Hospice Care Services. Medicaid and Other Medical Assistance Programs

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Hospice

Care

Services

Medicaid and Other Medical

Assistance Programs

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Health & Human Services, July 2004. Updated January 2005.

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Table of Contents i.1

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General Coverage Principles ...2.1 Services provided by the hospice (ARM 37.40.805)...2.1 Services provided by physicians (ARM 37.40.801) ...2.1 Services provided by contract staff (42 CFR 418.90) ...2.1 Non-covered services...2.1 Client Enrollment...2.2 Coverage of Specific Services ...2.4 Counseling services ...2.4 Crisis services ...2.4 Home health aide services ...2.4 Inpatient hospice care ...2.5 Inpatient respite care ...2.5 Medical supplies ...2.5 Nursing services...2.5 Physician services ...2.5 Social worker services ...2.6 Therapy services ...2.6 Other Programs ...2.6 Mental Health Services Plan (MHSP) ...2.6 Children’s Health Insurance Plan (CHIP) ...2.6

Coordination of Benefits ...3.1

When Clients Have Other Coverage...3.1 Identifying Additional Coverage ...3.1 When a Client Has Medicare ...3.1 Medicare claims ...3.2 When a Client Has TPL (ARM 37.85.407) ...3.2 Exceptions to billing third party first ...3.2 Requesting an Exemption ...3.3 When the Third Party Pays or Denies a Service ...3.3 When the Third Party Does Not Respond ...3.3

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i.2 Table of Contents

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ic Health and Human Services

Billing Procedures...4.1

Claim Forms ...4.1 Timely Filing Limits (ARM 37.85.406) ...4.1 Tips to avoid timely filing denials ...4.1 When To Bill Medicaid Clients (ARM 37.85.406) ...4.2 Client Cost Sharing ...4.2 When Clients Have Other Insurance ...4.2 Billing for Retroactively Eligible Clients ...4.2 Using the Medicaid Fee Schedule ...4.2 Coding...4.2 Billing For Hospice Services ...4.3 Routine home care day ...4.3 Continuous home care ...4.3 Inpatient respite day...4.3 General inpatient day ...4.3 Board and room for nursing facility residents ...4.4 Billing For Physician Services...4.4 Hospice Cap ...4.4 The Most Common Billing Errors and How to Avoid Them ...4.4

Submitting a Claim ...5.1

Electronic Claims...5.1 Billing Electronically with Paper Attachments ...5.2 Paper Claims ...5.2 Completing a UB-92 Claim Form ...5.3 Mailing Paper Claims ...5.5 Claim Inquiries ...5.5 Avoiding Claim Errors...5.5

Remittance Advices and Adjustments ...6.1

The Remittance Advice ...6.1 Electronic RA ...6.1 Paper RA...6.1 Key to the Paper RA ...6.4 Credit balance claims...6.5 Rebilling and Adjustments...6.5 How long do I have to rebill or adjust a claim?...6.5 Rebilling Medicaid ...6.5 When to rebill Medicaid ...6.5 How to rebill ...6.6 Adjustments ...6.6 When to request an adjustment ...6.6 How to request an adjustment...6.7 Completing an Adjustment Request Form...6.7 Mass adjustments ...6.9 Payment and The RA ...6.9

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Table of Contents i.3

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How Payment Is Calculated...7.1

Overview...7.1 Hospice Rates ...7.1 Calculating rates ...7.1 Calculating payment ...7.2 Caps ...7.2 Inpatient cap...7.2 Overall cap ...7.2 Appendix A ...A.1

Physician’s Certification for Medicaid Hospice Benefit ...A.2 Patient Election for Medicaid Hospice Services by Hospice and Assignment Benefits ...A.3 Paperwork Attachment Cover Sheet...A.4 Montana Medicaid Claim Inquiry Form ...A.5 Montana Medicaid Individual Adjustment Request ...A.6

Definitions and Acronyms...B.1 Index...C.1

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i.4 Table of Contents

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Key Contacts ii.1

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Key Contacts

Hours for Key Contacts are 8:00 a.m. to 5:00 p.m. Monday through Friday (Mountain Time), unless otherwise stated. The phone numbers designated “In state” will not work outside Montana.

Provider Relations

For questions about eligibility, payments, deni-als, general claims questions, Medicaid or PASSPORT provider enrollment, address or phone number changes, or to request provider manuals or fee schedules:

(800) 624-3958 In state

(406) 442-1837 Out of state and Helena Send written inquiries to:

Provider Relations Unit P.O. Box 4936

Helena, MT 59604

Claims

Send paper claims to:

Claims Processing Unit P. O. Box 8000

Helena, MT 59604

Client Eligibility

For client eligibility, see the Client Eligibility and Responsibilities chapter in the General Information For Providers manual.

Senior and Long Term Care

For hospice program information:

(406) 444-4064 Phone (406) 444-7743 Fax

Send written inquiries to:

Senior and Long Term Care P.O. Box 4210

Helena, MT 59604

Third Party Liability

For questions about private insurance, Medi-care or other third-party liability:

(800) 624-3958 In state

(406) 443-1365 Out of state and Helena (406) 442-0357 Fax

Send written inquiries to:

ACS Third Party Liability Unit P. O. Box 5838

Helena, MT 59604

Provider’s Policy Questions

For policy questions, contact the appropriate division of the Department of Public Health and Human Services; see the Introduction chapter in the General Information For Pro-viders manual.

Technical Services Center

Providers who have questions or changes regarding electronic funds transfer should call the number below and ask for the Direct Deposit Manager.

(406) 444-9500

ACS EDI Gateway

For questions regarding electronic claims sub-missions:

(800) 987-6719 Phone

(850) 385-1705 Fax

ACS EDI Gateway Services 2324 Killearn Center Blvd. Tallahassee, FL 32309

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ii.2 Key Contacts

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Secretary of State

The Secretary of State’s office publishes the most current version of the Administrative Rules of Montana (ARM):

(406) 444-2055 Phone

Secretary of State P.O. Box 202801

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Key Contacts ii.3

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Key Web Sites

Web Address

Information Available

Virtual Human Services Pavilion (VHSP)

vhsp.dphhs.mt.gov

Select Human Services for the following information:

• Medicaid: Medicaid Eligibility & Payment System (MEPS). Eligibil-ity and claims history information.

