General FAQs

Long Term Hospital Stays

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For long term hospital stays, what do we do if the baby is FFS Medicaid when admitted and gets enrolled in SALUD! while still in the hospital?

Bill all services for the inpatient hospital stay to FFS Medicaid. Once the baby is discharged from the inpatient hospital stay, bill the SALUD! MCO.

Here's some background to explain how and why this works:

  • Newborn babies born to moms who are NOT in SALUD! on the baby's date of birth are in fee-for-service Medicaid until they are enrolled in SALUD! by the normal enrollment process (assuming they are not exempt from SALUD!).
  • When a baby has fee-for-service Medicaid at birth but is enrolled in SALUD! during a long-term hospital stay, the inpatient charges and services are covered by fee-for-service; not SALUD!.
  • The SALUD! MCO only becomes responsible once the baby is discharged from the inpatient hospital stay.
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We were told to bill FFS Medicaid when the Mom was NOT enrolled in SALUD! on the baby's DOB, but our claim was denied for managed care enrollment. How do we get the claim paid?

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How does retroactive eligibility apply to newborns?

Just like any retroactive eligibility client, claims for a newborn are within timely filing limits if the claim is submitted within 120 days from the eligibility add date in Omnicaid.

Click here for more information on retroactive eligibility.

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Managed Care Organizations

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General Information

Medicaid clients can be enrolled in one or all of the following MCOs:

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SALUD! (Physical Healthcare)

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NMRx (Pharmacy)

  • NMRx Website

  • Presbyterian Customer Service: (505) 923-5224, or toll free, 1-866-593-7432

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Optum Health (Behavioral Health)

  • All Behavioral Health claims for DOS as of July 1, 2005, are covered by Optum Health, except for Medicare crossovers.

  • Optum Health Website

  • Optum Health New Mexico: 1-866-660-7182

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What does it mean when a Medicaid client is 'exempt'?

Exempt: Client's claims are paid for by FFS Medicaid

Non-Exempt: Client is enrolled in SALUD! Note: This is not an official NM Medicaid term, but providers often use it to refer to clients who are enrolled in SALUD!

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Why isn't everyone in a Managed Care Organization (MCO)?

Due to various categories of eligibility and funding, some Medicaid clients are not enrolled in Managed Care. The following is a list of clients who get some or all of their services from FFS Medicaid:

  • Presumptive Eligibles: Children and Pregnant Women who qualify for Presumptive Eligibility are never enrolled in any MCOs.

  • Family Planning COE clients are never in any MCOs.

  • Medicare/Medicaid Dual Eligible - never enrolled in SALUD!, but are enrolled in Managed care for behavioral (ValueOptions, for non-crossover claims) and pharmacy (NMRx, for items not covered by Medicare Part D). Dual-eligibles in Long Term Care are an exception.

  • Native Americans are enrolled in ValueOptions and NMRx. Native Americans are exempt for SALUD! enrollment, but can choose to enroll in SALUD!. Do not assume that a Native American is NOT enrolled in SALUD!

  • Long Term Care residents - clients authorized to be in an LTC facility (nursing homes and ICF-MRs) are not enrolled in SALUD! or NMRx, but are in ValueOptions.

  • HCBS Waiver clients can be enrolled in all managed care programs. However, HCBS Waiver services are paid for by FFS Medicaid.

  • Personal Care Option (PCO) services clients can be enrolled in all managed care programs. However, FFS Medicaid pays for PCO services.

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My client recently had her baby, why is she no longer enrolled in SALUD!?

During the pregnancy, most pregnancy-related only COE (non-presumptive eligibility) clients are enrolled in SALUD!, approximately eight weeks after delivery, they normally move to the family planning COE. Based on this change in eligibility, the client is disenrolled from SALUD! the following month. FFS Medicaid pays for family planning claims.

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What is fee-for-service (FFS) Medicaid?

Medicaid reimburses the provider based on a set fee for each service performed. FFS claims are typically for services performed for a client who is either not enrolled in a Managed Care Organization or the service is not covered by the Medicaid managed care program(s) the client is enrolled in. These are the only Medicaid claims paid by ACS.

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Q2-MCO: Can someone in managed care (MCO) still get Fee-For-Service (FFS) claims paid by Medicaid?

FFS claims will not be paid for most clients enrolled in managed care. However, HCBS Waiver and PCO services are paid for by FFS even when the client is enrolled in SALUD!.

Clients who are FFS Medicaid eligible when admitted to an inpatient hospital remain the responsibility of FFS until discharge from inpatient status, even if they become enrolled in SALUD! during their inpatient stay. This is especially important for Newborns who remain in the hospital for a long period of time. Click here for newborn billing FAQs.

Click here for more information on checking Medicaid eligibility.

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Are Medicare/Medicaid dual-eligibles enrolled in SALUD!?

No. FFS Medicaid pays physical health claims for all dual-eligibles.

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Are Medicare/Medicaid dual-eligibles enrolled in Optum Health?

Yes. If Medicare does not cover the behavioral health service, then Optum Health is the primary payer. Behavioral health crossovers are covered by FFS Medicaid.

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Who is enrolled in NMRx?

All clients who are not receiving pharmacy benefits through SALUD! (dual-eligibles and Native Americans) are enrolled in NMRx; with the exception of nursing home and ICF-MR residents.

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Why is someone in enrolled SALUD! one month and not the next? It is very frustrating trying to figure out how to bill these claims!

SALUD! enrollment depends primarily upon the client's Medicaid eligibility. Changes in a client's SALUD! enrollment fall into four categories:

1.      New Medicaid eligibility

2.      A loss of Medicaid eligibility and then reinstatement

3.      A change in the category of eligibility

4.      Addition of Medicare benefits

1. A 'gap' in client eligibility or enrollment:

You are most likely to see the first example with clients who are newly enrolled in NM Medicaid:

Once a client has Medicaid eligibility, clients who are required to enroll in SALUD! must select an MCO. Just as a company allows employees time to select a healthcare plan, Medicaid clients have time to make their decision. However, clients who do not make their selection in time will be auto-enrolled into an MCO.

Therefore, newly eligible Medicaid clients will be fee-for-service eligible for their physical healthcare until they either select an MCO or are automatically enrolled in an MCO.

Depending on when a new Medicaid client's information is loaded in Omnicaid, a newly eligible Medicaid client can be in the fee-for-service program from 3 to 6 weeks before being enrolled in SALUD!. Remember, SALUD! enrollments are always for an entire month.

2. A Loss of Medicaid Eligibility and Reinstatement.

If a client's Medicaid eligibility ends, the client is disenrolled from SALUD! for the upcoming month. Remember that eligibility and SALUD! enrollment are effective for the entire month. If the client's Medicaid eligibility is re-established to include the month the client was disenrolled from SALUD!, the client is automatically reenrolled in their prior SALUD! in the following month. The month(s) for which the client is now Medicaid eligible but not enrolled in SALUD! are paid for by FFS Medicaid.

3. A Change in the Category of Eligibility

Changes in a Medicaid client's financial and family circumstances might lead to a change in the COE under which they qualify for Medicaid. This change in COE can affect their eligibility to be enrolled in SALUD!. Consider the following example:

Sample time frame:

May 1-31: Client has pregnancy-related COE on-presumptive) and is enrolled in a SALUD! plan.

  • Has baby on May 2nd.

  • Client's COE changed to family planning after birth of child (the month of July).

  • SALUD! enrollment always lasts the full month

Effective July 1: Client has family planning COE.

Client is disenrolled from SALUD! plan for the months of July and August.

  • Based on household changes after the birth of the baby, on August 16th, client applies and is now eligible for full Medicaid benefits effective September 1.

  • Client's COE beginning in September is now full-benefits.

  • On September 1, client is reenrolled in her SALUD! plan. Claims are paid for by the client's SALUD! plan.

4. Addition of Medicare Benefits

A SALUD!-enrolled Medicaid client becomes eligible for Medicare benefits. The client's Medicare enrollment is added to Omnicaid. The following month the client is disenrolled from SALUD!. The client will also be retroactively disenrolled from the SALUD! based on the start date of the Medicare eligibility.

Can a Medicaid client change their SALUD! MCO?

Yes. Medicaid clients have the right to change their SALUD! enrollment within the first 90 days of plan enrollment. After that, they must stay in the plan for one year until they can change again. Some of the reasons clients elect to change plans include:

  • Moving

  • Another family member's SALUD! plan enrollment

  • Choice of doctors or hospital

  • Any reason at all as long as it is within 90 days of enrollment or after 1 year.

