2006 Long Term Care User Manual. for paper submitters

Transcription

1 2006 Long Term Care User Manual for paper submitters

2 Dear Long Term Care Provider, Welcome to the 2006 Long Term Care User Manual for paper submitters. The user manual is published for Long Term Care (LTC) providers who use Form 1290 to submit paper claims. It provides detailed instructions that must be used as a resource for completing Form The manual is sent to providers by the Texas Medicaid & Healthcare Partnership (TMHP), the claims administrator for the Texas Department of Aging and Disability Services (DADS). The Claims Management System (CMS) used for LTC claims processing is the result of a partnership between DADS and TMHP. 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 Contact Center 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 Barry Waller, Assistant Commissioner for Provider Services 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 Advantages of Using TDHconnect TDHconnect System 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 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 R&S Report Distribution R&S Report Section Descriptions Title Page Non-Pending Claims Pending Claims (Claims Activity Report) Financial Summary Explanation of Benefits (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 Crosswalk How to Use the LTC Crosswalk B-1 National HCPCS and Sets B-1 Long Term Care Crosswalk B-2 Appendix C: s Appendix D: s Appendix E: Modifiers Modifier Table E-1 Appendix F: Tooth Identification (TID) TID Chart F-1 Appendix G: Explanation of Benefits Glossary 1

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6 1Introduction to Claims Management System Chapter 1 In this chapter Claims Management System Overview Provider Support Advantages of Using TDHconnect TDHconnect System 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 TDHconnect or develop third-party software that meets CMS requirements. TDHconnect is the software used by acute care and most LTC providers to connect to the TMHP Electronic Data Interchange (EDI) Gateway system. TDHconnect 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 for services provided. 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 Waiver) Extended Care Facility (also known as Swing Beds)

7 Chapter 1 Emergency Dental 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 Respite Care Special Services to Persons with Disabilities (SSPD) Special Services to Persons with Disabilities-24 hours (SSPD-24) Specialized Services Transitional Assistance Services (TAS) These providers may submit claims using Form 1290, TDHconnect, or a third-party software. Upon receipt of a claim, CMS edits for 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 denied and/or rejected. 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 does not show 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 need to enter their nine-digit provider/contract number using a telephone keypad when contacting the TMHP Call Center/Help Desk. Providers calling from a rotary telephone are prompted to remain on the line for assistance. When the nine-digit provider/contract number is entered on the telephone keypad, the TMHP Call Center/Help Desk system automatically populates the TMHP call center representative s screen with the provider s information, including name and telephone number. Call center representatives can instantly view a provider s contact history, complete with prior communication dates, discussion topics, and any notes made by representatives the provider has spoken to previously. These enhancements enable the representative to research and respond to inquiries more effectively. When inquiring about a specific individual, providers must have the individual s Medicaid and/or Social Security number available. TMHP Call Center/Help Desk contact numbers are: Long Term Care (outside of Austin): or Long Term Care (Austin local):

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 TDHconnect Claim rejection and denials Understanding R&S reports Choose Option 1: Customer service/ general inquiry 1 Completing Claim Form CARE form Claim adjustments Forms 3618 or 3619 Claim status inquiries TILE levels Claim history Medical necessity Option 2: To speak with a nurse TDHconnect Technical issues, obtaining access, user IDs, and passwords Modem and telecommunication issues ANSI ASC X12 specifications, testing, and transmission Processing provider agreements Verifying that system screens are functioning Getting EDI assistance from software developers EDI and connectivity Option 3: Technical support Electronic transmission of 3652 CARE forms CARE form software (CFS) installation Option 3: Technical support Electronic transmission of Forms 3618 and 3619 Weekly Status Reports Transmitting forms Interpreting Quality Indicator (QI) Reports MDS submission problems Technical issues New messages (banner) in audio format for paper submitters Option 4: Headlines/topics for paper submitters Individual appeals Individual fair hearing requests Replay for menu options Appeal guidelines Option 5: Request fair hearing Option 6: Replay options The following is additional information about menu options. Option 1. Provider claims and 3652 CARE form and Forms 3618 and This option allows providers to: Obtain assistance on how to complete the 1290 form. Obtain the status of a claim or a CARE form. Obtain information about an individual s eligibility. Obtain assistance on how to read an R&S report. Obtain assistance on how to read the Weekly Status Report. Request a paper R&S report. Refer to Option