• Senior and Long Term Care: Provider search, home/housing options, healthy living, government programs, publications, protective/legal ser-vices, financial planning.

• DPHHS: Latest news and events, Mental Health Services Plan infor-mation, program inforinfor-mation, office locations, divisions, resources, legal information, and links to other state and federal web sites. • Health Policy and Services Division: Children’s Health Insurance

Plan (CHIP), Medicaid provider information such as manuals, newslet-ters, fee schedules, and enrollment information.

Provider Information Website

www.mtmedicaid.org or www.dphhs.mt.gov/hpsd/medicaid/medicaid2 • Medicaid Information • Medicaid news • Provider manuals

• Notices and manual replacement pages • Fee schedules

• Remittance advice notices • Forms

• Provider enrollment

• Frequently asked questions (FAQs) • Upcoming events

• Electronic billing information • Newsletters

• Key contacts

Medicaid Mental Health and Mental Health Services Plan

www.dphhs.mt.gov/about_us/divisions/ addictive_mental_disorders/services/ public_mental_health_services.htm

Mental Health Services information for Medicaid and MHSP

Senior and Long Term Care

http://www.dphhs.mt.gov/sltc/index.htm • Provider Search • Home/Housing Options • Healthy Living • Government Programs • Publications • Protective/Legal Services • Financial Planning

ACS EDI Gateway

www.acs-gcro.com/Medicaid_Account/Montana/ montana.htm

ACS EDI Gateway is Montana’s HIPAA clearinghouse. Visit this web-site for more information on:

• Provider Services • EDI Support • Enrollment • Manuals • Software • Companion Guides

Washington Publishing Company

www.wpc-edi.com

• EDI implementation guides

• HIPAA implementation guides and other tools • EDI education

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ii.4 Key Contacts

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Introduction 1.1

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Introduction

Thank you for your willingness to serve clients of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for providers of hospice services. Additional essential information for providers is contained in the separate General Information For Providers manual. Each provider is asked to review both manu-als.

A table of contents and an index allow you to quickly find answers to most ques-tions. The margins contain important notes with extra space for writing notes. Each manual contains a list of Key Contacts at the beginning. We have also included a space on the back side of the front cover to record your Medicaid Pro-vider ID number for quick reference when calling ProPro-vider Relations.

Manual Maintenance

Manuals must be kept current. Changes to manuals are provided through notices and replacement pages. When replacing a page in a manual, file the old pages and notices in the back of the manual for use with claims that originated under the old policy.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website (see Key Contacts). Paper copies of rules are available through Provider Relations, the Department (Senior and Long Term Care) and the Secretary of State’s office (see Key Contacts). In addition to the general Medicaid rules outlined in the General Information For Providers manual, the following rules and regulations are also applicable to the hospice program:

• Code of Federal Regulations (CFR)

• 42 CFR 418 Hospice Care

• Montana Codes Annotated (MCA)

• MCA 53-6-101 Montana Medicaid Program Authorization of Services

Providers are responsible for knowing and following current laws and regulations.

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1.2 Introduction

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• Administrative Rules of Montana (ARM)

• ARM 37.40.801 - 37.40.830 - Hospice

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Medicaid provider’s claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or pro-vider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer or Pro-vider Relations). The list of Key Contacts at the front of this manual has important phone numbers and addresses pertaining to this manual. The Introduction chapter in the General Information For Providers manual also has a list of contacts for specific program policy information. Medicaid manuals, notices, replacement pages, fee schedules, forms, and much more are available on the Provider Informa-tion website (see Key Contacts).

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Covered Services 2.1

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Covered Services

General Coverage Principles

Hospice programs provide health and support services to terminally ill clients and their families. These programs focus on palliative rather than curative care to help the client and those closest to the client come to terms with the terminal condition and live the remaining life as fully as possible.

When a client selects hospice, he or she waives all Medicaid benefits related to curative care. The client may receive palliative services provided by the desig-nated hospice, the client’s attending physician, or room and board by a nursing facility if the client is a resident. This chapter provides information on covered services supplied by hospice providers. Like all health care services received by Medicaid clients, services provided by hospice providers must also meet the gen-eral requirements listed in the Provider Requirements chapter of the Gengen-eral Infor-mation For Providers manual.

Services provided by the hospice (ARM 37.40.805)

• The hospice must be licensed under state law.

• The hospice must meet Medicare’s conditions of participation and have a

valid provider agreement with Medicare.

• The hospice must provide the Department with a list of physician

volun-teers and physicians employed by the hospice. This list must be kept cur-rent.

• The hospice must notify the Department when the client’s attending

physi-cian is not a hospice employee.

Services provided by physicians (ARM 37.40.801)

Physician services are defined as those services provided by individuals licensed under their state medical practice act to practice medicine or osteopa-thy.

Services provided by contract staff (42 CFR 418.90)

A hospice may use contracted staff to supplement hospice employees during periods of peak client loads or other extraordinary circumstances. The hospice remains responsible for the quality or services provided by contracted staff. Non-covered services

• Medicaid will not pay separately for palliative services. It is the

responsi-bility of the hospice to provide all palliative treatment, which is included in the hospice daily rate.

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2.2 Covered Services

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• Services used for curative care are not covered by the hospice or by

Medic-aid for hospice clients. For example, chemotherapy and radium are not covered for curative purposes but may be provided by the hospice when the purpose is to make the client more comfortable.

• Services provided by a hospice other than the elected hospice are not

cov-ered. However, services provided by a provider (or another hospice) other than the hospice or the client’s attending physician are only covered when the hospice has a contract with the provider.

• Medicaid does not cover physician services provided on a volunteer basis.

Client Enrollment

Hospice services are covered only for Medicaid clients enrolled in the hospice pro-gram. The following are client enrollment policies.