Because SALUD! enrollment is by month, a client who chooses to change MCOs usually has to wait until the following month before the change goes into effect. If the client waits until very late in the month, the change may not go into effect until the month after the following month.

So, if a client's SALUD! enrollment is effective June 1 and he decides to change his MCO and calls June 10 to change it, the new SALUD! MCO he selects will be in effect starting July 1. If the client calls on June 30, the new SALUD! MCO he selects will not go into effect until August 1.

In theory, clients can continue to change their SALUD! MCO every 90 days, but this is very rare.

Many factors can affect whether or not clients drop off SALUD! or change the SALUD! MCO in which they are enrolled. This is why it is important to check the client's eligibility and SALUD! enrollment status every time you see a patient.

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What are the rules for changing SALUD! MCO enrollment?

Medicaid clients have the right to change their SALUD! MCO enrollment within the first 90 days of plan enrollment. After that, they must stay in the plan for one year until they can change again. Some of the reasons clients elect to change include:

  • Moving

  • Another family member's SALUD! plan enrollment

  • Choice of doctors or hospital

  • Any reason at all as long as it is within 90 days of enrollment or after 1 year.

Enrollment changes are not immediate as SALUD! plan enrollment runs on a monthly cycle. See 'Can a Medicaid client change their SALUD! MCO?' for a sample time frame.

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If I provide services to a Medicaid client who is enrolled in a Managed Care program and I am not enrolled with that program, will FFS Medicaid reimburse me for those services?

No. As a Medicaid provider, it is your responsibility to be aware of the client's eligibility, including managed care enrollment. If you wish to enroll in the client's managed care organization, contact the plan for information about enrollment

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Q7-CD: A claim was denied because the DOS was within a Managed Care (MCO) enrollment period. How can I get this claim paid?

The denial was due to one of the following reasons:

Check the client's eligibility for both SALUD! and ValueOptions enrollment, and submit to the appropriate plan for payment. ACS does not process MCO claims; they must to be submitted to the appropriate organization.

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What are the most common Managed Care claim denial reasons?

0094 - Service Dates Overlap Managed Care Enrollment Period

0101 - Service Dates Within Managed Care Enrollment Period

0106 - Inpatient Claim: Service Dates Within Managed Care Enrollment Period

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Children's Medical Services (CMS)

What is it?

Children's Medical Services (CMS) is a state-funded program which provides services and support, medical care, and referrals for children with chronic conditions and preventive care for children who qualify for CMS' Healthier Kids Fund. Although CMS is assigned a COE, CMS is NOT part of NM Medicaid. Any eligibility inquiries for a client who only has CMS coverage ONLY for that DOS will return the response that the client is not eligible for DOS.

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What is the CMS-309 form?

Some clients' services are authorized with the Children's Medical Services Authorization/Eligibility Approval (CMS 309) form. This form is typically brought by the client or sent by the CMS office to your office. These forms are specific to the authorized service. Medicaid will only pay for those authorized services.

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What if there is a problem with the CMS 309 form or the services authorized?

If you as the service provider feel that the authorized services are not sufficient to complete an exam or report, you must contact the office that issued the authorization.

Do not add to or change the form. Only the issuing office can make changes to the form.

NM Medicaid will not pay for services authorized on the CMS 309 form that were furnished prior to the date(s) of service on the CMS 309 form. If, due to an error, the ISD 309 form is dated after the services were furnished, the issuing office must change the form to specifically authorize the prior services furnished.

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Which procedures are covered/not covered by the Children's Medical Services program?

CMS is not part of NM Medicaid. Contact the NM Department of Health for further information on covered procedures.

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Which services require prior authorization for a Children's Medical Services clients?

Children's Medical Services requires prior authorization for ALL services.

How do I bill Children's Medical Services (CMS) claims?

CMS claims are similar to billing for a Medicaid client with the following differences:

  • Always use the 14 digit CMS client ID number that begins with 07
  • Always enter the PA number (BOX 23 on CMS-1500, BOX 63 on UB04, and BOX 2 on ADA 2006)
  • If the PA number is 8 digits, add 2 zeros in front of it.
  • Always attach the CMS 309 form or a copy of the Healthier Kids card - this helps establish eligibility and/or authorizes the services being billed.
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How do we bill pharmacy claims for CMS?

If a CMS PA (CMS 309) for a pharmacy service is not on file, the provider needs to first contact the Point of Sale Help Desk and then fax the CMS PA (CMS 309) to them.

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What are the most common denials for Children's Medical Services claims?

0149 - Client / Partial Eligibility

0307 - Client Not Found: Eligibility/Authorization Attached

0711 - Invalid Authorization Attached

1290 - No Client eligibility for DOS



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Claims Submission

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When can I file a claim electronically and when do I have to file a claim on paper?

You must submit claims electronically within the 90 days from DOS. I.H.S (221 provider type) claims should be submitted electronically within 2 years from DOS. School Based (345 provider type) claims should be submitted electronically within 120 days as outlined in the Timely Filing Limits. DRG inpatient hospital claims should be submitted electronically 90 days from the last DOS.

Once the claim is past the 90 days from the initial DOS, the claim must be submitted on paper with proof of timely filing attached. School based (345 provider type) claims should be submitted on paper once the claim is past 120 days from the initial DOS. Claims for services that require attachments need to be submitted on paper along with the attachment.

Click here for information regarding proof of timely filing.

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How do we submit claims for clients with retroactive eligibility?

  • If a client's eligibility was added to Omnicaid AFTER the last DOS on the claim and the effective date of the eligibility is prior the eligibility add date, the filing limit is 120-days from the date the eligibility was added to the system.
  • Please note: For nursing home and ICF-MR residents' eligibility to be considered retroactive, the retroactive eligibility must meet the criteria above and the LTC span (abstract) must be added after the claim's last DOS. It is not enough just for the LTC span to be added late. The client's eligibility must be retroactive, too.
  • No special attachment is needed to file a claim for a client who has retroactive eligibility.
  • Claim can be filed electronically.

Click here for more information about retroactive eligibility.

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How quickly can I check on the status of a claim?

That depends upon how and when the claim was submitted. If it was submitted electronically prior to the day's claims pickup time, you can check on it the following day.

For claims submitted on paper, review the OCR Do's and Don'ts. If you followed the Do's and avoided the Don'ts, allow time for delivery to our facility plus 2-3 days to process the claim from the date of receipt.

Otherwise, allow time for delivery to our facility plus approximately 10 days to process from date of receipt (check yourRA newsletter for this week's data-entry timeline). Please note that some claims cannot be processed using the OCR and will have to be hand-keyed.

Click here to go toClaims Status Inquiry.

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What is the payment cycle once a claim is received and ready for payment?

We process claims all week. All claims processed by the end of business on Friday will show up on the following week's RA. The payment cycle runs on Friday night, which creates your RA and check.

You can access your RA online as early as Sunday. To register on the web portal go to: https://nmmedicaid.acs-inc.com/nm/general/home.do

Checks are mailed no later than Wednesday of each week.

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Where can I find more information about why my claims have denied?

Click here to go to the Denials List for a comprehensive listing of common claim denial reasons. The information there will help you understand why your claim denied and what you need to do to get the claim paid.

Click here to go to Most Common Claim Denial Reasons for All Provider Types, in which claim denial reasons are organized by categories (Eligibility, Timely Filing, etc.). You can link to Denials List from there as well.

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Why do claims pend/suspend?

The majority of claims sent for processing are adjudicated by the Omnicaid system automatically.

Claims that Omnicaid cannot make a decision on are pended for human review or are awaiting eligibility updates. The claims are reviewed in the order in which ACS received them.

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Should I resubmit a pended claim?

No. First wait to find out what happens with the claim. If the claim denies, the claim denial reason will indicate what caused the claim to deny. The Denials List of the web portal can help you get this claim paid.

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Does the TCN 'mean' anything?

There is some useful information on a TCN. Click here for the breakdown of a TCN #.

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What format should the signature be in?

The signature can be:

  • Signed
  • Stamped
  • Typed

As long as the signature consists of a person's name and not the name of the facility or 'Signature on File.'

Special Note for Payerpath Billers: When you print out a claim from Payerpath to submit to ACS on paper, be sure to sign the claim. Only a 'Y' prints out from Payerpath. This is not an acceptable signature for a paper claim.

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How do I resubmit a claim?

