIRED Insurance Plan Name or Program Name

10

REQUIRED

Is Patient's Condition Related To: - Enter an "X" in the

appropriate box.

• Employment

• Auto accident

• Other Accident (This includes schools, stores, assaults, etc.) NOTE:

The state should be entered if known.

10d

Conditional

Claim Codes (Designated by NUCC)

Medicare/Medicare Advantage Plan EOB should be

attached.

11

REQUIRED

Insured's Policy Number or FECA Number

11a

NOT REQUIRED Insured's Date of Birth

11b

NOT REQUIRED Other Claim ID

11c

REQUIRED Insurance Plan or Program Name

Enter the word ‘CROSSOVER’

IMPORTANT: DO NOT enter ‘HMO COPAY’ when billing for

Medicare/Medicare Advantage Plan copays! Only enter the word

‘CROSSOVER’

11d

REQUIRED If applicable Is There Another Health Benefit Plan?

If Medicare/Medicare Advantage Plan and Medicaid

only, check “NO”. Only check “Yes”, if there is additional

insurance coverage other than Medicare/Medicare

Advantage Plan and Medicaid.

12

NOT REQUIRED Patient's or Authorized Person's Signature

13

NOT REQUIRED Insured's or Authorized Person's Signature

14

NOT REQUIRED Date of Current Illness, Injury, or Pregnancy

Enter date MM DD YY format

Enter Qualifier 431 – Onset of Current Symptoms or

Illness

15

NOT REQUIRED Other Date

16

NOT REQUIRED Dates Patient Unable to Work in Current Occupation

17

NOT REQUIRED Name of Referring Physician or Other Source – Enter

the name of the referring physician.

17a red shaded NOT REQUIRED ID Number of referring physician. The qualifier ‘ZZ’

is entered if the provider taxonomy code is needed to

adjudicate the claim.

17b

NOT REQUIRED I.D. Number of Referring Physician - Enter the National

Provider Identifier of the referring physician.

18

NOT REQUIRED Hospitalization dates related to current services

19

NOT REQUIRED Additional Claim Information. Enter the CLIA#

20

NOT REQUIRED Outside Lab?

21 REQUIRED Diagnosis or Nature of Illness or Injury. Enter the

appropriate ICD diagnosis code, which describes the

nature of the illness or injury for which the service was

rendered in locator 24E.

NOTE: Line ‘A’ field should be the Primary/Admitting

diagnosis followed by the next highest level of

specificity in lines B-L.

Note: ICD Ind. - OPTIONAL

0=ICD-10-CM – Dates of service 10//1/15 and after

22 REQUIRED if applicable. Resubmission Code –

Original

Reference

Number. Required for adjustment or

void. Enter one of the following resubmission codes for

an adjustment:

1023 Primary carrier has made additional payment

1024 Primary carrier has denied payment

1026 Patient payment amount changed

1027 Correcting service periods

1028 Correcting procedure/service code

1029 Correcting diagnosis code

1030 Correcting charges

1031 Correcting units/visits/studies/procedures

1032 IC reconsideration of allowance, documented

1033 Correcting admitting, referring, prescribing provider

identification number

1053 Adjustment reason is in the miscellaneous category

Enter one of the following resubmission codes for a void:

1042 Original claim has multiple incorrect items

1044 Wrong provider identification number

1045 Wrong member eligibility number

1046 Primary carrier has paid DMAS’ maximum allowance

1047 Duplicate payment was made

1048 Primary carrier has paid full charge

1051 Member is not my patient

1052 Void reason is in the miscellaneous category

1060 Other insurance is available

Original Reference Number - Enter the claim reference number/ICN of the Virginia

Medicaid paid claim. This number may be obtained from the remittance voucher and is

required to identify the claim to be adjusted or voided. Only one paid claim can be

adjusted or voided on each CMS-1500 (02-12) claim form. (Each line under Locator 24 is

one claim).

NOTE: ICNs can only be adjusted or voided through the MES up to three years from the

date the claim was paid. After three years, ICNs are purged from the MES and can no

longer be adjusted or voided through the system. If an ICN is purged from the system,

the provider must send a refund check made payable to DMAS and include the following

information:

• A cover letter on the provider’s letterhead which includes the current address,

contact name and phone number.