• The Medicaid client must be certified as terminally ill, and certification

must be submitted to Medicaid (see Physician’s certification in following table).

• During the election process, the hospice must explain the benefits the client

will receive and those the client is waiving (see Election statement in fol-lowing table).

• The hospice must establish a plan of care for the client (see Plan of care in

following table).

• A client may receive hospice care until he or she is no longer certified as

terminally ill or until the election of hospice is revoked (see Revocation statement in following table).

• The hospice must obtain certification of the client’s terminal illness for two

consecutive 90-day periods followed by an unlimited number of 60-day periods (see Physician’s certification statement and Physician’s recertifica-tion statement in following table).

• A client may change hospice providers once in each election period. The

client submits a signed statement identifying the current hospice and the newly designated hospice. This statement must give the effective date of change. Both hospices must retain copies of this statement.

• A client may revoke the election of hospice at any time. After revoking

hospice election, the client may receive any Medicaid benefits previously waived when hospice care was chosen.

• A Medicaid client may elect hospice again at any time as long as the client

meets the hospice eligibility requirements.

• A client may live either in his or her home in the community or in a nursing

facility while receiving hospice services.

• Hospice providers must provide their own forms which must meet the

requirements shown in the following table.

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Hospice Form Requirements

See Appendix A For Sample Forms

Form Requirements

Plan of care

• The interdisciplinary group must assess the client’s needs and develop a written plan of care.

• The group member who writes the plan must confer with at least one physician or nurse member of the group while developing the plan.

• The other group members must review the client’s plan of care. • The hospice must provide services in accordance with the plan.

Election statement

• The election statement must include the following: • Name of the hospice that will provide care.

• An acknowledgment that the client understands that hospice provides palliative care, not curative, for the terminal illness.

• An acknowledgment that certain other Medicaid services are being waived when hos-pice is elected.

• The client’s or representative’s signature.

• A representative may be used for a client who is physically or mentally incapacitated. The representative may sign the election statement, sign the waiver of benefits or revo-cation statements, or change hospice providers on behalf of the client.

• The hospice must submit a copy of the election statement(s) to the Department’s Senior and Long Term Care Division (see Key Contacts), and give a copy to the client.

Revocation statement

• The revocation statement must include the following:

• Effective date for the revocation of Medicaid hospice care. • The client’s or representative’s signature.

• The effective date of the revocation must be on or after the date the form is signed. • Copy of form must be mailed to the Department’s Senior and Long Term Care Division

(see Key Contacts) within two business days after hospice receives the statement.

Physician’s certification

statement

• The hospice obtains and documents the certification of terminal illness.

• The certification must be obtained verbally within two calendar days after hospice care is initiated.

• Written certification must be obtained before billing Medicaid for services. Failure to obtain certification in a timely manner may result in the provider repaying the Depart-ment for claims.

• The initial certification is for 90 days.

• The initial certification must be signed by the medical director of the hospice or the phy-sician member of the interdisciplinary group and the client’s attending phyphy-sician, if he or she has one.

Physician’s recertification

statement

• The hospice must obtain a recertification statement stating that the client is terminally ill. • Verbal recertification must be obtained within two calendar days from the beginning of

each subsequent benefit period as defined by Medicare regulations.

• Written certification must be on file before submitting a claim. Failure to obtain recerti-fication in a timely manner may result in the provider repaying the Department for claims.

• The form must be signed by the medical director of the hospice or the physician member of the hospice’s interdisciplinary group or the client’s attending physician, if he or she has one.

• Certification and the first recertification periods are for 90 days and can be followed by an unlimited number of 60-day extensions.

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Coverage of Specific Services

The hospice must provide all services necessary for the palliation or management of the terminal illness and related conditions. Medicaid generally covers services that are covered under Medicare. In cases where Medicaid and Medicare policies are different, Medicaid policy applies. Medicaid also covers non-curative services that are not provided by the designated hospice such as insulin for diabetics. A hospice is required to provide the following services through the hospice or under contract with another provider. All palliative services, including the following, are included in the daily rate.

Counseling services

Counseling services are provided to the client and the family members or oth-ers caring for the client at the client’s home. The hospice will train the client’s family or other caregiver to provide care and to help the client and those caring for the client to adjust to the person’s approaching death. Counseling services also include dietary, spiritual, bereavement, and other counseling. Bereave-ment counseling is provided for up to one year following the client’s death and is available to the client’s family and those close enough to the client to be con-sidered family.

Crisis services

Continuous home care is provided only during a period of crisis. A period of crisis is a period in which a person requires continuous care to achieve pallia-tion or management of acute medical symptoms. Nursing care during a crisis must be provided by a registered nurse or licensed practical nurse. A minimum of eight hours of nursing care must be provided during a 24-hour day, with more than 50% of the care provided by licensed nurses. Home health aide and homemaker services may also be provided to supplement the nursing care dur-ing a period of crisis. The eight hours of nursdur-ing care does not have to be con-tiguous throughout the 24-hour period.

Home health aide services

Home health aides may provide personal care services such as bathing, dress-ing, groomdress-ing, etc. Aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the client, such as changing bed linens or light cleaning and laundering essential to the comfort and cleanliness of the client. Aide services must be provided under the general supervision of a registered nurse. Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the provider to carry out the treatment plan.

When a client is receiving short-term care in a nursing facility during a crisis period, 24-hour nursing services must be provided for the client.

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Inpatient hospice care

Inpatient hospice care is provided when a client’s symptoms become too severe for caregivers to manage at home. Inpatient hospice care includes pro-cedures necessary for pain control or acute or chronic symptoms management. Care must be provided in a Medicaid/Medicare certified hospital or a skilled nursing facility under contract with the hospice.

Inpatient respite care

The hospice may provide inpatient respite care for the client’s family or others caring for the client at home. The facility must also provide treatments, medi-cations, and diet as prescribed. Inpatient respite care must be provided in an inpatient hospice unit or a Medicaid/Medicare certified hospital or nursing facility under contract with the hospice. The hospice is paid for up to five con-secutive days of respite care at a time. Medicaid does not cover respite care when the client lives in a nursing facility.