When a claim has denied, an Adjustment/Void form is NOT required to reconsider the claim. Resubmit the claim with the correction instead of filing an adjustment. The correct method of filing a resubmission is as follows:

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What are the advantages to billing electronically?

The advantages for you as a provider include:

  • Complete control over data entry
  • Receive claim status (Paid/Denied/Suspending) in as little as a week
  • Receive payment in as little as a week
  • Confirmed receipt of the submitted claims
  • Eliminates expense of mailing claims
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How do I submit claims electronically?

You can submit claims electronically for free using Payerpath. Read the questions below for more information on Payerpath. You can also hire a 'clearinghouse' that will submit electronic claims for you. You can purchase and use your own software to submit electronic claims.

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What if we submitted a claim electronically, but it did not show up on the RA?

Contact the HIPAA Help Desk for assistance with electronic claims.

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How do I sign up for Payerpath?

Medicaid providers can download the Payerpath registration form from this website. Click here for registration form (Excel version). The completed form should be faxed to Payerpath at 804-323-5848.

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How do I reach Payerpath?

You can go to their website, http://www.payerpath.com/. You can call customer support at 804-560-2400.

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Do I need to sign up with the State's translator?

Submitting providers (providers that submit claims directly to the translator using their own or purchased software), billing agents, and clearinghouses must complete a trading partner agreement and test their claims submissions. Once the State has received the trading partner agreement, the trading partners will be notified by email with instructions regarding how to submit test files. The signed trading partner agreement is the mechanism the State uses to consider a provider, billing agent, or clearinghouse to be "signed up" with the translator.

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Do I need a trading partner agreement if I am going to use Payerpath to submit HIPAA standard electronic claims?

NO! If you are going to use Payerpath, you do not need a trading partner agreement.

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What does the state's translator do?

The translator, formally called the Transaction Interface Exchange (TIE), receives HIPAA standard electronic transactions, checks them for compliance with HIPAA standards, and then sends them to the NM Medicaid claims processor (ACS) for adjudication.

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What happens if the claim sent to the translator does not meet HIPAA standards?

The claim is rejected by the translator and will NOT be sent to ACS for adjudication.

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Will I know if the translator has rejected my claim?

If you submit claims directly to the translator, you will receive a 997 report detailing the claims that were accepted (and sent on to ACS) and those that were rejected (and NOT sent to ACS). If you submit using a clearinghouse or billing service, the clearinghouse or billing service will receive the 997. If you are using Payerpath, Payerpath will notify you of rejected claims.

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What if I don't understand why the translator rejected my claim?

Contact the HIPAA Help Desk for assistance. They will make the appropriate inquiries and assign a job ticket to your inquiry.

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How frequently does the translator send claims to ACS for adjudication?

The translator sends claims multiple times per day, based on the volume and frequency of claims received.

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Since my electronic claims have to go through the translator before they get to ACS, when does timely filing begin?

The translator does not affect Medicaid timely filing rules. You are still required to submit claims according to the timely filing guidelines.

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Since my electronic claims go through the translator, how is timely filing calculated?

For purposes of calculating timely filing, HSD and ACS have taken into account that electronic claims have to go through the translator prior to being received by ACS. Providers can be assured that if their electronic claims are submitted to HSD within the filing limits, ACS will recognize this when the claims are processed and adjudicated.

Always submit claims promptly to avoid missing filing limits.

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What do we do if TIE (the state translator) / ACS did not receive the claim?

You must check your report from TIE to confirm transmission. If you need assistance with a claim submitted to the translator, contact the HIPAA Help Desk for a job ticket number. The Help Desk can research the electronic transmission and identify any system issues that caused the error.

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Paper Claims

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What is OCR?

ACS is now using Optical Character Recognition (OCR) technology, which allows us to read paper claims electronically, resulting in shorter claim turn-around and improved quality. OCR provides accurate data entry, reduces errors, and allows faster claims processing, without waiting for manual data entry. To ensure the best results, review the OCR Do's and Don'ts for recommended procedures for paper claim submission.

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What are the recommended procedures for paper claim submission?

For paper claims to be processed in the fastest and most accurate manner, follow the do's and don'ts for OCR. If you cannot follow the do's and don'ts, be sure your claim is filled out properly, is legible, and that your NM Medicaid provider number is in the proper location on the claims.

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If I want to reduce human error in the paper claims submission process, what should I do?

Your paper claim will process quickly and accurately if OCR technology can read your claim. Just follow the OCR Do's:

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OCR DO'S:

  • Use an original, standard red-dropout form (CMS, UB, or ADA 2002)
  • Use machine print
  • Use a clean, non-proportional font (such as Courier)
    • Note: a non-proportional font is also called 'fixed-width' or monospace font.
    • Note: each letter/character in a non-proportional font has the same width, regardless of the character used, which makes it easier for the OCR to recognize characters.
  • Use black ink
  • Print claim data within the defined boxes on the claim form
  • Print only the information asked for on the claim
  • Use all capital letters
  • Use a laser printer for best results
  • Use white correction tape for corrections
  • Submit notes on 8�' x 11' paper
  • Use an 8-digit date format (10212006 for October 21, 2006)
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What if I don't follow the OCR guidelines? What will happen to my claim?.

If your claim has some of the 'OCR Don'ts' on it, this will not cause your claim to deny; however it will require manual intervention in the processing of your claim. Manual intervention means that additional human errors can be introduced and it will take longer to process your paper forms.

Not all claims can be processed quickly using the OCR due to information that must be written on the claim. These claims include:

  • HMO Copays
  • Medicare Replacement / Senior Plan
  • Medicare Non-Covered Service

However, this is OK. The claim will still process faster if it is submitted with the other OCR 'Do's.' So, please be sure to include this written information on the paper claim as necessary.

If you avoid the Don'ts below when you are able, your claims will process faster:

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OCR DON'TS:

  • Don't hand print or hand write your forms
    • If you must hand print, use neat block letters that stay within field boundaries
    • The signature box is an exception to this rule.
  • Don't use copies of claim forms
  • Don't use stamps, labels, or stickers
    • Stamps may be used in the signature field
  • Don't use dashes or slashes in date fields.
  • Don't use fonts smaller than 8 point
  • Don't use a dot matrix/impact printer, if possible
  • Don't use correction fluid
  • Don't put notes on the top or bottom of the claim form
  • Don't enter 'none' or 'NA' if there is no information; just leave the box blank
  • Don't fold claim forms
  • Don't use proportional fonts
    • Courier is an example of a font that is not proportional (USE)
    • Times New Roman is an example of a proportional font (DO NOT USE)
  • Don't use mixed fonts on the same form
  • Don't use italics or script fonts
  • Don't include narrative comments in treatment and diagnosis fields
  • Don't print slashed zeros
  • Don't use highlighters to highlight field information as this often causes the field data to turn black and become unreadable
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How will I know if my claim was entered by OCR or manually?

You will not be able to tell, but if you believe there may be a problem with the OCR, call the Provider Relations Help Desk and the claim can be researched.

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Are all paper claims scanned / OCR'd?

All paper claims submitted on the red 'drop' forms will be scanned and OCR'd. Claims submitted on black forms will be scanned, but cannot be read by the OCR.

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Will my claim be processed faster if I send it directly to provider relations, a field representative, or the research department?

No. If you must bill on paper:

  • If you are simply submitting claims, do not put 'Provider Relations' or 'Research Department' on the envelope:
    • These claims are reviewed in provider relations.
    • That can add up to 10 business days BEFORE the claims are sent to the mailroom for processing.
  • If you send claims to 'provider relations' or 'research department,' please include a cover sheet with a clear explanation of the problem/issue.
  • ACS does not have an 'appeals' department. Claims addressed to the appeals department go to the Provider Relations unit.
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Which claims always require paper claims submission?

Claims that always require paper claims submission due to attached forms include the following:

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What are the electronic claims submission deadlines?

Payerpath

For claims submitted through Payerpath, Payerpath picks up claims marked for send at 8 am. Claims submitted before Payerpath picks them up at 8 am on Thursday are guaranteed to appear on the following week's remittance advice. Sometimes claims picked up later than 8 am on Thursday will also appear on the following week's RA, but it is not guaranteed.

TIE (State Translator)

All HIPAA formatted electronic claims submitted directly to the translator (not submitted using Payerpath) must be transmitted no later than 11 pm Thursday in order to be guaranteed to be on the following week's remittance advice. Sometimes claims transmitted later that 11 pm on Thursdays are on the following week's RA, but this is not guaranteed.

