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Academic year: 2021



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How Medicaid Works

Reference List


Aspects of Electronic Billing


Websites available

Going Green with Remittance Advices

Member ID’s

Billing Scenarios

Points to Remember


How Medicaid Works

Department for Medicaid Services Medicaid Policy/Enrollment

Local DCBS office HP Enterprise Services


Department for Medicaid Services (DMS) and Medicaid Policy enforces the rules and regulations that were designed by Legislation.

The Local DCBS office enrolls members who apply according to the rules and regulations.

HP Enterprise Services, the KYMMIS contractor, can only process claims according to the rules and regulations that Medicaid has designed.


Representative List

Brenda Orberson 502-209-3053 brenda.orberson@hp.com

Adair Allen Barren Boyle Casey Clinton Cumberland Estill Green Jackson

Laurel Lincoln Madison McCreary Metcalfe Monroe Pulaski Rockcastle Russell Simpson Warren Wayne Whitley

Penny Germinaro 502-209-3278 penny.germinaro@hp.com

Bell Breathitt Boyd Carter Clay Elliot Greenup Floyd Harlan Johnson Knott Knox Lawrence Lee Lewis Leslie Letcher Martin Magoffin Morgan Owsley Perry Pike Rowan

Vicky Hicks 502-209-3050 vicky.hicks@hp.com


Leigh Ann Hayes 502-209-3087 leigh.hayes@hp.com

Boone Bracken Campbell Carroll Gallatin Grant Jefferson Kenton Pendleton Oldham Owen Trimble

Kristy Cabell 502-209-3051 kristy.cabell@hp.com

Anderson Ballard Breckinridge Bullitt Butler Caldwell Calloway Carlisle Christian Crittenden

Daviess Edmonson Franklin Fulton Graves Grayson Hancock Hardin Harrison Hart Henderson Henry Hickman Hopkins Larue

Livingston Logan Lyon Marion Marshall Mason Mccracken Mclean Meade Muhlenberg Nelson Ohio Robertson Scott Shelby Spencer Taylor Todd Trigg Union Washington Webster


Reference List

Phone Numbers

Web addresses


EDI Helpdesk 800-205-4696 Ky_edi_helpdesk@hp.com

HP Provider Billing Inquiry 800-807-1232 Ky_provider_inquiry@hp.com

Provider Enrollment 877-838-5085 Member Services 800-635-2570 Passport 800-578-0775 Fraud 800-372-2970 Medicaid Policy 502-564-5560 Departments KY Medicaid www.chfs.ky.gov/dms

Regulations, Provider updates, Provider Enrollment




HP Provider Inquiry Claim status, denials, RA’s, any billing questions, member eligibility, PA’s and limitations. (for providers only)

EDI Helpdesk Electronic billing, electronic RA’s, PIN #, and password reset.

Provider Field Representative Provider Workshops, training, one on one provider visits, mini-workshops, association meetings, teleconferences and escalated problems. (not for claim status and for providers only)

Medicaid Policy Questions concerning coverage, rate and regulations Medicaid Provider Enrollment Questions or updates to the provider file, such as:

NPI/Taxonomy, updating address, EFT’s and enrollment of providers.

Local DCBS office Eligibility updates

Member Services Question on member files, such as: program code information and member eligibility. (for providers and members)



•Department for Medicaid Services uses the following publications and tools to

communicate information to providers: RA Banner

Message board

KyHealth Net main page Provider Letters

All Websites


Aspects of Electronic Billing

•All claims submitted via paper or electronically appear in the claims inquiry area of

the KyHealth Net.

•Claims submitted via 837 or KyHealth Net are processed faster because manual

intervention is not required.

•KYMMIS Website holds DDE User Manuals and Companion Guides for

requirements providers must follow for proper claim submission.

•Provider may view, adjust and void paid claims and resubmit denied claims.


•The format you use to submit 837 transactions to health insurance carriers will be

upgraded in the coming months. The Centers for Medicare and Medicaid Services (CMS) are switching from the Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and from National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0.

•This will be fully implemented by January 1, 2012.