Medical supplies

Medical appliances, durable medical equipment and supplies including drugs and biologicals, and other self-help and personal comfort items related to the palliation or management of the client’s terminal illness are included in the hospice payment. The hospice must provide these supplies for use in the cli-ent’s home while he or she is receiving hospice care. Medical supplies must be specified in the written plan of care. When a client requires medication that is not related to their terminal condition and not curative (e.g., insulin), it will be covered by the client’s Medicaid pharmacy benefits.

Nursing services

The hospice must employ a registered nurse to coordinate client care so that all the client’s needs are met. During a crisis period (see Definitions), nursing ser-vices must be provided directly to the client by a registered nurse (see Crisis services earlier in this chapter). Inpatient hospice and respite facilities must have a registered nurse available within the facility 24 hours a day.

Physician services

The hospice must employ a physician as the hospice director and/or to provide medical care that is not being met by the client’s attending physician. These services are included in hospice daily rate and are not billed separately.

Services provided by the client’s attending physician are covered when the ser-vices are palliative only and not related to the treatment of the terminal (or related) condition for which the hospice care was elected. For example, a cli-ent who has diabetes may be treated for it by his or her attending physician. All drugs directly related to the terminal condition or for pain are prescribed by the client’s attending physician (or hospice director if the client has no attend-ing physician) and supplied by the hospice. When the client is treated by his or

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her attending physician, the physician bills Medicaid separately from the hos-pice and this fee is not included in the hoshos-pice cap. When billing Medicaid for physician services, refer to the Physician Related Services manual.

Social worker services

Medical social services must be provided by a social worker who has at least a bachelor’s degree from a school accredited or approved by the Council on Social Work Education, and who is working under the direction of a physician. Therapy services

Physical therapy, occupational therapy, and speech/language pathology ser-vices may be provided to maintain activities of daily living and basic func-tional skills.

Other Programs

This is how the information in this manual applies to Department programs other than Medicaid.

Mental Health Services Plan (MHSP)

The information in this manual does not apply to the Mental Health Services Plan (MHSP). Clients who qualify for MHSP may receive mental health ser-vices during hospice care. For more information on the MHSP program, see the Mental Health Manual available on the Provider Information website (see Key Contacts).

Children’s Health Insurance Plan (CHIP)

The information in this manual does not apply to CHIP clients. For a CHIP medical manual, contact BlueCross BlueShield of Montana at (800) 447-7828 x8647. Additional information regarding CHIP is available on the CHIP web-site (see Key Contacts).

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Coordination of Benefits 3.1

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Coordination of Benefits

When Clients Have Other Coverage

Medicaid clients often have coverage through Medicare, workers’ compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers should bill other carriers before billing Medicaid, but there are some exceptions (see Exceptions to Billing Third Party First in this chapter). Medicare is processed differently than other sources of coverage.

Identifying Additional Coverage

The client’s Medicaid eligibility verification may identify other payers such as Medicare or other third party payers (see the General Information For Providers manual, Client Eligibility and Responsibilities). If a client has Medicare, the Medicare ID number is provided. If a client has additional coverage, the carrier is shown. Some examples of third party payers include:

• Private health insurance

• Employment-related health insurance

• Workers’ Compensation Insurance*

• Health insurance from an absent parent

• Automobile insurance*

• Court judgments and settlements*

• Long term care insurance

*These third party payers (and others) may not be listed on the client’s eligibil-ity verification.

Providers should use the same procedures for locating third party sources for Med-icaid clients as for their non-MedMed-icaid clients. Providers cannot refuse service because of a third party payer or potential third party payer.

When a Client Has Medicare

Medicare claims are processed and paid differently than other non-Medicaid claims. The other sources of coverage are called “third party liability”, but Medi-care is not.

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3.2 Coordination of Benefits

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Medicare claims

Medicare Part A covers hospice services. Any claims for services covered by Medicare must be submitted to Medicare before submitting to Medicaid. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider, and the provider can then bill Medicaid.

When the provider knows Medicare will not cover services at a particular time, the claim does not need to be submitted to Medicare first. Providers may sub-mit the claim directly to Medicaid and certify that Medicare is not covering the service by writing “Force Exc. 261 - Hospice Room & Board” in form locator (FL) 84 of the UB-92 claim form. This exact wording must be used and writ-ten in dark ink, or the claim will be denied.

When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Submitting a Claim chap-ter.

When submitting a claim with the Medicare EOMB, use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must also include the Medicaid provider number and Medicaid client ID number.

When a Client Has TPL (ARM 37.85.407)

When a Medicaid client has additional medical coverage (other than Medicare), it is often referred to as third party liability or TPL. In most cases, providers must bill other insurance carriers before billing Medicaid.

Providers are required to notify their clients that any funds the client receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. The following words printed on the client’s statement will ful-fill this obligation, “When services are covered by Medicaid and another source, any payment the client receives from the other source must be turned over to Med-icaid.”

Exceptions to billing third party first

When a Medicaid client is also covered by Indian Health Services (IHS), pro-viders must bill Medicaid first. IHS is not considered a third party liability. If the third party has only potential liability, such as automobile insurance, the provider may bill Medicaid first. Do not indicate the potential third party on the claim. Instead, notify the Department of the potential third party by send-ing notification to the Third Party Liability Unit (see Key Contacts).

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Coordination of Benefits 3.3

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Requesting an Exemption

Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information should be sent directly to the Third Party Liability Unit (see Key Contacts).

• When a provider is unable to obtain a valid assignment of benefits, the

provider should submit the claim with documentation that the provider attempted to obtain assignment and certification that the attempt was unsuccessful.

• When the provider has billed the third party insurance and has received

a non-specific denial (e.g., no client name, date of service, amount billed), submit the claim with a copy of the denial and a letter of expla-nation.

