2009 Long Term Care User Manual. for Paper Submitters

Transcription

1 2009 Long Term Care User Manual for Paper Submitters

2 Dear Long Term Care Provider, Welcome to the 2009 Long Term Care User Manual for Paper Submitters. This user manual is published for Long Term Care (LTC) providers who use the LTC Claim Form 1290 to submit paper claims. It provides detailed instructions that must be used as a resource for completing the Form This manual is sent to providers by the Texas Medicaid & Healthcare Partnership (TMHP). TMHP is the claims administrator for the Texas Health and Human Services Commission (HHSC), including the Department of Aging and Disability Services (DADS). Under the state claims administrator contract, TMHP operates the Claims Management System (CMS). CMS is used for LTC claims processing in partnership with DADS. CMS is a comprehensive, user-friendly claims processing system for the LTC provider community that supports both electronic and paper submissions. For questions about CMS, billing, electronic enrollment, or the user manual, call the TMHP Call Center/Help Desk at The Texas Department of Aging and Disability Services and the Texas Medicaid & Healthcare Partnership appreciate your continued support. Sincerely, Gordon Taylor, Chief Financial Officer Texas Department of Aging and Disability Services

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4 1Contents Chapter 1: Introduction to Claims Management System Claims Management System Overview Provider Support TexMedConnect Advantages of Using TexMedConnect TexMedConnect Requirements Enrollment for Electronic Submission Chapter 2: LTC Claim Form 1290 Type of Claims Paper Claims Process Submission Guidelines Form Retention Detailed Claims Filing Instructions Claims Using the LTC Bill Code Crosswalk Required Information Section A Header Information Section B Complete for Nurse Aide Training (NAT) Only Section C Line Item Information Line Item Adjustments Form Chapter 3: Remittance and Status (R&S) Report R&S Report Overview PDF R&S Report ANSI 835 R&S Report (only for providers billing ANSI claims) Claim Data Export R&S Report Distribution R&S Report Section Descriptions Title Page Non-Pending Claims Pending Claims Financial Summary EOB Codes R&S Report Examples Title Page R&S Non-Pending Claims R&S Financial Summary R&S EOB Page R&S Appendix A: Commonly Asked Questions Appendix B: LTC Bill Code Crosswalk Appendix C: Service Groups Appendix D: Service Codes Appendix E: Modifiers Appendix F: Tooth Identification (TID) Appendix G: Explanation of Benefits Appendix : Glossary CPT only copyright 2008 American Medical Association. All rights reserved.

5 Copyright Acknowledgements Use of the AMA s copyrighted CPT is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply. Microsoft Corporation requires the following notice in publications containing trademarked product names: Microsoft and Windows are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. 2 CPT only copyright 2008 American Medical Association. All rights reserved.

6 1Introduction to Claims Management System Chapter 1 In this chapter Claims Management System Overview Provider Support Advantages of Using TexMedConnect TexMedConnect Requirements Enrollment for Electronic Submission Claims Management System Overview The Claims Management System (CMS) provides a comprehensive, user-friendly claims processing system for the Long Term Care (LTC) provider community. This system supports electronic and paper submissions. Most providers may exchange information electronically through a Windows -based software application called TexMedConnect or develop third-party software that meets CMS requirements. TexMedConnect is the software used by acute care and most LTC providers to connect to the Texas Medicaid & Healthcare Partnership (TMHP) Electronic Data Interchange (EDI) Gateway system. TexMedConnect enables agencies to bill more efficiently when providing services to acute care and LTC individuals. CMS streamlines claims processing for most programs under the Texas Department of Aging and Disability Services (DADS). The goals of CMS are to: Present an accurate way to reimburse provided services. Eliminate duplicate functions. Provide flexibility for future modifications. Improve community relations with providers. Lower administrative costs associated with processing claims. Have a common payment and tracking system. While claims are processed and managed through a single system, specific program policies are accommodated. Providers of the following services use CMS for reimbursement: Adult Foster Care (AFC) Assisted Living/Residential Care Services (AL/RC) Consumer Managed Personal Attendant Services (CMPAS) Community-Based Alternatives (CBA) Community Living Assistance and Support Services (CLASS) Consolidated Waiver Program (CWP) Day Activity and Health Services (DAHS) Deaf/Blind Multiple Disabilities Program (DB-MD Waiver) Extended Care Facility (also known as Swing Beds) CPT only copyright 2008 American Medical Association. All rights reserved.