•Please contact your vendors and clearinghouses to be sure

they are compliant before January 1, 2012.

•More information will be forthcoming for changes specific to

Kentucky Medicaid.


Medicaid’s Website


Kymmis Website Provider Directory


KYMMIS Website

KyHealth Net Claims Submission/Information Member Information Provider Directory Billing Instruction,

Forms and Workshop Updates


KyHealth Net Website

Home Page


RA Viewer


Remittance Advice

•Available on the pay-to provider RA viewer of the KyHealth Net. •Available prior to receipt of the hard copy version.

•Even if the provider has opted out of receiving paper RAs, RAs will be available on

the KyHealth Net for six months.

•To obtain RAs older than six months, providers may contact Provider Inquiry. •RAs on the KyHealth Net are image files of the paper RAs.


Format for larger print on RA

Choose Preferences Choose Image Options Enlarge to 125


Member ID’s

Use Current ID


Billing Scenarios

The Member ‘s Medicaid ID is entered in field 9a of the CMS 1500 claim form. Medicaid does not review field 1a.


Billing Scenarios


Points to Remember

•Fields 11, 11c and 29 are used for Commercial insurance payments only. If a TPL

(Commercial insurance) denies or does not pay money, leave these fields blank.

•TPL claims- When a payment is received from a commercial insurance, the claim may

be billed electronically. The money received must be entered on the claim,

(no contractual amount). When no money is received from a commercial insurance the claim must be billed on paper with the EOB attached to the back of the claim.

•When TPL makes payment on all charges submitted on the CMS 1500 claim form:

Medicaid will calculate the Medicaid allowed amount per line. The TPL payment is then applied to the claim per detail until the TPL payment has been applied in its entirety.

•When TPL pays several lines of the CMS 1500 claim form but denies other lines:

Two claims are billed. The first claim must hold lines paid by the primary carrier and carrier paid amount in field 29. The second claim must hold all charges denied


Points to Remember

•Adjustments and Voids can only be done on “Paid” claims. If the claim has denied, it

must be resubmitted.

•Adjusting Paid Claims on KyHealth Net. Select the claim to adjust.

Once changes are made, select the “Adjust” button.

•Once the steps have been completed, the new claim and ICN will display.

Refer to the information at the top of the page to see how your new claim processed.

•Voiding Paid Claims, choose the claim to void and select the “Void” button. •To verify the status or research the history of your Void, use the claim search

functionality from the Claims Inquiry tab to locate the original claim.

•The diagnosis cross reference must be billed on all claims.


Points to Remember

•For Medicare primary claims – If Medicare denies a services, that service is billed on a

separate claim than allowed amount from Medicare. Medicaid then becomes primary.

•If a Medicare crossover claim is billed paper, attach the Medicare coding sheet,

which includes Medicare Replacement Policies. Medicare Replacements do not cross electronically.

•Member Program Codes to watch for:

Z-QMB Only-Medicaid only allows after Medicare, so if Medicare denies, Medicaid will deny.

ZJ, ZL, ZQ Buy-In Member-Medicaid is only paying the Medicare Premiums. No claims coverage.


Top Denials

•EOB 0102 Timely filing – All timely filing claims must be billed on paper with

documentation attached behind the claims showing proof.

•EOB 0465 Member has other medical coverage – Medicaid is payor of last resort, always

bill the commercial insurance first. The commercial insurance information will be given on the RA and KyHealth Net.

•EOB 2003 Member not eligible on dates of service – Verify the member’s eligibility either


Top Denials

•EOB 0121 This service not payable for QMB only members – Program code of a “Z”,

Medicaid will allow the charges after Medicare. If Medicare denies, Medicaid will deny.

•EOB 0260 Buy In - Program codes of “ZJ, ZL and ZQ”, the member does not


True or False

•A claim must be billed paper when a commercial insurance pays providers.

True or False

•Member’s ID is entered in field 1a.

True or False

•Claim denied for timely filing, resubmit electronically.

True or False

•Claim is in suspense, wait before you bill again.

True or False

•Void a denied claim.



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