• If another insurance has been billed, and 90 days have passed with no

response, submit the claim with a note explaining that the insurance company has been billed (or a copy of the letter sent to the insurance company). Include the date the claim was submitted to the insurance company and certification that there has been no response.

When the Third Party Pays or Denies a Service

When a third party payer is involved (excluding Medicare) and the other payer:

• Pays the claim, indicate the amount paid when submitting the claim to

Medicaid for processing.

• Allows the claim, and the allowed amount went toward client’s

deduct-ible, include the insurance Explanation of Benefits (EOB) when billing Medicaid.

• Denies the claim, submit the claim and a copy of the denial (including

the reason explanation) to Medicaid.

• Denies a line on the claim, bill the denied lines together on a separate

claim and submit to Medicaid. Include the explanation of benefits (EOB) from the other payer as well as an explanation of the reason for denial (e.g., definition of denial codes).

When the Third Party Does Not Respond

If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows:

• Submit the claim and a note explaining that the insurance company has

been billed (or a copy of the letter sent to the insurance company).

• Include the date the claim was submitted to the insurance company.

• Send this information to the ACS Third Party Liability Unit (see Key

Contacts).

If the provider receives a payment from a third party after the Depart-ment has paid the provider, the provider must return the lower of the two pay-ments to the Department within 60 days.

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3.4 Coordination of Benefits

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Billing Procedures 4.1

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Billing Procedures

Claim Forms

Services provided by the health care professionals covered in this manual must be billed either electronically or on a UB-92 claim form. UB-92 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

Timely Filing Limits (ARM 37.85.406)

Providers must submit clean claims to Medicaid within the latest of:

• Twelve months from whichever is later:

• the date of service

• the date retroactive eligibility or disability is determined

• Medicare Claims: Six months from the date on the Medicare explanation

of benefits approving the service (if the Medicare claim was timely filed and the client was eligible for Medicare at the time the Medicare claim was filed).

• Claims involving other third party payers (excluding Medicare): Six

months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.

Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12 month period.

Tips to avoid timely filing denials

• Correct and resubmit denied claims promptly (see the Remittance Advices

and Adjustments chapter in this manual).

• If a claim submitted to Medicaid does not appear on the remittance advice

within 30 days, contact Provider Relations for claim status (see Key Con-tacts).

• If another insurer has been billed and 90 days have passed with no

response, you can bill Medicaid (see the Coordination of Benefits chapter in this manual for more information).

• To meet timely filing requirements for Medicare/Medicaid crossover

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4.2 Billing Procedures

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When To Bill Medicaid Clients (ARM 37.85.406)

In most circumstances, providers may not bill Medicaid clients for services cov-ered under Medicaid.

More specifically, providers cannot bill clients directly:

• For the difference between charges and the amount Medicaid paid.

• When the provider bills Medicaid for a covered service, and Medicaid

denies the claim because of billing errors.

• When a third-party payer does not respond.

• When services are provided by a hospice volunteer physician. Medicaid

may not be billed for those services either.

Client Cost Sharing

Hospice clients are exempt from Medicaid cost sharing. Providers may not charge for cost sharing on any services provided to the hospice client.

When Clients Have Other Insurance

If a Medicaid client is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the client’s health care, see the Coor-dination of Benefits chapter in this manual.

Billing for Retroactively Eligible Clients

When a client becomes retroactively eligible for Medicaid, the provider has 12 months from the date retroactive eligibility was determined to bill for those ser-vices. When submitting claims for retroactively eligible clients, attach a copy of the FA-455 (Eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. For more infor-mation on retroactive eligibility, see the Client Eligibility and Responsibilities chapter in the General Information For Providers manual.

Using the Medicaid Fee Schedule

When billing Medicaid, it is important to use the Department’s fee schedule for your provider type. The hospice fee schedule is updated each October. Current fee schedules are available on the Provider Information web site (see Key Con-tacts). For disk or hardcopy, contact Provider Relations (see Key ConCon-tacts).

Coding

Hospice services are billed with five revenue codes and various ICD-9-CM diag-nosis codes. The following suggestions may help reduce coding errors and unnec-essary claim denials:

If a provider bills Medicaid and the claim is denied because the client is not eligible, the provider may bill the client directly.

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• Use current ICD-9-CM coding books.

• Always read the complete description and guidelines in the coding books.

Relying on short descriptions can result in inappropriate billing.

• Attend classes on coding offered by certified coding specialists.

Billing For Hospice Services

Medicaid pays the hospice for each day a client is under hospice care. The pay-ment amounts, limits, and cap amounts are the same as in the Medicare program. The daily rate paid to hospices covers all services normally paid for by Medicare. Rates are set for routine home care, inpatient respite care, general in inpatient care, and continuous home care. Providers must bill for only one of these four fixed daily rates established by Medicare that include all services except for certain phy-sician services and room and board for clients living in a long-term care facility. Please refer to the hospice fee schedule located on the Provider Information web site or available from Provider Relations (see Key Contacts).

Routine home care day

This is a day in which the client is at home and is not receiving continuous home care during a crisis and is billed per day.

Continuous home care

This is a day in which the client receives nursing services, home health, or homemaker services on a continuous basis during a period of crisis (see Defini-tions). The hospice must provide at least eight hours of nursing care per 24 hour period, which does not have to be continuous. Continuous care is billed using the hourly rate for the hours of service provided.

Inpatient respite day

This is a day in which the client receives inpatient care for respite. The hospice can bill for up to five consecutive days beginning with the day of admission, but excluding the day of discharge. Any respite care days beyond the five con-secutive covered days must be billed as routine home care days.

General inpatient day

This is a day in which the client receives general inpatient care in a hospital for control of pain or management of acute or chronic symptoms that can’t be managed in the home. The hospice may bill for the date of admission, but not the date of discharge unless the client is discharged deceased.

Always refer to the long descriptions in coding books.

The Depart-ment will not pay a hospice for inpatient days (general and respite) that exceed 20% of the total hospice care days provided to a client.