7 Chapter 1 Emergency Response Service (ERS) Home-Delivered Meals (HDM) Hospice Intermediate Care Facilities for Persons with Mental Retardation (ICF-MR) Medically Dependent Children Program (MDCP) Nurse Aide Training (NAT) Nursing Facilities (NF) Primary Home Care/Family Care/Community Attendant (PHC/FC/CA) Program of All-Inclusive Care for the Elderly (PACE) Rehabilitative Services/Specialized Services Respite Care Special Services to Persons with Disabilities (SSPD) Special Services to Persons with Disabilities-24 hours (SSPD-24) Transitional Assistance Services (TAS) These providers may submit claims using Form 1290, TexMedConnect, or third-party software. Upon receipt of a claim, CMS edits check the validity of the information on the claim and compliance with the business rules for the service/program billed. Claims that do not meet necessary requirements are rejected or denied. The Remittance and Status (R&S) Report notifies providers that a claim is paid, denied, or in process. If a claim is rejected, the claim is not shown on the R&S Report. The provider is notified through a claim response. Only electronic claims reject. CMS calculates the payment amount and applicable reductions for claims approved for payment. Reductions can be due to money owed to the state by the provider, retroactive adjustments, change in rates, individual and provider eligibility, or service authorization changes. CMS totals all payments, less the reductions, and if the payable amount is greater than zero, sends the information to DADS accounting for further processing. Provider Support TMHP operates a Call Center/Help Desk that provides billing and payment support to providers billing through TMHP. The TMHP Call Center/Help Desk operates Monday through Friday, 7 a.m. to 7 p.m., Central Time (excluding TMHP-recognized holidays). Providers should have their nine-digit LTC Provider/Contract number ready when they call the TMHP Call Center/Help Desk. They will be prompted to enter the LTC Provider/Contract number using the telephone keypad. Providers who use a rotary telephone can remain on the line for assistance. The TMHP Call Center/Help Desk system uses the LTC Provider/Contract number to automatically populate the call center representative s screen with the provider s specific information, such as name and telephone number. Providers should have their four-digit Vendor/Facility or Site ID number available for calls about Minimum Data Set (MDS), Medical Necessity and Level of Care Assessment (MN and LOC), Preadmission Screening and Resident Review (PASARR) instrument, Forms 3618, 3619, 3071, 3074, and through August 31, 2009, the CARE Form 3652-A Purpose Code E. Providers must have a Medicaid or Social Security number and a medical chart or documentation for inquiries about a specific individual. Providers can contact the TMHP Call Center/Help Desk at: Long Term Care (outside of Austin): or Long Term Care (Austin local): CPT only copyright 2008 American Medical Association. All rights reserved.

8 Introduction to Claims Management System Refer to the following table for a list of telephone options and definitions: For questions about General inquiries Using TexMedConnect Completing Claim Form 1290 Claim adjustments Claim status inquiries Claim history CARE Form 3652-A Purpose Code E Claim rejection and denials Understanding R&S Reports Minimum Data Set Medical Necessity and Level of Care Assessment PASARR Instrument Forms 3618 or 3619 Texas Index for Level of Effort (TILE) levels Choose Option 1: Customer service/ general inquiry 1 Medical necessity Option 2: To speak with a nurse TexMedConnect Technical issues, obtaining access, user IDs, and passwords Modem and telecommunication issues American National Standards Institute (ANSI) ASC X12 specifications, testing, and transmission Electronic transmission of Forms 3618 and 3619 Electronic transmission of Forms 3071 and 3074 Electronic transmission of Medical Necessity and Level of Care Assessment Electronic transmission PASARR Instrument Weekly status reports Processing provider agreements Verifying that system screens are functioning Getting EDI assistance from software developers EDI and connectivity Minimum Data Set submission problems Technical issues Transmitting forms Interpreting Quality Indicator (QI) Reports Option 3: Technical support Option 3: Technical support New messages (banner) in audio format for paper submitters Option 4: Headlines/topics for paper submitters Individual appeals Individual fair hearing requests Appeal guidelines Option 5: Request fair hearing Replay for menu options Option 6: Replay options The following is additional information about menu options. Option 1. Provider claims, MDS, MN and LOC, PASARR, Form 3618, Form 3619, and CARE Form 3652-A Purpose Code E. This option gives providers: Assistance on how to complete Form The status of a claim or an MDS, MN and LOC, and PASARR. Information about an individual s eligibility. CPT only copyright 2008 American Medical Association. All rights reserved. 1 3