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My client's claim was denied due to a duplicate bill. How can I locate the original claim?

If the duplicate claim was paid to the same provider number, the related TCN and RA date is provided for reference on your RA and in our online claims inquiry system. Be sure to use EOB Troubleshooting for assistance with resubmitting the claim.

If the TCN is not on your RA, contact the Provider Relations Help Desk so that they can identify the original claim and to clarify why your claim denied as a duplicate.

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Which services are not generally covered by Medicaid?

Please refer to the Program Policy Manual, Medicaid General Benefit Description for an overview of noncovered services.

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If a service has been determined to be medically necessary, does that mean that the service is a covered benefit of New Mexico Medicaid?

Not necessarily. Refer to Program Policy Manual, Medicaid General Provider Policies for more information about how medically necessary services are defined. Also review the Program Policy Manual, Medicaid General Benefit Description for an overview of noncovered services.

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Does a prior authorization for a service guarantee the client is Medicaid eligible?

No. Prior authorizations determine medical necessity, not a client's Medicaid eligibility.

What are the most common electronic and paper claim denials?

0268 - Claim Exceeds Filing Time Period

0345 - Claim Exceeds Filing Time Period (no attachment)

0670 Sterilization Form Required

0673 Diagnosis Sterilization Form Required

0675 Hysterectomy Form Required

0756 - TPL Payment is less than 20%



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Adjustments and Voids

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What's the difference between a void and an adjustment?

An adjustment is used to make changes to a previously paid claim usually with the expectation that the payment will increase or decrease. Sometimes, however, adjustments are submitted to correct billing errors, such as the number of units billed on the original claim.

A void is used to completely 'negate' a paid claim. Voids result in recoupment of the payment. Void a claim when you billed the claim in error (example: client did not inform you that she had TPL coverage).

Only PAID claims can be voided or adjusted. DO NOT resubmit a denied claim with an adjustment sheet attached.

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Is proof of timely filing required for an adjustment/void?

Yes, proof of timely filing is required for adjustments and voids.

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Required for an adjustment....

You must attach
proof of timely filing to show that the adjustment request falls within the 90 days of the date of the RA where the claim paid.

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Required for a void...

You must attach
proof of timely filing to show that the adjustment request falls within 90 days of the date of the RA where the claim paid.

However, if you are simply refunding money to the state, no proof of timely is required.

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Can I submit an adjustment or void without the Adjustment/Void form?

Adjustments and voids will not be considered unless submitted on the
Adjustment/Void Request Form with the corrected claim and original RA attached.

Adjustment requests are not accepted by telephone, unless the mispayment was due to a keying error on ACS' part. In this case, contact the Provider Relations Help Desk. A representative will review the claim and submit the adjustment on your behalf as appropriate.

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What happens if a claim that has been paid is resubmitted without an Adjustment Form attached?

The claim will process as an original claim and will deny as a duplicate against the original paid claim.

ACS recommends the following best practices for Adjustment/Void submission:

  • Attach a copy of the RA to all adjustment and void requests.
  • For voids, send a void request and allow the funds to be recouped on the RA instead of mailing a check.
    • However, when refunding monies for claims paid close to 3 or more years ago, please send a completed adjustment/void form and a check for the exact amount of the refund.
  • For adjustments, submit a complete adjustment request (with the corrected claim and RA attached) and let the difference be recouped or credited on the RA.
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I've read about mass adjustments in theRA Newsletter, could you tell me why they're done?

Mass adjustments are always approved by the State (MAD). There are various reasons for mass adjustments:

  • Rate changes for specific provider types
  • System changes that have affected claims
  • Specific provider issues

For your reference, the TCN for a mass adjustment will always begin with the number '4.' Click here for more information about 'What can a TCN tell me?'

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I found a claim on our RA that paid, but one of the line items denied. Do I need to submit an adjustment/void for that claim and resubmit the whole thing?

No, if the claim was submitted on a CMS 1500 or ADA 2002 Dental claim form, and one or two items denied, you can correct the problem and rebill the denied services on a new claim. If the services were billed using a UB-04, contact the Provider Relations Help Desk for assistance in determining how to resubmit the claim.

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I resubmitted a paid claim due to errors on the original. Why did the resubmitted claim deny as duplicate?

Be sure to fill out anadjustment/void form for claims that previously paid, even if Medicaid paid the original claim at $0 or if the adjustment will not result in a net change in the amount paid.

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Can I submit an adjustment and a rebilled claim together?

Yes, in fact, you must do so. An adjustment cannot be processed without a corrected claim. Remember, an adjustment means you are replacing the original claim with a new claim.

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We were paid for a claim but the amount was less than expected...what happened?

Check your EOB for code 7238:

EOB 7238 = Units cut back to Medicaid allowed amount

The units used to bill the procedure exceeded Medicaid's allowed units for the procedure. It is in your best interest to review the claim to ensure that the correct procedure code and units were billed. If you billed an incorrect procedure code, void the paid claim and resubmit with the correct code.

If EOB 7238 is not present, check to be sure the number of units were billed and/or keyed correctly. Check for other billing or data entry errors that might have affected payment.

For Medicare crossovers, check your EOB for code 9001 and click here to go to the Medicare section of this FAQ.

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What if the claim was paid, but one of the lines was denied, do I submit an adjustment to get the denied line paid?

It depends on the claim form submitted. If the claim was submitted on a CMS 1500 or Dental claim form, and one or two items denied, you can correct the problem and rebill these services on a new claim. If the services were billed using a UB-04, contact the
Provider Relations Help Desk for assistance in determining how to resubmit the claim.

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What are the steps for submitting an adjustment?

  1. Complete Adjustment/Void form, see Adjustment/Void Instructions
  2. Fill out a corrected claim form - complete all information as it was on the original claim, with the exception of the changes being made.
    • You must include all lines from the original claim (unless that is the error that you are adjusting) because the adjustment consists of a credit of the full amount of the original claim and will only debit back what you have put on the corrected claim form.
  3. Attach a copy of the page of the RA the claim paid incorrectly in
  4. Make and keep a copy for your files
  5. Mail to ACS.
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What are the steps for submitting a void?

ACS recommends handling the void process through the
RA (allow the money to be recouped against paid claims on the RA) rather than sending a refund check.

  1. Complete Adjustment/Void form, see Adjustment/Void Instructions
  2. Attach a copy of the page of the RA the claim paid incorrectly in
  3. Make and keep a copy for your files
  4. Mail to ACS.
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Can I adjust a claim by telephone?

No. Adjustments will not be considered unless submitted on the adjustment request form, with a copy of the remittance advice and claim attached.

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I need to adjust a previously adjusted claim. Which TCN do I use?

You can only adjust the DEBIT of the adjusted claim. You cannot adjust the credit or the original claim. For more information on Adjustment/Void TCNs, click here.

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What if I just need to make a change to the prior authorization number used on the claim?

What if I just need to make a change to the date(s) of service?

What if the change will not result in a monetary adjustment of the original claim, do I still need to submit an adjustment?

Any change to the original claim still requires an adjustment even if the adjustment will not result in a monetary change. The original claim will still be debited and then credited to your account to reflect the changes.

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How quickly after I submit a void can I resubmit a claim?

You must wait until the void shows up on your RA to resubmit a claim. Otherwise, the newly resubmitted claim will deny as a duplicate.

You can also submit a void request with a new claim attached and request that the adjustments department submit your new claim after the void has been processed.

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Can I adjust a claim on the web or through Payerpath?

No. Not at this time.



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Remittance Advice and RA Newsletter

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What is the remittance advice?

What does my RA tell me about my claims?

The Remittance Advice (RA) is also known as an Explanation of Benefits (EOB), and is sent weekly along with any payment. The RA details the claims that a provider has submitted, explains which claims were paid or denied, and indicates which claims have been pended. Any financial transactions and a financial summary statement are included at the end of the RA.

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When is the RA issued?

Can I access my RA on-line?

RAs are created every Friday night during the weekly payment cycle. You can access your RA online as early as Sunday of each week. To sign up go to: http://nmmedicaid.acs-inc.com/signup.html

The RA andRA Newsletter are mailed by no later than Wednesday of each week. Even if you were not issued a check, as long as you have claims or financial transactions that were processed the preceding week, you will still receive an RA and newsletter. If you were not issued an RA, you can still access the RA newsletter online to find out about updates at NM Medicaid and ACS.

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What do I do if I am having problems accessing my RA online?

Contact the
HIPAA Help Desk if you cannot read or get access to the RA.