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Board and room for nursing facility residents

For clients who reside in a nursing facility, the payment rate of the hospice board and room in a nursing facility is the Medicaid rate for that facility, less the client’s personal resources applied to the cost of the room and board (and applicable disregards) as determined by the local Office of Public Assistance. This payment replaces the regular Medicaid payment for long-term care while the person receives hospice care. The hospice must instruct the nursing facility to bill the hospice rather than Medicaid. The hospice bills Medicaid and pays the nursing facility for these services.

Billing For Physician Services

The client’s attending physician, whether employed by the hospice or not, may be paid separately. These payment amounts are not included in the hospice cap amount. Payment for these services is the Medicaid rate for physician services. Physicians must use the Physician Related Services manual when billing Medic-aid. Manuals are available on the Provider Information web site or from Provider Relations (see Key Contacts).

Hospice Cap

The hospice may be paid for up to the current established Medicare cap amount on hospice care for a client. Hospice physician services are included in the cap amount. Room and board payments to a long-term care facility and certain pay-ments to the client’s attending physician (according to Medicare criteria) are not considered when the cap amount is calculated.

The Most Common Billing Errors and How to Avoid Them

Paper claims are often returned to the provider before they can be processed, and many others are denied. To avoid returns and denials, double check each claim form to confirm the following items are included and accurate.

Common Billing Errors

Reasons for Return How to Prevent Returned Claims

Medicaid provider number missing or invalid The provider number is a 7-digit number assigned to the pro-vider during Medicaid enrollment. Verify the correct

Medic-aid provider number is on the billing form.

Authorized signature missing Each claim form must have an authorized signature belong-ing to the provider, billbelong-ing clerks, or office personnel. The signature may be typed, stamped, computer generated, or hand-written.

Signature date missing Each form must have a signature date.

Incorrect claim form used Hospice services are billed either electronically or on a UB-92 claim form.

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Common Billing Errors (continued)

Reasons for Return How to Prevent Returned Claims

Information on claim form not legible Information on the claim form should be legible. Use dark ink and center the information in the field – information should not be obscured by lines.

Recipient number not on file, or recipient was not eligible on date of service

Before providing services to the client, verify client eligibility by using one of the methods described in the General

Infor-mation For Providers manual, Client Eligibility and Respon-sibilities chapter.

Duplicate claim • Please check all remittance advices for previously submit-ted claims before resubmitting.

• When making changes to previously paid claims, submit an adjustment form rather than a new claim form (see

Remit-tance Advices and Adjustments).

TPL on file and no credit amount on claim • If the client has any other insurance (or Medicare), bill the other carrier before Medicaid, or the claim must be certified by the provider (see the Coordination of Benefits chapter in this manual).

• If the client’s TPL coverage has changed, providers must notify the TPL unit (see Key Contacts) before submitting a claim.

Claim past 365-day filing limit • The Claims Processing Unit must receive all clean claims and adjustments within the timely filing limits described in the Billing Procedures chapter.

• To ensure timely processing, paper claims and adjustments should be mailed to Claims Processing at the address shown in Key Contacts.

Missing Medicare EOMB When Medicare is involved in payment on a claim, it must have an EOMB attached or be certified by the provider (see the Coordination of Benefits chapter in this manual). Provider is not eligible during dates of services, or

pro-vider number terminated

• Out-of-state providers must update enrollment early to avoid denials. If enrollment has lapsed, claims submitted with a date of service after the expiration date will be denied.

• New providers cannot bill for services provided before Medicaid enrollment begins.

• If a provider requests to be terminated from the Medicaid program, claims submitted with a date of service after the termination date will be denied.

Type of service/procedure is not allowed for provider type • Provider is not allowed to perform the service, or type of service is invalid.

• Check the Medicaid fee schedule to verify the procedure code is valid for your provider type.

Date of service later than date of death • Check that both the correct dates of service and number of days were billed

Line level date of service missing The date of service must be recorded in FL45 and must fall within the Statement covers period shown in FL6.

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Submitting a Claim

Electronic Claims

Professional and institutional claims submitted electronically are referred to as ANSI ASC X12N 837 transactions. Providers who submit claims electronically experience fewer errors and quicker payment. Claims may be submitted electroni-cally by the following methods:

• ACS field software WINASAP 2003. ACS makes available this free

software, which providers can use to create and submit claims to Mon-tana Medicaid, MHSP, and CHIP (dental and eyeglasses only). It does not support submissions to Medicare or other payers. This software creates an 837 transaction, but does not accept an 835 (electronic RA) transaction back from the Department. The software can be down-loaded directly from the ACS EDI Gateway website. For more infor-mation on WINASAP 2003, visit the ACS EDI Gateway website, or call the number listed in the Key Contacts section of this manual.

• ACS clearinghouse. Providers can send claims to the ACS

clearing-house (ACS EDI Gateway) in X12 837 format using a dial-up connec-tion. Electronic submitters are required to certify their 837 transactions as HIPAA-compliant before sending their transactions through the ACS clearinghouse. EDIFECS certifies the 837 HIPAA transactions at no cost to the provider. EDIFECS certification is completed through ACS EDI Gateway. For more information on using the ACS clearinghouse, contact ACS EDI Gateway (see Key Contacts).

• Clearinghouse. Providers can contract with a clearinghouse so that the

provider can send the claim to the clearinghouse in whatever format the clearinghouse accepts. The provider’s clearinghouse then sends the claim to the ACS clearinghouse in the X12 837 format. The provider’s clearinghouse also needs to have their 837 transactions certified through EDIFECS before submitting claims to the ACS clearinghouse. EDIFECS certification is completed through ACS EDI Gateway. Providers should be familiar with the Implementation Guides that describe federal rules and regulations and provide instructions on preparing electronic transactions. These guides are available from the Washington Publishing Company (see Key Contacts). Companion Guides are used in conjunction with Implementation Guides and provide Montana-specific information for sending and receiving elec-tronic transactions. They are available on the ACS EDI Gateway website (see Key Contacts).