9 Chapter 1 Assistance with how to read an R&S Report. Assistance with how to read the Weekly Status Report. Assistance with how to download the Electronic R&S (ER&S) Report. Option 2. To speak with a nurse. This option allows providers to: Speak with a nurse about a pending or denied MDS, MN and LOC assessment, or PASARR Instrument. Provide additional or missing information to a nurse for an MDS, MN and LOC assessment, or PASARR instrument. Option 3. Technical support. This option provides information about: TexMedConnect, MDS, and ANSI specifications. Submitter IDs and passwords. How to obtain an application for TexMedConnect, ER&S, or the LTC Online Portal. How to request an ER&S Report (within the 30-day period). How to correct MDS error messages. How to run MDS Validation and Quality Indicator reports. Option 4. Audio messages for paper submitters. This option allows providers to listen to recorded messages about headlines/topics and news (banner) information. Option 5. Fair Hearings. This option allows a fair hearing to be requested for denied medical necessity for a nursing facility resident. Option 6. To replay menu options. TexMedConnect TexMedConnect is a standalone, web-based application that can be accessed online at Providers must have both a contract number and a National Provider Identifier (NPI) to use TexMedConnect. Advantages of Using TexMedConnect The advantages of using TexMedConnect are: TexMedConnect is free of charge. No service packs are required. It can be used by anyone with a computer and internet access. Providers can receive payment within five to seven business days after the claim reaches approve-to-pay status. The billing cycle is more closely related to business needs. Time delays due to mailing are avoided. Advantages of processing claims and adjustments electronically: Users can submit a batch of claims or adjustments and receive a response (usually within 24 hours). Users receive a response within one minute after submission of an interactive claim. (Interactive is not available for adjustments.) Users receive a response electronically when a claim or an adjustment has errors and needs to be corrected and resubmitted (avoid waiting for the next billing cycle to receive payment by correcting and resubmitting rejected claims). Benefits of using the claim status inquiry function: Electronically track accepted claims from the day of submission to the date of payment. Electronically request individual payment history information. 1 4 CPT only copyright 2008 American Medical Association. All rights reserved.

10 Introduction to Claims Management System Advantages of ER&S Reports: Electronically access claim information by individual, provider, or claim. Facilitate timely reconciliation of claim information. Verify claim information for an individual for a requested period. 1 TexMedConnect Requirements Internet service provider (ISP) One of the following web browsers: Microsoft Internet Explorer Netscape Navigator A broadband connection is recommended but not required. Enrollment for Electronic Submission Providers interested in utilizing electronic submission should contact the TMHP Call Center/Help Desk at , Option 3, or refer to How do providers enroll in electronic billing? in Appendix A, Commonly Asked Questions on page A-1 for procedures on how to enroll. CPT only copyright 2008 American Medical Association. All rights reserved. 1 5

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12 2LTC Claim Form 1290 Chapter 2 In this chapter Type of Claims Paper Claims Process Submission Guidelines Detailed Claims Filing Instructions Using the LTC Bill Code Crosswalk Type of Claims Note: Providers may submit the following types of claims on the Form 1290: New Dental Nurse Aide Training (NAT) Adjustments Expedited Form 1290 only allows billing for one individual per claim. For example, if providers bill for 25 individuals, 25 individual forms must be completed, one for each individual. A single claim form may contain up to 17 line items for one individual. Paper Claims Process The following is a brief summary of the TMHP paper claims process: 1) Receive claim 2) Sort claim 3) Image (take a picture of) claim for tracking and archiving purposes 4) Enter claims data into the Claims Management System (CMS) Information is entered into CMS exactly as it appears on the claim form. No editing or correcting is performed. After the claim data is entered into CMS, the system checks the claim for validity and acceptance requirements. TMHP approves, denies, or suspends the claim according to business requirements. Once the claim is received by TMHP, the normal processing time averages seven to ten business days. The amount of time may be impacted by: Suspension, awaiting manual or system review Provider on hold Ineligible data Form filled out incorrectly or information missing CPT only copyright 2008 American Medical Association. All rights reserved.

13 Chapter 2 Submission Guidelines Submit claims for processing using one Form 1290 for each individual. Providers may submit more than one Form 1290 in the same mailing envelope. The claim forms should not be stapled together. No attachments should be submitted with the claim. TMHP sorts and images all claims submitted on Form 1290 before entering the claims into CMS. To ensure quality imaging, TMHP recommends using only black ink. Printing the completed claim using computer software or a typewriter is preferred. Providers will receive information about finalized claims on the Remittance and Status (R&S) Report. The R&S Report is mailed weekly. Refer to Chapter 3, Remittance and Status (R&S) Report on page 3-1. Providers should use the following guidelines when completing the Form 1290: Print legibly. Do not write in cursive. If data is typed, use a font large enough to distinguish between characters. Complete all required fields. Use the most current LTC Bill Code Crosswalk. Review the form for accuracy before submitting. Sign each form: An original signature is required on each form. Copied or stamped signatures are not accepted. Mail the Form 1290 to the following address: Texas Medicaid & Healthcare Partnership Attention: Long Term Care PO Box Austin, TX Note: Delivery to TMHP could take five business days. Allow ten business days for the claim to appear in the system. Send overnight mail to: Texas Medicaid & Healthcare Partnership Attention: Long Term Care, MC-B B Riata Trace Parkway Austin, TX Important: To avoid processing delays when sending overnight mail, the address on the envelope should include Attention: Long Term Care, MC-B02. Delivery to TMHP could take an additional day, depending on the time of day the claim is mailed. Allow three days for the overnighted claim to appear in the system. When calling to check the status of the claim, the overnight mail tracking number must be provided. For assistance completing the Form 1290, contact the TMHP Call Center/Help Desk at or (Austin), and choose Option 1. Note: Providers initially receive an original camera-ready copy of the Form Save this form and make submissions using a photocopy of the original camera-ready form. Additional copies can be found on the Department of Aging and Disabilities Services (DADS) website at handbooks/ccpfm/forms/index.asp or by contacting the provider s contract manager. Form Retention The original Form 1290 must be submitted to TMHP. A copy should be retained according to LTC Program contract retention requirements. 2 2 CPT only copyright 2008 American Medical Association. All rights reserved.