9 Chapter 1 Option 2. To speak with a nurse. This option allows providers to: Speak with a nurse about a pending or denied CARE form. Provide additional/missing information to a nurse for a CARE form, and so forth. Option 3. Technical support. This option provides information about: TDHconnect, CARE form system (CFS) software, Minimum Data Set (MDS), or American National Standards Institute (ANSI). Submitter IDs and passwords. How to obtain an application for TDHconnect, Electronic R&S (ER&S), and CFS. How to request an ER&S report (within the 30-day period). How to download the ER&S report. Refer to Option 1 above. How to download weekly status reports. Refer to Option 1 above. 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 providers to request a fair hearing for denied medical necessity. Option 6. To replay menu options. Advantages of Using TDHconnect Advantages to using TDHconnect are: TDHconnect is free of charge. Providers can receive payment within five to seven days after the claim is in 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 to 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. Advantages available for R&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. TDHconnect System Requirements TDHconnect is software designed for the electronic submission of claims. Refer to Appendix A, Software on page A-2 for system requirements. 1 4

10 Introduction to Claims Management System 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

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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 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 billing 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 pays, denies, or suspends the claim according to business requirements. Once the claim is received by TMHP, the normal processing averages seven to ten 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

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 only using 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 Crosswalk. Review the form for accuracy before submitting. Sign each form: An original signature is required on each form. Copies 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 on 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 may be obtained from the DADS website at index.cfm, under the Community Care Information Letters link, 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

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 Crosswalk will be referenced throughout this manual for instructions on completing the Form The LTC 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 Crosswalk associated with the bill code that reflects the service billed. The LTC 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 Crosswalk is located in Appendix B, LTC Crosswalk. The LTC Crosswalk is updated quarterly. The most current version of the LTC Crosswalk must always be used and is available at the following website addresses: DADS HIPAA website at TMHP website at Programs, listed under the LTC helpful links 2 Using the LTC Crosswalk Follow these steps when using the LTC Crosswalk: 1) Identify the service group/service code (SG/SC) to be billed. 2) Go to the LTC 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 Provider No. This item is required. Enter the provider s nine-digit number as it appears on the contract. Block 2 Provider Name This item is required. Enter the provider s name as it appears on the contract. Block 3 Address This item is required. Enter the provider s address as it appears on the contract. Block 4 Telephone No. Enter the provider s telephone number as it appears on the contract. Block 5 Client/Medicaid No. This item is required for all claims except Nurse Aide Training (NAT) claims. Enter the individual s ninedigit client/medicaid number. Block 6 Patient Account No. Enter the provider s internal patient account number. 2 3

15 Chapter 2 Block 7 Client Last Name This item is required. Enter the individual s last name. For NAT claims, enter the trainee s last name. Block 8 Client First Name This item is required. Enter the individual s first name. For NAT claims, enter the trainee s first name. Block 9 Client Middle Initial Enter the individual s middle initial. For NAT claims, enter the trainee s middle initial. Block 10 Client Suffix Name Enter the individual s suffix name (for example, Jr., Sr.). Block 11 VA Indicator Complete item 11 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 12 Billed Applied Income/Copay Complete item 12 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 13 Complete item 13 for Personal Assistance Services (PAS) expedited claims only. Enter the service group. Refer to Appendix C, s on page C-1, for a list of service groups. Block 14 Complete item 14 for Personal Assistance Services (PAS) expedited claims only. Enter the service code. Refer to Appendix D, s on page D-1, for a list of service codes. Block 15 Fund Code Complete item 15 for Personal Assistance Services (PAS) expedited claims only. Enter the fund code. Block 16 Billed Amount Complete item 16 for Personal Assistance Services (PAS) expedited claims only. Enter the billed amount. Block 17 Billing Month/Year Complete item 17 for Personal Assistance Services (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 18 NAT SSN This item is required. Enter the trainee s nine-digit Social Security number. Block 19 This item is required. Enter the service group. Refer to Appendix C, s on page C-1 for a list of service groups. This item is required. Enter the service group which is the five-character code for the specific service provided to the individual. Refer to the column in Appendix B, LTC Crosswalk on page B-1. Block 20 This item is required. Enter the bill code, the five-character code for the specific service provided to the individual. Refer to the column in Appendix B, LTC Crosswalk on page B