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5.2 Submitting a Claim

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Billing Electronically with Paper Attachments

When submitting electronic claims that require additional supporting documenta-tion, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider’s Medicaid ID number followed by the client’s ID number and the date of service, each separated by a dash:

9999999 - 888888888 - 11182003

The supporting documentation must be submitted with a paperwork attachment cover sheet (located on the Provider Information website and in Appendix A). The number in the paper Attachment Control Number field must match the number on the cover sheet. For more information on attachment control numbers and submit-ting electronic claims, see the Companion Guides located on the ACS EDI website (see Key Contacts).

Paper Claims

The services described in this manual are billed on UB-92 claim forms. Claims submitted with all of the necessary information are referred to as “clean” and are usually paid in a timely manner (see the Billing Procedures chapter in this man-ual).

When completing a claim, remember the following:

• Please use this information together with the UB-92 Reference Manual.

• All form locators shown in this chapter are required.

• Providers bill Medicaid for hospice services using the following revenue

codes:

Revenue Codes

Code Description

651 Routine Home Care 652 Continuous Home Care 655 Inpatient Respite Care 656 General Inpatient Care 659 Nursing Facility Rate

(Hos-pice Room and Board) Medicaid Provider ID Client ID Number Date of Service (mmddyyyy)

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Completing a UB-92 Claim Form

These two fields are required when billing for a client who receives hospice services in a nursing facility.

FL Form Locator Title Instructions

1-2 Unlabeled fields Enter the hospice agency name, address, and phone number

4 Type of Bill Use 81X for non-hospital based and 82X for hospital based hospice services. Only values of 81X and 82 X will be accepted. For more information, see the UB-92 Reference manual.

6 Statement covers period Enter the beginning and ending dates of service.

12 Patient Name Medicaid client’s last name, first name, and middle initial

22 Patient Status If the client has been discharged to an inpatient care facility, enter “04”, other-wise leave blank.

42 Revenue Codes Enter the appropriate revenue code (see Revenue Code table on the previous page).

43 Description Revenue code description (see Revenue Code table on the previous page) 45 Serv. Date Date of service (must be within Statement covers period shown in FL6) 46 Serv. Units Number of services (or days)

47 Total Charges Enter the sum of all charges for this service.

50* Payer When a client receives hospice care in a nursing facility, enter the client’s name. 51 Provider Number Hospice provider’s seven-digit Medicaid ID number

54* Prior Payments When a client receives hospice care in a nursing facility, enter the clients per-sonal resources.

60 Cert. - SSN - HIC - ID. No. Enter the client’s Medicaid ID number as it appears on the client’s ID card. It is nine digits long and is usually the client’s social security number.

67-75 Principal Diagnosis Code Record the appropriate ICD-9-CM diagnosis code. At least one code is required for payment, and additional codes may be reported in FL 68 - 75.

82 Attending Physician ID Enter the name and license number (or UPIN number) of the attending physi-cian.

84 Remarks When the client has Medicare and Medicaid, and Medicare denied the claim, enter “Force Exc. 261 - Hospice Room & Board”. This statement must be written in FL 84 exactly as shown here, or the claim will be denied.

85 Provider Representative The signature of the individual authorized to represent the hospice, which may be hand-written, typed, stamped, or computer generated.

86 Date Enter the billing or signature date in MMDDYY format. This date must be on or after the last date of service reported in FL 6 of the claim, or it will be denied.

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A

B

○ ○ ○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○ ○ ○○○○○○

5 FED. TAX NO. 6 STATEMENT COVERS PERIOD 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 12 PATIENT NAME 13 PATIENT ADDRESS

14 BIRTHDATE 15 SEX 16 MS

42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE52 REL 53 ASG

58 INSURED’S NAME 59 P. REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO.

OF BILL

1

17 DATE ADMISSION18 HR 19 TYPE 20 SRC21 D HR 22 STAT 23 MEDICAL RECORD NO.

CONDITION CODES

FROM THROUGH

32 OCCURRENCE

CODE DATE 33 OCCURRENCECODE DATE 34 OCCURRENCECODE DATE 35 OCCURRENCECODE DATE 36 OCCURRENCE SPANCODE FROM THROUGH

39 VALUE CODES

CODE AMOUNT 40 VALUE CODESCODE AMOUNT

41 VALUE CODES CODE AMOUNT ○○○○○○ ○○○ ○○○○○○ ○ ○ ○ INFO BEN A B C 37 31 11 a b 38 ST11843 1PL Y UB-92 A B C 24 25 26 27 28 29 30 a b c d a b c d

DUE FROM PATIENT

56

57

63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION

76 ADM. DIAG. CD. 77 E-CODE 78

A B C A B C

OTHER DIAG. CODES

A B C A B C

80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE

79 P.C.

CODE DATE CODE DATE CODE DATE

84 REMARKS

OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE CODE DATE CODE DATE CODE DATE

82 ATTENDING PHYS. ID 83 OTHER PHYS. ID

OTHER PHYS. ID

85 PROVIDER REPRESENTATIVE 86 DATE

I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. UB-92 HCFA-1450 OCR/ORIGINAL

a b c d a b a b

x

A B C D E A B C

68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE

67 PRIN. DIAG. CD. 2 3 4 8 9 6 11 12 13 14 16 17 19 20 21 22 23 1 2 3 4 5 8 9 6 7 12 13 14 15 16 17 18 19 20 21 22 23 11 10 1 5 7 10 18 15

Hospice Care Center 123 Medical Drive Anytown, MT 59999

(406) 555-5555

81X

Rose Floweree

651 Routine Home Care 652 Continuous Home Care

15 8 1,725 00 224 00 9999999 99999999 154.1 D99999 03/01/04 1,949 00 02/01/04 02/29/04 02/15/04 02/29/04

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Mailing Paper Claims

Unless otherwise stated, all paper claims are mailed to: Claims Processing

P.O. Box 8000 Helena, MT 59604

All Medicaid claims must be submitted on Department approved claim forms. UB-92 forms are available through various publishing companies; they are not available from the Department or Provider Relations. A Medicaid Form Order sheet is available under the Forms section of the Provider Information website.