14 LTC Claim Form 1290 Detailed Claims Filing Instructions Claims Claims must contain the provider s complete name, address, and nine-digit provider/contract number. All required items of the Form 1290 must be completed. The following instructions describe what information providers must enter in each item of the Form TMHP will not process a claim that is missing the required information. Important: The LTC Bill Code Crosswalk will be referenced throughout this manual for instructions on completing the Form The LTC Bill Code Crosswalk is a cross-referenced code set used to match the National Standard Codes (procedure and revenue codes) to the Texas LTC local codes, such as bill codes. When billing for LTC services, use information on the LTC Bill Code Crosswalk associated with the bill code that reflects the service billed. The LTC Bill Code Crosswalk includes codes necessary when billing services, such as revenue codes, procedure codes qualifiers, and Healthcare Common Procedure Coding System (HCPCS) codes. A copy of the LTC Bill Code Crosswalk is located in Appendix B, LTC Bill Code Crosswalk. The LTC Bill Code Crosswalk is updated quarterly. This manual includes the LTC Bill Code Crosswalk that was last updated on September 1, The most current version of the LTC Bill Code Crosswalk must always be used and is available online at the following website addresses: DADS website at TMHP website at Programs, listed under the LTC helpful links 2 Using the LTC Bill Code Crosswalk Follow these steps when using the LTC Bill Code Crosswalk: 1) Identify the service group/service code (SG/SC) to be billed. 2) Go to the LTC Bill Code Crosswalk table and find the same SG/SC. 3) Continue on the same line to find the corresponding information to complete the applicable items on the Form 1290, such as bill codes, HCPCS codes, and revenue codes. Required Information The following instructions describe the information that must be entered in each of the block numbers of the Form Section A Header Information Block 1 National Provider Identifier (NPI) This item is required. Enter the provider s NPI number or, for atypical providers, the nine-digit contract number preceded by the letter D (e.g., D ). Block 2 Contract No. This item is required. Enter the provider s contract number. Block 3 Provider Name This item is required. Enter the provider s name as it appears on the contract. Block 4 Address This item is required. Enter the provider s address as it appears on the contract. Block 5 Telephone No. Enter the provider s telephone number as it appears on the contract. Block 6 Client/Medicaid No. This item is required for all claims except NAT claims. Enter the individual s nine-digit client/medicaid number. CPT only copyright 2008 American Medical Association. All rights reserved. 2 3

15 Chapter 2 Block 7 Patient Account No. Enter the provider's internal patient account number. Block 8 Client Last Name This item is required. Enter the individual s last name. For NAT claims, enter the trainee s last name. Block 9 Client First Name This item is required. Enter the individual s first name. For NAT claims, enter the trainee s first name. Block 10 Client Middle Initial Enter the individual s middle initial. For NAT claims, enter the trainee s middle initial. Block 11 Client Suffix Name Enter the individual s suffix name (e.g., Jr., Sr.). Block 12 VA Indicator Complete item 12 when billing for a Veteran Affairs (VA) individual residing in a VA facility. This item is applicable only to SGs 1 and 8. Enter VA if the individual is residing in a VA facility. Block 13 Billed Applied Income/Copay Complete item 13 when billing for an individual that requires applied income (AI)/copay. Enter the dollar amount of the individual s income contributed to the individual s care or the individual s assessed copay amount. Block 14 Service Group Complete item 14 for Personal Assistance Services (PAS) expedited claims only. Enter the service group. Refer to Appendix C, Service Groups on page C-1 for a list of service groups. Block 15 Service Code Complete item 15 for PAS expedited claims only. Enter the service code. Refer to Appendix D, Service Codes on page D-1 for a list of service codes. Block 16 Fund Code Complete item 16 for PAS expedited claims only. Enter the fund code. Block 17 Billed Amount Complete item 17 for PAS expedited claims only. Enter the billed amount. Block 18 Billing Month/Year Complete item 18 for PAS expedited claims only. Enter the two-digit month and four-digit year of the billing month/year (mm/yyyy). Section B Complete for Nurse Aide Training (NAT) Only Complete only for Section B or C. Do not complete both sections. Block 19 NAT SSN This item is required. Enter the trainee s nine-digit Social Security number. Block 20 Service Group This item is required. Enter the service group. Refer to Appendix C, Service Groups on page C-1 for a list of service groups. Block 21 Bill Code This item is required. Enter the bill code, the five-character code for the specific service provided to the individual. Refer to the Bill Code column in Appendix B, LTC Bill Code Crosswalk on page B CPT only copyright 2008 American Medical Association. All rights reserved.