16 LTC Claim Form 1290 Block 21 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 (for example, 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 (for example, 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 (for example, 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 (for example, 030.0). Block 22 This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item (for example, 01/01/2006). Block 23 This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item (for example, 01/31/2006). Block 24 Training Hours This item is required. Enter the number of training hours completed. Include one digit after the decimal point (for example,79.5). Block 25 Number of Units This item is required. Enter the number of service units provided to the individual. Include one digit after the decimal point (for example, 139.0). Block 26 Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (for example, 33.00). Block 27 Line Item Total This item is required. Enter the line item total by calculating the information entered in items 24 and 26. The line item should include two digits after the decimal point (for example, ). 2 Section C Line Item Information Block 28 This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item (for example, 01/01/2006). Block 29 This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item (for example, 01/31/2006). Block 30 Rev 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 column in Appendix B, LTC Crosswalk on page B-1. Block 31 Proc Code Qual () 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 column in Appendix B, LTC Crosswalk on page B

17 Chapter 2 There are three types of procedure code qualifiers: ZZ Texas LTC Local Codes (usually referred to as a bill code) HC Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes AD American Dental Association codes Block 32 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, HCPCS, or columns in Appendix B, LTC 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 33 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 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 at times. 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 and/or budget number, and are not included in the LTC 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 Field 1 is only used: If shown on the LTC Crosswalk, or If provider has a single contract with multiple SGs. Use modifier 1 to indicate the SG of the individual s billed services, or A Hospice provider is billing for an Intermediate Care Facility for the 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 U3 SG 3 U7 SG 7 2 6

18 LTC Claim Form 1290 Example: A Hospice provider billing for a SG 4 MHMR individual. (For example, modifier U4 in SG 04). Modifier U4 SG 4 U5 SG 5 2 Modifier Field 2 is used: If shown on the LTC Crosswalk, or To specify a budget when billing a service if required by contract. Example: A provider has a single contract for two services. 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 34 POS Code (Place of Service) This code is 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 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 35 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 36 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. 2 7

19 Chapter 2 Refer to the following table for examples of rendering provider names: Skilled/Professional Service Provided Dental services Physical therapy Nursing services Name of Rendering Provider David Davis Patty Dee Nadine Doe Block 37 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 (for example, 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 was provided, enter in the number of units field. Block 38 Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (for example, 33.00). Block 39 Line Item Total This item is required. Enter the line item total by calculating the information entered in Block 37 Number of Units and Block 38 Unit Rate, and when applicable, Block 12 Billed Applied Income/ Copayment. Block 40 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 (for example, ). Block 41 Signature This item is required. Sign each form. Each Form 1290 must have an original signature. Block 42 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