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Can I access the RA Newsletter online?

Yes. You do not need to sign up to access theRA Newsletter. It is posted on the Thursday following the week's RA. Be sure to read theRA Newsletter even if you are not receiving an RA. It will help keep you up to date with issues related to Medicaid billing.

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How do I use my RA?

What do I do with my RA once I receive it?

Once you receive your
RA, compare it to the claims you have submitted and update your accounts receivable/patient accounting system:

  • Post Payments
  • Review Claim Adjustments
  • Account Reconciliation
  • Use EOB Codes to Identify Errors
    • Explains why claim denied or was not paid in full
    • If possible, resubmit claim with corrected information.
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Is an electronic RA available (HIPAA electronic RA 835)?

No. The state translator (TIE) does not produce a HIPAA standard electronic RA (HIPAA 835).

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I noticed that we only have so many weeks of RAs available on line, how can I archive them?

RAs are available online for a maximum of 8 weeks. As a NM Medicaid provider, it is your responsibility to maintain your RA records for 5 years. Due to space constraints and the ability to search electronic files, is to your advantage to store your RAs electronically.

Electronic saving/storage options used by providers include:

  • CD-ROM
  • Hard Drive
  • EDI

Be sure to backup whichever method you choose!

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What happens if I attach an RA to a claim that does not need one?

If you attach an RA to a claim as
proof of timely filing when it does not need one, it will not affect the processing of the claim.



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Remittance Advice (RA) Walkthrough

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What's on the RA?

Can you walk me through each section of the Remittance Advice?

The RA contains up to 8 main sections:

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Banner Page

This page contains the following information:

  • Provider ID
  • Mailing address we have on file
  • ACS mailing address
  • Sometimes contains special messages
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Paid and Denied Claims

This section lists all claims that have paid or denied in the remittance cycle. Note that claims are reported by claim type. For example, if a doctor's office submits claims for professional medical services and also receives crossovers payments from Medicaid, the RA will have sections for 'Claim Type B - Medicare Part B Crossover' and 'Claim Type P - Practitioner Claim.'

If a hospital bills for both inpatient and outpatient hospital facility services, the RA will be sorted by 'Claim Type A - Institutional Crossover,' 'Claim Type C - UB04 Medicare Part B Crossover,' 'Claim Type I - Inpatient Hospital' and 'Claim Type O - Outpatient Hospital.'

Within each section, claims are listed in alphabetical order by client last name with the exception of pharmacy RAs. On an RA issued to a pharmacy, the claims are sorted by prescription number.

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Can I get the RA sorted in a different order such as by medical record number?

No. This option is not available.

Adjustments

Click here for more information on adjustments.

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What is the adjustment section on my RA telling me?

Adjustments are listed by claim type. Adjustments for each claim type will follow the listing of 'adjudicated' claims for that claim type. This is all indicated in the upper left hand corner on each page of the RA.

The adjustment sections of the RA show the status of adjusted claims. These claims have been processed for one of the following reasons:

  1. Because the provider submitted an adjustment/void to correct overpayment or underpayment.
  2. A system-generated mass adjustment for over or underpayment

All adjustments for one client ID are grouped together. Other claims are separated by a row of asterisks (*).

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How do I know which adjustments were submitted by our office?

How do I know which adjustments were generated by the state?

Look at the TCN:

  1. Adjustments for which someone in the provider's office submitted an adjustment/void form start with an '8' (because they were submitted on paper). Please note that if you have been working with an ACS Field Rep or Help Desk Representative, a paper adjustment could have been submitted on your behalf as they work to correct a claim payment issue.
  2. System-generated mass adjustments start with a '4'

Click here for more information on 'What can a TCN tell me?'

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What is a debit?

What is a credit?

For each adjustment, there are two sets of data.

The first set is the CREDIT:

  • This is the original claim payment being 'credited' back to Medicaid.

The second set is the DEBIT:

  • This is the replacement claim with the new payment being 'debited' from Medicaid (the State Treasury).

When the debit amount is greater than the credit amount (the original payment), NM Medicaid will pay the difference to the provider. When the credit was greater than the debit, the difference will be collected against the provider's current and, if applicable, future RA payment amount.

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When would Medicaid collect payment from future RA payment amounts?

An accounts receivable will be created when the provider has no paid claims on that RA cycle or only part of the amount owed by the provider is satisfied by the payment amount Medicaid owes on the RA. When this happens, a financial transaction will be listed in the 'Accounts Receivable' section of the RA for the amount still owed by the provider. That amount will post in the 'cycle increase' column in the Accounts Receivable section on the RA summary page.

 

If you have questions about a financial transaction that shows on your RA, please call the Provider Relations Help Desk. Please do not call ACS' financial department.

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The TCNs for my debit and credit look so similar that I cannot tell them apart, what's the difference?

Look at the twelfth digit of the TCN:

  • The CREDIT will contain a '1'

  • The DEBIT will contain a '2'

Click here for more information on 'What can a TCN tell me?'

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Voids

These claims have been processed because the provider submitted an adjustment/void to correct an error on the original claim. The person who filled out theAdjustment/Void form checked the Void box. The State (MAD) can also direct ACS to initiate a void through the mass adjustment process.

This typically means that the provider was paid in error and does not need to receive an adjusted amount for the claim. Sometimes there are enough problems with the original claim that it is too difficult to correct the claim with an adjustment; this is another situation in which the provider uses a void to negate the original claim and then resubmits a corrected claim.

Click here for more information on how to fill out the adjustment/void form.

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Pended Claims

The 'In-Process' section of the RA contains information about claims that are pended at ACS (as of the date that the RA).

You can review the following information in this section:

  • Client ID/Medical Record Number
  • Client Name
  • DOS
  • Billing Amount
  • TCN

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Why can't I see what is happening with pending claims on my RA?

In order to process claims correctly, some must be reviewed manually to ensure accurate claim processing. In the case of claims that require review, it is difficult for the system to indicate the exact nature of the problem.

The most common cause for pending claims is due to system checks for client eligibility. If the client's eligibility for the DOS on the claim is not on file at the time the claim is processed, the claim is listed as pending and then is 'recycled' by the Omnicaid claims processing system every night in case eligibility has been added. If no eligibility is added 40 days after the first DOS on the claim, the claim will deny.

See 'Why do claims pend/suspend?' for more information.

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Error Messages

This is the key to the EOB codes displayed in the adjudicated and adjusted claim sections of the RA. This section explains why claims or line items denied. It also indicates why claims can pay $0.00 or less than expected.

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Financial Transactions

This section of the RA contains 'gross level' financial transactions such as the creation of an account receivable, the recoupment of an account receivable amount against the payment owed or even an account payable. The term 'gross level' means these financial transactions are not associated with a particular claim or set of claims.

Some of the reasons gross level financial transactions are created include:

  • Providers owe money to MAD due to adjustments or voids and the amount owed cannot be completely satisfied on the RA where the monies owed were created. These adjustments could be provider initiated or state initiated mass adjustments.
  • The recoupment or payout (refund) may also be due to TPL issues.
  • A payout may be created due to a cost settlement
  • A payout may be created due to the refunding of money that the provider has returned in error.
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What is a Financial Control Number (FCN)?

An ACS-assigned unique identifier that is connected to all TCNs with which a financial transaction is associated. You can use the FCN to associate the financial transaction (recoupment or payout) the original claims.

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We received a TPL refund. How do we know which client to apply it to?

Contact the TPL Help Desk for assistance. They can identify the original claim information.

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How do I know which claims apply to a recoupment?

If the recoupment is due to adjusted or voided claims, you need to go to the RA on which those claims were originally voided or adjusted. Any funds not recouped on that RA become an account receivable and are applied to payments on future RAs. The money being recouped however applies to the voided or adjusted claims where the accounts receivable was created. All paid claims on subsequent RAs are still considered 'paid' even though the payment owed on those claims is reduced by the existing accounts receivable amount.

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What is the 'prior balance' amount in the Account Receivables section of the Remittance Summary page?

This is the remaining amount of an account receivable (A/R) that was set up on a previous RA. To find where the A/R amount was originally created, you need to go back through your RAs to find where an amount appears in the 'cycle increase' column in the A/R section.

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Remittance Summary

How do I read the Remittance Summary page?

This section summarizes all transactions processed for the current pay period, incorporating the data from previous sections of the RA.