• An explanation about the refund.

• A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to: Department of Medical Assistance Services

Attn: Fiscal & Procurement Division, Cashier

600 East Broad St. Suite 1300

Richmond, VA 23219

23 REQUIRED if applicable. Service Authorization (SA) Number – Enter the PA

number for approved services that require a service authorization. NOTE: The

locators 24A thru 24J have been divided into open and shaded line areas. The

shaded area is ONLY for supplemental information. DMAS has given

instructions for the supplemental information that is required when needed for

DMAS claims processing. ENTER REQUIRED INFORMATION ONLY.

24 lines 1-6 open area. Dates of Service - Enter the from and thru dates in a 2-digit

format for the month, day and year (e.g., 01 01 14).

24 A-H lines 1-6 red shaded. REQUIRED. DMAS is requiring the use of the following

qualifiers in the red shaded for Part B billing: A1 = Deductible (Example:

A120.00) = $20.00 ded A2 = Coinsurance (Example: A240.00) = $40.00 coins

A7= Copay (Example: A735.00) = $35.00 copay AB= Allowed by

Medicare/Medicare Advantage Plan (Example AB145.10) = $145.10 Allowed

Amount MA= Amount Paid by Medicare/Medicare Advantage Plan (Example

MA27.08) see details below CM= Other insurance payment (not

Medicare/Medicare Advantage Plan) if applicable (Example CM27.08) see details

below N4 = National Drug Code (NDC)+Unit of Measurement

This qualifier is to be used to show Medicare/Medicare Advantage payment. The

MA qualifier of the payment by Medicare/Medicare Advantage Plan Example:

Payment by Medicare/Medicare Advantage Plan is $27.08; enter MA27.08 in the

red shaded area

This qualifier is to be used to show the amount paid by the insurance carrier

other than Medicare/Medicare Advantage plan. The CM qualifier is to be

followed by the dollar/cents amount of the payment by the other insurance.

Example:

Payment by the other insurance plan is $27.08; enter

CM27.08 in the red shaded area

NOTE: No spaces are allowed between the qualifier and dollars. No $ symbol is

allowed. The decimal between dollars and cents is required.

This qualifier is to be used for the National Drug Code (NDC) whenever a drug

related HCPCS code is submitted in 24D to DMAS. The Unit of Measurement

Qualifiers must follow the NDC number. The unit of measurement qualifier code

is followed by the metric decimal quantity or unit. Do not enter a space between

the unit of measurement qualifier and NDC.

.

Example: N400026064871UN1.0

Any spaces unused for the quantity should be left blank.

Unit of Measurement Qualifier Codes:

F2 – International Units GR – Gram

ML – Milliliter UN – Unit

Examples of NDC quantities for various dosage forms as follows:

Tablets/Capsules – bill per UN

Oral Liquids – bill per ML

Reconstituted (or liquids) injections – bill per ML

Non-reconstituted injections (I.E. vial of Rocephin powder) – bill as UN (1 vial = 1

unit)

Creams, ointments, topical powders – bill per GR

Inhalers – bill per GR

Note: All supplemental information entered in locator 24A thru 24H is to be left

justified.

Examples:

Deductible is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $20.00,

Medicare/Medicare Advantage Plan Paid Amt is

$16.00, Coinsurance is $4.00.

Enter:A110.00 AB20.00 MA16.00 A24.00

Copay is $35.00, Medicare/Medicare Advantage Plan Paid Amt is $0.00

Medicare/Medicare Advantage Plan Allowed Amt is $100.00

Enter: A735.00 MA0.00 AB100.00

Medicare/Medicare Advantage Plan Paid Amt is

$10.00, Other Insurance payment is $10.00, Medicare/Medicare Advantage Plan

Allowed Amt is $10.00, Coinsurance is $5.00, NDC is 12345678911, Unit of

measure is 2 grams

Enter:

MA10.00 CM10.00 AB10.00 A25.00 N412345678911GR2

24b open area REQUIRED Place of Service - Enter the 2-digit CMS code, which

describes where the services were rendered.

24c open area REQUIRED if applicable. Emergency Indicator - Enter either ‘Y’ for YES

or leave blank. DMAS will not accept any other indicators for this locator.