20 LTC Claim Form 1290 Form 1290 LONG TERM CARE CLAIM DADS Form 1290 May 2005 SECTION A Header Information 1. Provider No. 2. Provider Name 3. Address 4. Telephone No. 5. Client/Medicaid No. 6. Patient Account No. 7. Client Last Name 8. Client First Name 9. Client Middle Initial 10. 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 11. VA Indicator 12. Billed Applied Income/Copay Fund Code 16. Billed Amount 17. Billing Month/Year SECTION B Nurse Aide Training 27. LINE ITEM TOTAL 26. UNIT RATE 25. NUMBER OF UNITS 24. TRAINING HOURS 23. END DATE (mm/dd/yyyy) 22. BEGIN DATE (mm/dd/yyyy) 21. PATIENT DAYS % 20. BILL CODE 19. SERVICE GROUP 18. NAT SSN MEDICAID MEDICARE PRIVATE SECTION C Line Item Information (Note: Negative Number of Units should appear as Show parts of units as decimal fractions.) 39. LINE ITEM TOTAL 38. UNIT RATE 37. NUMBER OF UNITS 33. MODIFIERS 35. TID 36. RENDERING PROVIDER NAME 34. POS CODE 32. PROC/ ITEM CODE 31. PROC CODE QUAL 30. REV CODE 29. END DATE (mm/dd/yyyy) 28. 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. 41. Signature 42. Date 2 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 The Remittance and Status (R&S) report provides information about the status of claims submitted to TMHP. The report is a valuable tool for tracking billing and payment activities and assists providers in tracking accounts receivable. The R&S report has 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. This manual generally describes R&S reports on paper. The TDHconnect Online Help or the TMHP Call Center/Help Desk at , should be consulted to access information about electronic R&S reports or web-based R&S reports.

23 Chapter 3 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. 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: 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 Number 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. For future use. 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. 3 2

24 Remittance and Status (R&S) Report 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 R&S Date Payee Identification Number (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 was generated appears at the top right-hand corner on the paper R&S report. The providers PIN appears below the page number at the top lefthand 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. 3 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 Clients Name Clients/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 Stat 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 day s. Percentage of patient Medicare day s. Percetnage of patient private day s. 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 3

25 Chapter 3 Claims Header Information Warr/DD No. 2 Warr/DD Date 2 Warr Stat 2 Transmission ID Warr/DD No. 3 Warr/DD Date 3 Warr Stat 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. 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 Uts Allowed AI/Co-pay Unit Rate Paid Units EOB 1 The adjustment indicator. The original ICN of the claim line items of as 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. The explanation of benefits codes explain the reasons for payment, denial, or pending of the claim s line item. 3 4

26 Remittance and Status (R&S) Report Claim Detail Information Status Begin/End Srvc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 The claim status indicator: P Paid PZ Paid zero. The entire payment was applied to the balance owed the state (i.e., administrative expedited payment) D Denied (claim not paid) T Transferred (no funds paid or recouped at this time) The start and/or end dates of service for the service billed. The service code authorized on the individual s service authorization. The item code of the service billed. The number of days the client was on leave. The dollar amount billed for a service. The dollar amount allowed for the service billed. Billed Applied Income represents the individual s income that must be contributed toward the cost of the service billed by the provider. Copayment represents the amount the individual is responsible for contributing. Both amounts are applied to the line item billed amount. This identifies the budget number the claim is being charged against. The dollar amount approved for payment. The explanation of benefits codes explain the reasons for payment, denial, or pending of the claim s line item. 3 Pending Claims (Claims Activity Report) The Pending Claims section includes claims and adjustment requests that have been suspended and are awaiting manual review by a TMHP examiner, or are claims approved for payment, but the warrant information was not available when the R&S report was generated. The following status codes appear on a pending R&S report: A Approved to pay (passed editing/no warrant issued yet) S Suspended (awaiting further information) I In process Claims in this section are still processing in the system. This section informs providers of the status of claims that have not finalized to a paid or denied status. The EOB message located on the R&S report explains why the claim has not completed processing. Providers should not interpret the EOB message on a pending detail line of a claim as a final reason for payment or denial. Providers cannot adjust a pending claim (A, S, or I) until the claim receives a paid or denied status and appears in the Non-Pending Claims section of the R&S report. The format of the Pending Claims section resembles that of the Non-Pending Claims section except for the Pending Claims section that appears in the top center of the page. Additionally, some fields may be blank because the claim is still processing through the system. 3 5