The Remittance Summary consists of three parts:

Left Side 'Claim Transactions'

The left side summarizes all claim activity for this RA cycle:

  • Originals refers to paid claims. The total number of paid claims is provided in addition to the amount that Medicaid has paid for the claims.
  • Debit/Credit Adjustments refer to adjustments that were processed during this RA cycle. Refer to What is a Debit?/What is a Credit? for more information.
  • Voided refers to voids that were processed during this RA cycle. A void completely wipes out a previously paid claim.
    • For general information about Voids, click here for the Adjustment/Void FAQ.
  • Net Approved totals the previous four numbers, including any increase or decrease in payment generated through the adjustment/void process.
  • Pended refers to claims that are pended or pended. No payment amount is listed because Omnicaid has yet to make a decision on the claim.
  • Denied refers to claims that denied at the header level, which means that the entire claim denied (not just individual lines). No payment amount is listed because this claim was not paid.

Right side 'Financial Transactions'

The right side of the Remittance Summary details all financial transactions on this payment cycle that affect the amount on your warrant/check amount. Although a financial transaction may reduce or increase your check amount, it does not affect the amount that you were paid for the claims on this week's RA. You were paid in full for all of the 'Net Approved' claims. Financial Transactions are generated as a result of 'activity' related to previous weeks' claims.

Account Receivables refers to any recoupment activity that occurs on this RA.

  • Prior Balance is an accounts receivable created on a previous RA that has not yet been satisfied. Refer to your previous RAs' Financial Transactions section to identify the source of the prior balance.
  • Cycle Increase is an accounts receivable generated on this RA Refer to the Financial Transactions section on this RA to identify the source of the cycle increase.
  • Cycle Decrease is the amount of money from this RA applied to satisfy the accounts receivable balance. Although you were paid for all of the Net Approved claims on this RA, your payment could be $0 due to the cycle decrease.
  • Net Cycle refers to any accounts receivable amount remaining after cycle decrease. If there is a positive amount in the net cycle, there is a forward balance.
  • Forward Balance is carried over from the net cycle column. The amount in this column will be the 'Prior Balance' on the following week's RA

Payout refers to any payments issued that are not associated with a claim.

  • System payouts are paid out on the RA immediately after MAD directs ACS to issue the payout.
  • Manual payouts are paid on a date determined by MAD.

Payouts occur for a number of reasons including advance payments (payment to a provider before services are rendered) and cost settlements. Refer to Reading the RA, Financial Transactions for more information about Payouts.

Bottom Totals

The bottom section totals the claim and financial sections.

  • 'Net Claim Transactions' carries over the balance from the 'Net Approved' section.
  • 'Payouts' carries over the 'Net Cycle' positive balance from 'Payout.'
  • 'Receivable Recoupment' carries over the 'Net Cycle' negative balance from 'Account Receivables.'
  • 'Remittance Cycle Total' is the calculated difference between the paid claims on this RA and any payouts or recoupments (accounts receivable).
  • 'Check Number' refers to the provider warrant for payment. Note that the New Mexico Human Services Division issues the checks and ACS mails these checks on behalf of the state. ACS accepts no money from providers; all payments are made to/from the state.
  • 'Year-To-Date Total Paid' includes the total of all warrants issued to your provider ID this year
  • 'Year-To-Date Count' tallies the total number of paid claims for this year
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What information is on the RA newsletter and do I really need to read it?

All enrolled providers must keep abreast of any changes/updates related to Medicaid policy and the Omnicaid claims processing system. The RA newsletter is designed to help you stay on top of changes relevant to your practice and billing office. It is important to read the RA newsletter even when you do not have any paid claims so that future claims will be paid.

Here are some examples of information that you might find on the RA newsletter:

  • Information about Omnicaid
    • State-generated mass adjustments
    • Claims reprocessing
  • Billing Information
    • Electronic claims submission updates
    • Billing training events
  • Changes in claims processing
  • Changes at ACS
    • New Phone System
    • Web Portal

Click here to access the RA newsletter online (no log-in required).

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What is a TCN?

What can a TCN tell me?

Does the TCN have any meaning?

The TCN consists of 17 digits.

Example:

80631400174000002

The first digit represents the claim's submission media:

  • 1 = pharmacy claim (electronic AND paper)
  • 2 = electronic crossover
  • 3 = other electronic claim
  • 4 = system generated claim or adjustment
  • 8 = paper claim

The next two digits represent the year in which the claim was processed:

  • 05 = 2005
  • 06 = 2006
  • 07 = 2007

The two-digit year plus the next three digits represent the Julian Date, which indicates the date on which ACS received the claim.

  • In this case, the claim was received on the 314th day of 2006, or November 10, 2006.

The media code and Julian Date are the most useful information in the TCN.

 

The next group of numbers (00174) represents the batch number assigned to a group of claims.

The last group of numbers (000002) indicates the claim number within the batch.

 

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There's a mass adjustment on my RA, how do I find out what caused the mass adjustment?

Be sure to check the
RA newsletter for announcements concerning mass adjustments.

Mass adjustments are always approved by the State. There are various reasons for mass adjustments:

  • Rate changes for specific provider types
  • System changes that have affected claims
  • Specific provider issues

For your reference, the TCN for a mass adjustment will always begin with the number '4.' Click here for more information about 'What can a TCN tell me?'

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My client's claim was denied due to a duplicate bill. How can I locate the original claim?

My claim denied as an exact duplicate. How do I know what the paid claim is?

If the duplicate claim was paid to the same provider number, the related TCN and RA date is provided for reference on your RA and in our online claims inquiry system. Be sure to use EOB Troubleshooting for assistance with resubmitting the claim.

If the TCN is not on your RA contact the Provider Relations Help Desk so that they can identify the original claim and to clarify why your claim denied as a duplicate.

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Why didn't I get an RA last week?

RAs are available on the portal to providers who had claims that adjudicated during the preceding week. This includes paid, denied, or pended claims. Providers who had any financial transactions (such as a recoupment) will also be issued an RA available on the portal.

The RA newsletter is available on the ACS website at: Provider Information



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Client Eligibility

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How do I determine a client's eligibility for Medicaid?

Ways to Check Medicaid Eligibility:

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Why would I want to use online eligibility inquiry (or AVRS) instead of talking to a real person?

You can now obtain your client's category of eligibility code usingonline eligibility inquiry (as well as through AVRS).

Online eligibility inquiry delivers 'real time' information - it is the same information from Omnicaid used by our help desks.

There is no limit on the number of inquiries that you can do.

  • You do not have to call back after a certain number of inquiries.
  • You are not limited by the number of dates that you can check for each client.

Online eligibility inquiry is available all day, every day so you can check eligibility at any time that is convenient for you.

An audit number is assigned to each inquiry. This number can be used to trace back to the inquiry record if there is a discrepancy between the information you received and the manner in which your claim processed.

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What information do I need to obtain when I check eligibility?

When checking eligibility, be sure to verify the following information:

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How often should I verify client eligibility?

As a rule, verify client eligibility every time you see the client. However, clients who are enrolled in SALUD! are enrolled for the entire month regardless of changes in eligibility. If the client is disenrolled from SALUD!, be sure to check eligibility every time you see the client until s/he is re-enrolled.

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What paperwork do I need to attach to my claim in order to establish the client's Medicaid eligibility?

It is not necessary to attach any paperwork to the claim to establish eligibility. In fact, ACS does not review any attachments related to Medicaid eligibility because all eligibility is submitted/transmitted electronically by the authorizing agencies. If the client's eligibility information is not in Omnicaid, then the claim will deny for 'Client not eligible' regardless of any attached paperwork.

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Is it possible to get incorrect information when I check eligibility using MEVS, AVRS or online inquiry?

Sometimes a data entry error by the user can lead to an incorrect response from our eligibility inquiry systems. Examples:

When staff checks eligibility, it is either written down or entered into your computer system. Be sure to write down information carefully!

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What should I do when checking eligibility for a newborn?

For newborns, always check the mom's eligibility first to determine if the mom was enrolled in SALUD! on the date the baby was born. If so, the baby is always enrolled in the same SALUD! MCO as the mom for the birth month as long as the baby was eligible for Medicaid in his/her birth month.

Click here for more information on billing for newborns.

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What does the category of eligibility mean?

What is a category of eligibility (COE)?

From Appendix 1:

To be eligible for Medicaid benefits, a client must meet the eligibility requirements for one or more specifically defined coverage groups. The COE code identifies the coverage group that the client qualifies for.