16 LTC Claim Form 1290 Block 22 Patient Days % This item is required. One or all of the subtypes can be completed. The sum of all three types must equal percent. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 100.0). Medicaid. Enter the percentage of filled beds in the facility for Medicaid residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 040.0). Medicare. Enter the percentage of filled beds in the facility for Medicare residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 030.0). Private. Enter the percentage of filled beds in the facility for private-pay residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 030.0). Block 23 Begin Date This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item. Block 24 End Date This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item. Block 25 Training Hours This item is required. Enter the number of training hours completed. Include one digit after the decimal point (e.g., 79.5). Block 26 Number of Units This item is required. Enter the number of service units provided to the individual. Include one digit after the decimal point (e.g., 139.0). Block 27 Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (e.g., 33.00). Block 28 Line Item Total This item is required. Enter the line item total by calculating the information entered in items 26 and 27. The line item should include two digits after the decimal point (e.g., ). 2 Section C Line Item Information Block 29 Begin Date This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item. Block 30 End Date This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item. Block 31 Rev Code (Revenue Code) This item is required for some services. Revenue codes are used to classify types of services. To determine if a revenue code is required for the service billed, refer to the Revenue Code column in Appendix B, LTC Bill Code Crosswalk on page B-1. Block 32 Proc Code Qual (Procedure Code Qualifier) This item is required when a procedure code is used. The procedure code qualifier describes the source of the procedure code entered in Block 32. To determine the procedure code qualifier to enter when billing for a particular service, refer to the Procedure Code Qualifier column in Appendix B, LTC Bill Code Crosswalk on page B-1. There are three types of procedure code qualifiers: ZZ Texas LTC Local Codes (usually referred to as a bill code) HC HCPCS and Current Procedural Terminology (CPT) codes CPT only copyright 2008 American Medical Association. All rights reserved. 2 5

17 Chapter 2 AD American Dental Association codes Block 33 Proc/Item Code (Procedure/Item Code) This item is required for some services. The procedure/item code uniquely identifies a procedure, product, or the service provided to the individual. Services provided are described by codes. To determine the procedure/item codes to use when billing for a particular service, refer to the Bill Code, HCPCS, or CPT Code columns in Appendix B, LTC Bill Code Crosswalk on page B-1. There are four types of procedure codes: 1) Bill codes (also referred to as Texas LTC local codes) 2) HCPCS codes 3) CPT codes 4) AD codes (also referred to as Current Dental Terminology [CDT] codes) Complete this block as follows: If ZZ is entered in Block 31 Proc/Item Code Qual, enter a local/bill code. If HC is entered in Block 31 Proc/Item Code Qual, enter a HCPCS or CPT code. If AD is entered in Block 31 Proc/Item Code Qual, enter a dental (CDT) code. Block 34 Modifiers Modifiers are two-digit codes used to further define a service and/or assist in determining what to pay during the claims adjudication process. There are four modifier fields on the Form Refer to the Modifier columns in Appendix B, LTC Bill Code Crosswalk on page B-1 and the Important Information About Modifiers 1 and 2 below, to determine if a modifier should be billed for a particular service. A copy of the Modifier table is available in Appendix E, Modifiers on page E-1. The Modifier table may be updated on occasion. The most current version of the Modifier table is available on the DADS website at Note: Modifiers 1 and 2 are used to provide contract-specific information, such as the service group (SG) and/or budget number, and are not included in the LTC Bill Code Crosswalk. To determine if a modifier should be included when billing for a particular service, refer to the following modifiers 1 and 2 examples. Important Information About Modifiers 1 and 2 Modifier 1 Modifier Field 1 is only used: If shown on the LTC Bill Code Crosswalk. If provider has a single contract with multiple SGs. Use modifier 1 to indicate the SG of the individual s billed services. If a hospice provider is billing for an Intermediate Care Facility for a Mentally Retarded (ICF-MR) individual. Use modifier 1 to indicate the SG of the individual before entering hospice. Example: A provider has a single contract for both SG 3 Community-Based Alternatives (CBA), Assisted Living/Residential Care (AL/RC), and SG 7 Community Care for the Aged and Disabled (CCAD RC) shown here. Modifier Service Group U3 SG 3 U7 SG 7 Example: A Hospice provider billing for a SG 4 MHMR individual (e.g., modifier U4 in SG 04). Modifier Service Group U4 SG CPT only copyright 2008 American Medical Association. All rights reserved.