24d open area REQUIRED Procedures, Services or Supplies – CPT/HCPCS – Enter

the CPT/HCPCS code that describes the procedure rendered or the service

provided. Modifier - Enter the appropriate CPT/HCPCS modifiers if applicable.

24e open area REQUIRED Diagnosis Code - Enter the diagnosis code reference letter

A-L (pointer) as shown in Locator 21 to relate the date of service and the

procedure performed to the primary diagnosis. The primary diagnosis code

reference letter for each service should be listed first. NOTE: A maximum of

4 diagnosis code reference letter pointers should be entered. Claims with values

other than A-L in Locator 24-E or blank will be denied.

24f open area REQUIRED Charges - Enter the Medicare/Medicare Advantage Plan

billed amount for the procedure/services. NOTE: Enter the Medicare/Medicare

Advantage Plan Copay amount as the charged amount when billing for the

Medicare/Medicare Advantage Plan Copay ONLY.

24g open area REQUIRED Days or Unit - Enter the number of times the procedure,

service, or item was provided during the service period.

24h open area REQUIRED if applicable EPSDT or Family Planning - Enter the

appropriate indicator. Required only for EPSDT or family planning services.

1 Early and Periodic, Screening, Diagnosis and Treatment Program Services

2 Family Planning Service

24i open area REQUIRED if applicable. NPI – This is to identify that it is a NPI that is in

locator 24J

24i red shaded REQUIRED if applicable. Rendering provider ID# - Enter the 10 digit

NPI number for the provider that performed/rendered the care.

24j open and red shaded REQUIRED if applicable. Rendering provider ID# - If the

qualifier ‘ZZ’ was entered in 24I shaded area enter the provider taxonomy code if

the NPI is entered in locator 24J open line.

25 NOT REQUIRED Federal Tax I.D. Number

26 REQUIRED Patient's Account Number – Up to FOURTEEN alpha-numeric

characters are acceptable.

27 NOT REQUIRED Accept assignment

28 REQUIRED Total Charge - Enter the total charges for the services in 24F

lines 1-6

29 REQUIRED If applicable, Amount Paid - For personal care and waiver services only

enter the patient pay amount that is due from the patient.

NOTE: The patient pay amount is taken from services billed on 24A - line 1. If

multiple services are provided on same date of service, then another form must be

completed since only one line can be submitted if patient pay is to be considered

in the processing of this service.

30 NOT REQUIRED Rsvd for NUCC Use

31 REQUIRED Signature of Physician or Supplier Including Degrees or Credentials –

The provider or agent must sign and date the invoice in this block.

32 REQUIRED If applicable. Service Facility Location Information Enter the name as

first line, address as second line, city, state and 9 digit zip code as third line for the

location where the services were rendered.

NOTE: For physician with multiple office locations, the specific Zip code must

reflect the office location where services given. Do NOT use commas, periods or

other punctuations in the address. Enter space between city and state. Include the

hyphen for the 9 digit zip code.

32a open REQUIRED if applicable. NPI # - Enter the 10 digit NPI number of the service

location.

32b red shaded REQUIRED if applicable. Other ID#: - entered in the provider taxonomy

code if the NPI is entered in locator 32a open line.

33 REQUIRED Billing Provider Info and PH # - Enter the billing name as first line,

address identify the provider that is requesting to be paid.

NOTE: Do NOT use commas, periods or other punctuations in the address. Enter

space between city and state. Include the hyphen for the 9 digit zip code. The

phone number is to be entered in the area to the right of the field title. Do not use

hyphen or space as separator within the telephone number.

33a open REQUIRED NPI Enter the 10 digit NPI number of the billing provider.

33b red shaded REQUIRED if applicable. Other Billing ID – the qualifier ‘1D’ is required

with the API entered in this locator. The qualifier ‘ZZ’ is required with the provider

taxonomy code if the NPI is entered in locator 33a open line.

NOTE: DO NOT use commas, periods, space, hyphens or other punctuations

between the qualifier and the number.

The information may be typed (recommend font Sans Serif 12) or legibly handwritten.

Retain a copy for the office files. Mail the completed claims to:

Department of Medical Assistance Services CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444