27 Chapter 3 Financial Summary The Financial Summary section contains the following information: Expedited, administrative, and deduction payment processing information for the week being reported on the R&S report Total amount paid for this R&S report (non-pending only) Summary of all the warrants contained in the R&S report The Financial Summary section contains four parts. The first part, referred to as general information, contains the same information described in the Non-Pending section of general information in this chapter. The second part of the Financial Summary section contains expedited, administrative, and deduction payment processing information. For providers who receive expedited payments, recoupable administrative payments, or who are placed on deduction, the amount column reflects the total amount of the payment or deduction. The withheld column reflects paid claims to date applied toward repaying the payment or deduction. The balance column reflects any amount owed to repay the payment or deduction and includes the following fields on the form, from left to right: Financial Summary Type of Financial Action Expedited Payment(s) Administrative Payment(s) Provider Total Deduction(s) Provider Monthly Deduction(s) Total Paid Amount for this R&S (Non-Pending Only) Total Withheld to Date Total Withheld this R&S Expedited, administrative, or deductions are financial transactions that may appear under this heading. These types of transactions may or may not be associated with a specific claim. This is applicable to Personal Assistance Services (PAS) only. A special payment to a provider agency authorized by DADS. The directive by the state to withhold claim payment from a provider. The directive by the state to withhold a specific monthly claim payment amount from a provider. The cumulative total of all the warrants included in the specific R&S report number. The dollar amount withheld from a provider for an expedited payment, administrative payment, or deduction. The amount the provider owes to zero-out balance. The third part of the Financial Summary section, titled Total Paid Amount for this R&S report, Non- Pending, reflects total dollars that were paid on all the claims appearing on the Non-Pending R&S report. This total does not reflect the amounts withheld on this R&S report. The fourth part of the Financial Summary section, referred to as Warrant Summary Information, contains information that applies to the warrants included in the R&S report. Up to nine warrants appear in this section. The form includes the following fields from left to right: Warrant Summary Information Warrant Information for This Report Warrant/Direct Deposit Number Warrant/Direct Deposit Date The information on all warrants included in the specified R&S report. The check number of the warrant that is used to pay providers and vendors for services rendered. The date the warrant was issued. 3 6

28 Remittance and Status (R&S) Report Warrant Summary Information Total Amount Paid Warrant Status The total amount of the warrant. The final status of the warrant: H Comptroller hold M Warrant mailed C Warrant canceled D Direct deposit A Agency hold W Warrant issued 3 Explanation of Benefits (EOB) Codes All the EOB codes shown on the Non-Pending and Pending claims pages appear on the EOB code and description page. Codes for non-pending claims explain the payment or denial reason of a claim or line item within a claim. Codes for pending claims explain the reason a claim suspended or informs the provider of an approved claim for payment. However, the warrant information is not available when the R&S report is generated. The EOBs for pending claims serve only to explain the status of the claims and should not be interpreted as a final reason of payment or denial. A list of EOBs is located in Appendix G, Explanation of Benefits on page G-1. Electronic providers should refer to the national EOBs for a complete set of codes and descriptions. R&S Report Examples The following pages provide examples of R&S reports. 3 7

29 Chapter 3 Title Page R&S TEXAS DEPARTMENT OF HUMAN SERVICES TEXAS DEPARTMENT OF MENTAL HEALTH MENTAL RETARDATION REMITTANCE AND STATUS NO.: Report Sequence No Report From Date: Report To Date: Run Date: Provider Number: PIN: National Provider Number: Mail Original Claim To: Mail All Other Correspondence To: Texas Medicaid & Healthcare Partnership Texas Medicaid & Healthcare Partnership PO Box B Riata trace Parkway Austin, Texas Austin, Texas R&S Address: Provider Name Street City State Zip 3 8