18 LTC Claim Form 1290 Modifier Service Group U5 SG 5 Modifier 2 Modifier Field 2 is used: If shown on the LTC Bill Code Crosswalk. To specify a budget when billing a service (if required by contract). Example: A provider has a single contract for two services. 2 Modifier Budget U1 Budget 1 U2 Budget 2 Modifier Field 3 is used only if shown on the crosswalk. Modifier Field 4 is used only if shown on the crosswalk. Block 35 POS Code (Place of Service) This code is not required. The place of service (POS) code identifies the location, such as a nursing facility, individual s home, assisted living/residential care facility, or dentist s office, where the service was provided. A table containing POS codes and descriptions is available on the DADS website at The following is an example of a few of the POS codes: Service Place of Service Place of Service Code Personal Assistance Services (PAS)/Emergency Response Services (ERS) Home 12 Dental Care Office or other POS 11 or 99 Day Activity and Health Services (DAHS) Assisted Living/Residential Care Other POS 99 Assisted Living Facility 13 Block 36 TID (Tooth ID) Complete this block if billing for services for an individual receiving dental services/treatment by a licensed dentist. Enter up to a two-digit number (the tooth identification [TID] number) that identifies the tooth on which the service was performed. Refer to Appendix F, Tooth Identification (TID) on page F-1. Block 37 Rendering Provider Name This item is required if the service billed is a skilled/professional service and was provided by someone other than the provider agency, such as a dentist, therapist, or other licensed professional. The rendering provider name identifies the person that provided the service to the individual. This block does not apply to unskilled/nonprofessional services delivered by the provider agency, such as meals, personal attendant services, day activities, and health services. Refer to the following table for examples of rendering provider names: Skilled/Professional Service Provided Dental services Name of Rendering Provider David Davis CPT only copyright 2008 American Medical Association. All rights reserved. 2 7

19 Chapter 2 Skilled/Professional Service Provided Physical therapy Nursing services Name of Rendering Provider Patty Dee Nadine Doe Block 38 Number of Units This item is required. Enter the number of units of service provided to the individual. The units are based on the bill code, not the procedure code. Include one digit after the decimal point (e.g., 139.0). Note: If the unit rate for the services billed is hourly and is being billed for less than one hour of service, enter the unit in quarter-hour (15-minute) increments. For example, if 25 hours and 30 minutes of service were provided, enter in the number of units field. Block 39 Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (e.g., 33.00). Block 40 Line Item Total This item is required. Enter the line item total by calculating the information entered in Block 38 Number of Units and Block 39 Unit Rate, and when applicable, Block 13 Billed Applied Income/ Copayment. Block 41 Claim Total This item is required. Enter the claim total. The claim total is the sum of all line items. Include two digits after the decimal point (e.g., ). Block 42 Signature This item is required. Sign each form. Each Form 1290 must have an original signature. Block 43 Date Enter the date the claim is submitted. Line Item Adjustments Line item adjustments are submitted to change a previously paid claim. Line items should contain the original claim s information exactly as shown on the R&S Report. TMHP matches line item information to the original claim detail line item using data that includes (but is not limited to) service dates, units paid, and dollar amount paid codes (revenue, bill, and procedure/item). The line item adjustments may contain one or more negative line items. The negative line items cancel applicable line items listed on the original claim to be adjusted. To submit an adjustment, in Section C of the Form 1290, enter the line item to be adjusted as it appears on the original claim, except enter the units and line item totals in negative (-) amounts. More than one line item for a claim may be adjusted. Each line item adjusted must be credited back before any corrections are made. The credit appears on the adjusted line item as a negative number of units on the R&S Report. Not all negative line items (credited line items) have a corresponding positive line item (adjusted charge) adjustment associated with it. 2 8 CPT only copyright 2008 American Medical Association. All rights reserved.

20 LTC Claim Form 1290 Form 1290 Long Term Care Claim DADS Form 1290 Section A Header Information January NPI No. 2. Contract No. 3. Provider s Name 4. Address 5. Area Code and Telephone No. 6. Client/Medicaid No. 7. Patient Account No. 8. Client Last Name 9. Client First Name 10. Client Middle Initial 11. Client Suffix Name This information is for a VA individual residing in a VA facility This information is for an individual requiring AI/Copay This information is for expedited PAS use only. 12. VA Indicator 13. Billed Applied Income/Copay 14. Service Group 15. Service Code 16. Fund Code 17. Billed Amount 18. Billing Month/Year Section B Nurse Aide Training 28. Line Item Total 27. Unit Rate 26. Number of Units 25. Training Hours 24. End Date (mm/dd/yyyy) 23. Begin Date (mm/dd/yyyy) 22. Patient Days % 21. Bill Code 20. Service Group 19. NAT SSN Medicare Private Medicaid Section C Line Item Information (Note: Negative Number of Units should appear as Show parts of units as decimal fractions.) 40. Line Time Total 39. Unit Rate 38. Number of Units 36. TID 37. Rendering Provider Name Modifiers 35. POS Proc/Item Code Code 32. Proc Code Qual 31. Rev Code 30. End Date (mm/dd/yyyy) 29. Begin Date (mm/dd/yyyy) Line Claim Total: I certify that this information is true, accurate and complete to the best of my knowledge. I understand that claiming for services not actually provided constitutes fraud. 42. Signature 43. Date 2 CPT only copyright 2008 American Medical Association. All rights reserved. 2 9