Claim Inquiries

Claim inquiries can be obtained electronically through ANSI ASC X12N 276/277 transactions or by contacting Provider Relations. See the Companion Guides located on the ACS EDI Gateway website for more information on electronic transactions (see Key Contacts). Providers may contact Provider Relations for questions regarding payments, denials, and other claim questions (see Key Con-tacts).

If you prefer to communicate with Provider Relations in writing, use the Montana Medicaid Claim Inquiry form in Appendix A. Complete the top portion of the form with the provider’s name and address.

Provider Relations will respond to the inquiry within 7 to 10 days. The response includes the status of the claim: paid (date paid), denied (date denied), or in pro-cess. Denied claims will include an explanation of the denial and steps to follow for payment (if the claim is payable).

Avoiding Claim Errors

Claims are often denied or even returned to the provider before they can be pro-cessed. To avoid denials and returns, double check each claim form to confirm the following items are accurate. For more information on returned and denied claims, see the Billing Procedures chapter in this manual.

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Common Claim Errors

Claim Error Prevention

Required field is blank All fields shown in the Completing a UB-92 Claim Form section in this chapter must be complete. If any of these fields are blank, the claim may either be returned or denied.

Client ID number missing or invalid This is a required field (FL60); verify that the client’s Medicaid ID number is listed as it appears on the client’s ID card. Client name missing This is a required field (FL12); check that it is correct. Medicaid provider number missing or invalid The provider number is a 7-digit number assigned to the

provider during Medicaid enrollment. Verify the correct

Medicaid provider number is on the claim (FL51).

Authorized signature missing Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signa-ture may be typed, stamped, computer generated, or hand-written.

Signature date missing Each claim must have a signature date.

Incorrect claim form used When billing on paper, services covered in this manual require a UB-92 claim form.

Information on claim form not legible Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.

Missing Medicare EOMB When Medicare is involved in payment on a claim, it must have an EOMB attached or be certified by the provider (see the Coordination of Benefits chapter in this manual). Line level date of service missing The date of service must be recorded in FL45 and must fall

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Remittance Advices and Adjustments 6.1

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Remittance Advices

and Adjustments

The Remittance Advice

The Remittance Advice (RA) is the best tool providers have to determine the status of a claim. RAs accompany payment for services rendered. The RA provides details of all transactions that have occurred during the previous RA cycle. Pro-viders may select a one or two week payment cycle (see Payment and the RA in this chapter). Each line of the RA represents all or part of a claim, and explains whether the claim or line has been paid, denied, or suspended (also referred to as pending). If the claim was suspended or denied, the RA also shows the reason.

Electronic RA

Providers may receive the RA electronically as an ANSI ASC X12N 835 trans-action, or through the Internet on the Montana Eligibility and Payment System (MEPS). For more information on 835 transactions, see the Companion Guides available on the ACS EDI Gateway website and the Implementation Guides on the Washington Publishing Company website (see Key Contacts). MEPS is available through the Virtual Human Services Pavilion (see Key Con-tacts). In order to access MEPS, you must complete an Access Request Form. After this form has been processed, you will receive a password. Entry into the system requires a valid provider or group number and password. Each pro-vider or group number requires a unique password, so propro-viders must complete a separate request form for each provider or group.

RAs are available from MEPS in PDF and a flat file format. You can read, print, or download PDF files using Adobe Acrobat Reader, which is available on the “SOR Download” page. The file layout for flat files is also available on the SOR download page. Due to space limitations, each RA is only available for six weeks. For more information on MEPS, see Payment and the RA later in this chapter.

Paper RA

The paper RA is divided into the following sections: RA notice, paid claims, denied claims, pending claims, credit balance claims, gross adjustments, and reason and remark codes and descriptions. See the following sample paper RA and the Keys to the Paper RA table.

If a claim was denied, read the reason and remark code description before taking The pending claims section of the RA is informational only. Do not take any action on claims shown here. any action on the claim. Electronic RAs are available for only six weeks on MEPS.

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Sections of the Paper RA

Section Description

RA notice The RA Notice is on the first page of the remittance advice. This section contains important messages about rate changes, revised billing procedures, and many other items that may affect providers and claims.

Paid claims

This section shows claims paid and any claims paid with denied lines during the previ-ous cycle. It is the provider’s responsibility to verify that claims were paid correctly. If Medicaid overpays a claim and the problem is not corrected, it may result in an audit requiring the provider to return the overpayment plus interest. If a claim was paid at the wrong amount or with incorrect information, the claim must be adjusted (see

Adjustments later in this chapter).

Denied claims

This section shows claims denied during the previous cycle. If a claim has been denied, refer to the Reason/Remark column (Field 16). The reason and remark code description explains why the claim was denied and is located at the end of the RA. See

The Most Common Billing Errors and How to Avoid Them in the Billing Procedures

chapter.

Pending claims

All claims that have not reached final disposition will appear in this area of the RA. The RA uses “suspended” and “pending” interchangeably. They both mean that the claim has not reached final disposition. If a claim is pending, refer to the Reason/ Remark Code column (Field 16). The reason and remark code description located at the end of the RA will explain why the claim is suspended. This section is informa-tional only. Please do not take any action on claims displayed here. Processing will continue until each claim is paid or denied.

Claims shown as pending with reason code 133 require additional review before a deci-sion to pay or deny is made. If a claim is being held while waiting for client eligibility information, it may be suspended for a maximum of 30 days. If Medicaid receives eli-gibility information within the 30-day period, the claim will continue processing. If no eligibility information is received within 30 days, the claim will be denied. When a claim is denied for lack of eligibility, the provider should verify that the correct Medic-aid ID number was billed. If the ID number was incorrect, resubmit the claim with the correct ID number.

Credit balance claims

Credit balance claims are shown here until the credit has been satisfied.

Gross adjustments

Any gross adjustments performed during the previous cycle are shown here.

Reason and Remark Code Description

This section lists the reason and remark codes that appear throughout the RA with a brief description of each.