  • Federal and state law defines eligibility requirements for individual coverage groups.
  • Benefits may vary based on the client's COE.
  • In New Mexico, a client may be eligible in as many as four COEs at once.
  • Claims processing uses the COE to determine whether the services billed are covered by the client's COE.
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What are the categories of eligibility?

Link to State list of COEs.

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Why should I care about the category of eligibility?

Do I need to be concerned about the category of eligibility?

Certain COEs have limited benefits and special billing requirements such as co-payments.

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What are the categories of eligibility with limited benefits?

029 - Family Planning

What is it?

Medical Assistance for family planning services only.

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Which services does this COE cover?

  • Counseling services, laboratory tests, medical procedures, and pharmaceutical supplies and devices related to family planning purposes, e.g., birth control pills
  • Sterilizations, i.e., tubal ligations
  • Regular reproductive health exams/screenings, i.e., pap smears and sexually transmitted disease screenings
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Which services are NOT covered by this COE?

  • Abortions
  • Hysterectomies
  • Treatment services for infertility
  • Inpatient Services
  • Management or treatment of medical conditions/ problems discovered during screenings or caused by or following a family planning procedure, i.e., treatment for STDs, ultrasounds or cervical cancer

If your client receives an abnormal pap smear, she may be eligible for the Breast or Cervical Cancer Program (COE 052).

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What if my patient develops a condition that needs treatment that is directly related to a family planning procedure, such as a post-operative infection after sterilization? Is that covered?

When there are complications after a family planning procedure, the claim must be submitted to
MAD. In these cases, submit the claim to ACS and upon denial, appeal them to the state. Send your claim to MAD with a cover letter, medical records, doctors' notes, and any conditions related to the family planning procedure. The Medical Assistance Division considers these claims on a case-by-case basis.

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My client has the Family Planning Category of Eligibility (029) and desires a treatment that is not covered by this COE. What should I tell the client?

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What are the most common claim denial reasons for the Family Planning COE?

0029 - Service Not Family Planning Related

0035 - Pregnancy Related

What is it?

Medical Assistance for pregnancy-related services only.

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Which services does this COE cover?

  • Pregnancy related services only
  • Prenatal care
  • Delivery
  • 2 months of postnatal care
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Which services are NOT covered by this COE?

  • Abortions (elective)
  • Vision, Dental, Hearing
  • Psychiatric/Psychological
  • Chiropractic
  • Plastic Surgery (elective)
  • Anything not medically related to the pregnancy
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My client has Pregnancy Related eligibility and her claim was denied due to the service not being pregnancy related (0707). This was for an OB visit, why did the claim deny?

When Pregnancy-related claims are processed,
Omnicaid looks at all relevant codes on the claim to determine that the service was pregnancy related: diagnosis code, revenue code and/or procedure code. Be sure that you have used codes that correspond to pregnancy-related conditions.

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This claim was for a complication related to the pregnancy. Why did this claim deny?

While
Omnicaid looks at codes to determine whether or not the claim was pregnancy-related, sometimes the system does not detect a connection between the client's pregnancy and a condition or procedure. If a claim like this is denied by ACS, send your claim to MAD with a cover letter explaining why the procedure is pregnancy-related, medical records, doctors' notes, and any conditions related to the pregnancy. The Medical Assistance Division considers these claims on a case-by-case basis.

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My client has COE 035 (Pregnancy Related), but has trouble making it to appointments. Will Medicaid cover transportation costs?

Yes. Transportation to a Medicaid provider is a benefit of the pregnancy related COE.

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What are the most common claim denial reasons for the Pregnancy Related COE?

0707 - Service Not Pregnancy-Related

035 - Pregnancy Related (Presumptive Eligibility)

What is it?

Short-term (60 days or less) Medicaid coverage for pregnant women so that they can receive prenatal care while Medicaid eligibility is being established.

Which services does this COE cover?

Same as non-presumptive eligibility for pregnancy except Medicaid will not pay for inpatient claims when the client's COE is presumptive. See EOB 0314 for further information.

Which services are NOT covered by this COE?

Same as Non-presumptive eligibility for pregnancy plus ALL inpatient services.

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What are the most common claim denial reasons for pregnancy COE?

0707 - Service Not Pregnancy-Related

0314 - No Inpatient Services for Presumptive Eligibility

041, 044 - Qualified Medicare Beneficiary (QMB)

What is it?

QMB pays for Medicare premiums as well as the deductible and coinsurance amounts on Medicare-covered services. To be eligible, the applicant must already have, or be conditionally eligible for Medicare Part A (Hospital Insurance).

041 = QMB - age 65 and over

044 = QMB - under 65

Which services are NOT covered by this COE?

For QMB clients, Medicaid will only pay for the deductible and co-insurance amounts on Medicare-covered services. For QMB, Medicaid does not pay for services that are denied or not covered (such as dental services) by Medicare.

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What are the most common claim denial reasons for QMB claims?

0266 - QMB Client Eligible for Medicare Crossovers Only

052 - Breast or Cervical Cancer Program

What is it?

Managed by the NM Department of Health, the Breast or Cervical Cancer Program is Full Benefits Medicaid. Women who may be eligible for this program are/have:

  • Met screening criteria as set forth in the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
  • Under 65 years of age
  • Uninsured

This COE requires diagnostic testing by a contracted CDC provider that results in a diagnosis of breast or cervical cancer including pre-cancerous conditions.

Which services does this COE cover?

This COE has full Medicaid benefits.

062, 063, or 064 - State Coverage Insurance

What is it?

State Coverage Insurance (SCI) is a program to increase insurance coverage among workers whose employers don't offer health insurance and among the self-employed.

  • SCI is NOT Medicaid even though clients are given a COE by ISD
  • The SCI Health Plan they have enrolled in may issue insurance cards; but SCI enrollees are NOT issued NM Medicaid cards..
  • ACS and SALUD! MCOs will ABSOLUTELY NOT pay claims for SCI enrollees.

Follow the links below for more information about these plans:

071 - SCHIP (State Children's Health Insurance Program)

What is it?

State Children's Health Insurance Program (SCHIP) is a program that provides Medicaid to children under 19 whose family income is between 185-235% of the Federal Income Poverty Guidelines.

Which services does this COE cover?

SCHIP includes full Medicaid benefits, but clients may owe co-pays for some services.

 

074 - WDI: Qualified Working Disabled/WDI (Working Disabled Individuals)

What is it?

Disabled working individuals, who do not qualify for Medicaid under any other programs for disabled individuals, may be eligible for this program.

Which services does this COE cover?

WDI includes full Medicaid benefits, but clients may owe co-pays for some services.

085 - Emergency Medical for Undocumented Aliens

What is it?

Also referred to as EMSA, this is coverage of emergency services for certain undocumented or ineligible aliens who meet all eligibility criteria for an existing Medicaid category except for alien status. The provider must do both of the following:

  • Provide bona fide emergency medical services to the alien must
  • Referred the alien to the local Income Support Division (ISD office

If the client is found eligible by ISD, s/he must notify the provider so that the claim can be submitted to the utilization review (UR) contractor, Molina. Molina Healthcare is the new UR contractor as of 07/01/2009.

Which services does this COE cover?

Coverage is available only for emergency services approved by Molina and only for the duration of the specific emergency.

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What are the most common claim denial reasons for EMSA/Alien Emergency claims?

1289 - Client Information Not Available - Alien Emergency

1291 Client Not Eligible - Alien Emergency Attachment

90 - 96 HCBS Waiver Categories of Eligibility

What is it?

Categories 90-96 are for Home and Community Based Services Waivers.

Recipients in these programs are persons who qualify both financially and medically for institutional care but who remain in the community.

Which services does this COE cover?

Clients with an HCBS Waiver COE are eligible for full benefits plus waiver services.

The kinds and quantities of waiver services are determined based on case management assessments and the development of an Individual Service Plan. All waiver services must be authorized by the ISP. Physical health services (not included on the waiver) are paid for by SALUD! unless the client is exempt.

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What are the most common claim denial reasons for waiver claims?

0141 - Client ID not on file

Special notes for Waiver Providers:

The waiver client's eligibility depends on receiving services for 30 days. Once that occurs, they are made eligible back to the month when their services began.

However, eligibility doesn't get to ACS until at least a month after receiving services, which can lead to eligibility denials in the meantime.

To avoid this denial for case management assessments that are performed prior to the client's eligibility, enter a 14-digit client ID as follows:

  • The 3-digit Category of Eligibility (COE) for the program they are being assessed for, 2 zeros, and then the SSN.
  • Example: 09600111223333
  • The claim will not be paid if the Client ID is not entered as described above.