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22 3Remittance and Status (R&S) Report Chapter 3 In this chapter R&S Report Overview R&S Report Distribution R&S Report Section Descriptions R&S Report Overview Remittance and Status (R&S) Reports are valuable tools for tracking billing activities. A successful business typically has good accounting practices, such as the reconciliation of R&S Reports. Agencies that do not reconcile their R&S Reports may be billing incorrectly, which can result in audits and penalties. The R&S Report includes the following five sections: Section Title Page Non-Pending Claims (R&S) Pending Claims (Claim Activity Report) Financial Summary Explanation of Benefits (EOB) Code and Description Description Provider address and R&S Report information pertinent to the reported week Claims and adjustment requests that have completed processing during the reported week and have finalized to either a paid or denied status Suspended claims and adjustments awaiting manual review/adjudication by an examiner or claims approved for payment but not yet paid. Pending claims may be for periods outside of the reported week Warrant summary information and other financial transactions such as expedited, administrative, and deduction payment processing EOB codes and descriptions found in the Non-Pending and Pending Claims sections. Instructions for submitting claim adjustments for previously paid and/or denied claims The R&S Report includes information about paid claims, denied claims and the reason for denial, inprocess claims and the reason for their status, warrants, and payment summary information. Claims received and/or processed with a status of paid, denied, or in-process during the previous week for the same provider number appear on the R&S Report. R&S Reports are available in three types of media: paper, electronic, and web-based portable document format (PDF) files. The paper R&S Reports may contain different information than the web-based or electronic versions. The TexMedConnect Online Help or the TMHP Call Center/Help Desk at , should be consulted to access additional information about electronic R&S Reports or webbased R&S Reports. PDF R&S Report Description: The R&S Report is in a PDF format. The report provides financial reconciliation information that is similar to what electronic providers used to get but in the same layout as the current paper R&S. The information can be printed and/or downloaded, but not manipulated. A report is generated for each unique National Provider Identifier (NPI) or Contract Number. CPT only copyright 2008 American Medical Association. All rights reserved.

23 Chapter 3 How to Access: Within TexMedConnect, users must click R and S on the navigation bar on the left side of the screen. Who has Access: Administrators and users with the R&S Report Viewer permission can access this option. Availability: The report can be viewed online for up to three months. Three months after the posting date, the report will be removed from the website. Multiple users can access the report at any time. ANSI 835 R&S Report (only for providers billing ANSI claims) Description: The ANSI 835 file is a Health Insurance Portability and Accountability Act (HIPAA)-compliant R&S Report format used by providers or third-party software and other back-end financial systems. The ANSI 835 file provides financial reconciliation information in a comma-delimited format. The information is downloaded in a flat file for use in software that can manipulate the data to meet a provider's needs (e.g., third-party billing software, Microsoft Access). How to Access: Within TexMedConnect, users must click ANSI 835 on the navigation bar on the left side of the screen. The provider's submitter ID must be entered so that the file can be placed on the File Transfer Protocol (FTP) server. The file must then be downloaded from the FTP server. The submitter ID is different from the TexMedConnect username and password that are used to access the website. Providers who do not already have a submitter ID must call the TMHP Electronic Data Interchange (EDI) Help Desk at Who has Access: Administrators and users with the View 835 Report permission can access this option. Availability: The report file is available until a user downloads it from the FTP server. Important: After the file has been downloaded by a user, it will not be available for other users. Claim Data Export Description: A claim data export is a customized user search that allows providers to request up to three months of claim data for up to three years in the past. The results are returned in a user-friendly, formatted Microsoft Excel file. The information is similar to the data in the PDF format above but in an excel format. The primary use of this report is to give specific claim data for an NPI/Contract Number in an easily-readable format. How to Access: Within TexMedConnect, users must click Data Export Request on the navigation bar on the left side of the screen to perform the search. The provider's submitter ID must be entered so that the file can be placed on the FTP server. Once the request is submitted, an off-line batch process runs to retrieve the requested data and place the results on an FTP server. Users must then click Data Export Download on the navigation bar to download the file with the results of the search. The submitter ID is different from the TexMedConnect username and password that are used to access the website. Providers who do not already have a submitter ID must call the TMHP EDI Help Desk at Who has Access: Only Administrators can access this option. Availability: The report file is available until a user downloads it from the FTP server. Important: After the file has been downloaded by a user, it will not be available for other users. R&S Report Distribution An R&S Report is available to providers each Monday with claim activity in the reporting week. The paper R&S Reports are mailed to paper submitters on Mondays. Allow sufficient time for mail delivery before inquiring about missing R&S Reports. Note: Copies of all R&S Reports must be retained for a minimum of five years. 3 2 CPT only copyright 2008 American Medical Association. All rights reserved.

24 Remittance and Status (R&S) Report R&S Report Section Descriptions Title Page The first page of the R&S Report, called the title page, contains provider and R&S information for the reported week. The title page includes the provider s address (as listed in the Department of Aging and Disability Services [DADS] provider file) and the TMHP mailing address. Note: Address changes must be reported to the provider s DADS contract manager or program consultant. The following is a description of the information included in the title page: 3 Title Page Information Agency Name Remittance and Status No. Report Sequence No. Report From Date Report To Date Run Date Provider Number PIN National Provider Identifier TMHP Address Provider Name and Address The name of the state agency The unique number assigned to each Report The date the report was generated The From date of service in MMDDYYYY (month, day, year) format The To date of service in MMDDYYYY (month, day, year) format The date the report was generated by the Claims Management System (CMS) The provider/contract number assigned to an agency by DADS. A provider with more than one provider/contract number will receive an R&S Report for each provider/contract number Payee Identification Number. A unique number assigned by the Texas Comptroller s Office to an individual or entity to enable them to receive state payments The standard unique health identifier for health care providers. On standard transactions it replaces the use of all legacy provider identifiers, such as the Medicaid LTC Provider Number The PO Box address for submitting paper claims and the TMHP physical address The name and address of the provider Non-Pending Claims Claims finalized to a paid or denied status during the reported week are included in the Non-Pending Claims section. The Non-Pending Claims section has three parts: General Information, Claim Header Information, and Claim Detail Information. Claims in the Non-Pending Claims section are sorted and shown in alphabetical order by the individual s last name. CPT only copyright 2008 American Medical Association. All rights reserved. 3 3

25 Chapter 3 The General Information component applies to the entire section and is located at the top of each page of the Non-Pending Claims section. General Information Page Number Title of the Report Report Date PIN Non-Pending Claims Provider Number The specific page of the report appears on the top left-hand corner of each page The title of the report appears at the top center of each page The date the R&S Report was generated appears at the top righthand corner on the paper R&S Report Payee Identification Number. The provider s PIN appears below the page number at the top left-hand corner The label appears centered and below the title of the report and identifies the claims found in this section of the report This is the provider/contract number associated with the agency whose claims are contained in this report The second part of the Non-Pending Claims section is the claim header. It includes the following fields and information from left to right, top to bottom: Claims Header Information Client Name Client/Mcaid No. Trainee SSN Client/Control No. ICN Svc Group Mcaid Days % Mcare Days % Private Days % Warr/DD No. 1 Warr/DD Date 1 Warr Status 1 DLN The last name, first name, and middle initial (if applicable) of the individual who received LTC services The nine-digit number identifying the individual as being eligible for services The Social Security number of the nurse aide trainee The optional number used by the provider to identify the individual s account number assigned by the provider s accounting system The internal control number assigned to a claim that has passed acceptance editing, sometimes referred to as the claim number The number assigned to designate the LTC Program associated with the claim Percentage of patient Medicaid days Percentage of patient Medicare days Percentage of patient private days The first warrant or direct deposit number that the Comptroller issued The date the Comptroller issued the first warrant or direct deposit The status of the first warrant or direct deposit, such as on hold at the Comptroller or DADS The document locator number to identify each warrant request 3 4 CPT only copyright 2008 American Medical Association. All rights reserved.

26 Remittance and Status (R&S) Report Claims Header Information Warr/DD No. 2 Warr/DD Date 2 Warr Status 2 Transmission ID Warr/DD No. 3 Warr/DD Date 3 Warr Status 3 Tot Billed Tot App Pay The second warrant or direct deposit number that the Comptroller issued The second warrant or direct deposit date that the Comptroller issued the warrant number The second warrant status of the warrant or direct deposit, such as on hold at the Comptroller or DADS This field is blank for paper submitters The third warrant or direct deposit number that the Comptroller issued The third warrant or direct deposit date that the Comptroller issued the warrant number The third warrant status of the warrant or direct deposit, such as on hold at the Comptroller or DADS The total dollar amount billed for the claim The total dollar amount approved for payment for the claim 3 The third part of the R&S Non-Pending section, referred to as the Claim Detail, has information from each claim s detail. Positive and negative line items uniquely identify adjustment requests. Claim Detail Information # The claim detail line item number Adj Original ICN Srvc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Units Allowed AI/Co-pay Unit Rate Paid Units The adjustment indicator The original Internal Control Number (ICN) of the claim line item of the adjustment requests Begin and end dates for a billed service, also known as dates of service (DOS) The billing code The procedure code used to identify a procedure. The TID is the tooth identification number The number of training hours used for a nurse aide trainee The number of units billed The number of units allowed for the service billed The applied income or copayment on file in the system. The allowed amount is applied to the line item billed amount The approved-to-pay unit rate of the service The number of units approved for payment CPT only copyright 2008 American Medical Association. All rights reserved. 3 5