This applies to case management assessments ONLY.

Once the client has received 30 days of services, checkonline eligibility inquiry or AVRS to see if the eligibility is on file. If so, submit or resubmit the claim.

0436 - Authorization Required/PA is missing/invalid

0437 - Procedure Not Covered on DOS

0502 - PA / Client Conflict

0504 - Authorization/Modifier Conflict

Special notes for Waiver Providers:

Check the online PA Inquiry to make sure that the procedure code and modifiers you used are match the procedure/modifier combinations authorized by the PA.

0510 - Authorization/Provider Conflict

0511 - Authorization/Service Conflict

Special notes for Waiver Providers:

If the PA's information doesn't match the approved MAD-046, contact BCBS to get the PA corrected.

0518 - Authorization Line Status Denied

0546 - Procedure Requires Price

0605 - Authorization / Service Date Conflict

0958 - Client not eligible for Waiver services

9617 - Prior Authorization Used or Units Billed Greater than Remaining PA

9727 - Prior Authorization Not on File


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Should I bill claims for services provided in the first 30 days, even knowing the claim will deny?

It is up to the provider to determine whether they want to go ahead and submit claims knowing the denial will occur or waiting until after eligibility is added in the system. You have 90 days from the first DOS on the claim to file; waiting 30 days will not affect your filing limit. Assuming the claim is submitted within 90 days from the DOS, you have an additional 90 days from denial date to resubmit for payment.

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What is presumptive eligibility?

Presumptive eligibility is a temporary determination of Medicaid coverage, 'effective from the date of the eligibility determination until the last day of the following month'. Presumptive eligibility is typically extended to pregnant women and to children so that they may receive health care services while ISD reviews their Medicaid application. Medicaid will pay for services during the presumptive eligibility period even if the client is ultimately determined ineligible for Medicaid. However, inpatient claims are not covered for women with pregnancy-related presumptive eligibility.

Presumptive Eligibility is effective from the date of the eligibility determination until the last day of the following month. This means Medicaid will pay for covered medical services accessed during this time.

What are the categories of eligibility with limited benefits?

Follow these links to find out more about each COE and associated claim denial reasons:

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What are the categories of eligibility that may owe a co-payment?

Follow links to find out more about each COE and common claim denials:

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How do we bill for State Coverage Insurance (SCI)?

If you do not know which SCI plan the client has enrolled in, you can useonline eligibility inquiry to find out. Once you know the client's SCI plan, you must submit the claim directly to the plan. Even though clients are assigned SCI eligibility through ISD, SCI is not Medicaid. Claims for SCI clients will deny for Medicaid ineligibility.

Follow the links below for more information about these plans:

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My client started receiving Medicaid benefits after the date of service (DOS). OR My client had a lapse in Medicaid coverage that does not cover the date of service. Can my client obtain retroactive coverage?

According to MAD guidelines, it is possible for clients to be awarded retroactive coverage. However, the client must contact her/his caseworker to determine eligibility during that time period.

What happens if the client's eligibility is added retroactively?

The client is required to notify you immediately of their retroactive Medicaid eligibility. Claims for DOS covered by the retroactive eligibility must be submitted within 120 days of the date the retroactive eligibility is added to Omnicaid. You can determine the eligibility 'add date' by using theonline eligibility inquiry service or by calling the eligibility help desk.

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Do I have to file on paper with a copy of the retroactive eligibility award letter if the client gets retroactive eligibility?

No. The Omnicaid system is programmed to determine whether or not the claim qualifies for retroactive eligibility timely filing guidelines (instead of standard timely-filing rules) as follows:

  • If the client's eligibility was added to Omnicaid AFTER the last DOS on the claim and the retroactive eligibility's begin date is PRIOR to the date the eligibility was added to Omnicaid.
  • If Omnicaid determines the eligibility was retroactive as described above, it is programmed to 'know' that the filing limit is 120-days from the date the eligibility was added to the system.
  • Special note for DRG Inpatient Claims: In addition to above requirements, the retroactive eligibility span must cover the last DOS on the claim, because client eligibility is always calculated based on the last DOS on a DRG inpatient claim.
  • Because Omnicaid is programmed to determine when eligibility is retroactive and what the filing limit is for claims with retroactive eligibility, the claim can be filed electronically.
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How do I find out if eligibility was added retroactively?

It is the client's responsibility to inform providers of retroactive eligibility. Providers must verify eligibility using one of the following inquiry methods:

 

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Client Eligibility Batch Inquiry

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Our facility provides services to a large number of the same Medicaid clients each month. Is there a way to check eligibility for many clients at once?

Yes, you can contact a MEVS vendor to see if they can do batch inquiries. A batch inquiry allows you to submit a request for eligibility information on all of your clients at once instead of entering each name individually. MEVS vendors that offer batch inquiry send back a batch file, which includes all of the requested information in one document.

Advantages of Batch Inquiry:

  • As many inquiries as you want
  • Save information for future inquiry
  • Check the same clients each month

Disadvantages of Batch Inquiry

  • Data not in 'real time'
    • Report is run overnight, not the moment that you make the inquiry
    • Must wait for information to come back from vendor
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Our client received retroactive Medicaid benefits, but failed to notify our office within 120 days, what do we do?

Click here for 'Can I bill the patient?' FAQ.

My client's claim was denied due to a name/date of birth mismatch (0222). I know that I have the correct name and date of birth, what's going on?

Make sure that you are using the Client's ID # and not that of the financially responsible party (relative, guardian, etc.).

Check the Client ID # to be sure it was entered correctly on your claim. If there was a data entry error on your end, please correct and resubmit the claim.

If you believe there was a data entry error on ACS' part, please contact the Provider Relations Help Desk for assistance.

If the client ID on the original claim and listed on the RA are the same as the client ID in your records:

  • The client ID belongs to a parent or guardian
  • The client provided an incorrect Medicaid ID #
  • The client ID was written down/entered incorrectly by your staff

Please contact the Eligibility Help Desk for assistance.

The client ID you have may be correct, but the name you have is wrong. Two examples of this problem:

  • The client is on file with her maiden name, but your records have her married surname
  • A baby's Medicaid eligibility was established under the mother's last name, but the baby is now using dad's last name.

Omnicaid matches the first 3 digits of the first name and first 5 digits of the last name. Please contact the Eligibility Help Desk for further assistance.

The last reason for this error is that client ID you have is correct, but the date of birth in your records does not match the date of birth in Omnicaid. ACS cannot correct a date of birth on our system. Only the ISD or the SOSA worker can update the information by correcting it in their system. It is sometimes easier simply to use the date of birth that is in our system until it is corrected by the eligibility-determining agency.

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My client's claim was denied due to eligibility not on file, but she has been receiving full Medicaid benefits for years. What happened?

First of all, check to be sure the client ID number was entered correctly in the claim. If it is correct, there are a number of reasons why the eligibility appears to have ended: Sometimes there are gaps in a client's coverage due to:

  • Changes in employment status
  • Changes in household
  • Income guidelines changes
  • Failure to re-apply on time.

Be sure to reverify the client's eligibility. If the eligibility inquiry response indicates the client does not have coverage but the client insists that he does have Medicaid, contact the Eligibility Help Desk for assistance. The help desk can check to see if eligibility exists in ISD2 or SDX and add it to Omnicaid. If the Help Desk identifies gaps in coverage, but your client insists she or he has Medicaid coverage on the DOS, ask your client to contact his or her caseworker to reapply or establish eligibility.

Click here for 'Can I bill the patient?' FAQ.

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Q2-Gen: I checked eligibility for my client and received confirmation of full eligibility, but when I received the remittance advice, the claim was denied because the client was not eligible...

This happens for a number of reasons, but these are the main reasons that claims incorrectly deny for eligibility issues:

Check your claim for errors. Correct and resubmit:

  • If original was paper claim and you believe that ACS made a data entry error, contact the Provider Relations Help Desk. They can verify the information and resubmit the claim for you.
  • If the original claim was submitted electronically, correct and resubmit with proof of timely filing as required

If your records indicate that the client was eligible on the DOS, you may have entered incorrect information when you checked eligibility. If you used ouronline eligibility system, MEVS or AVRS, you were provided with an audit number. Please locate that number and contact the MEVS vendor or the ACS Eligibility Help Desk to explain the situation.

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What are the most common eligibility denials?

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Financial Issues

Be sure to review the Remittance Advice section on Financial Transactions for more information.

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I did not receive my check/RA, what do I do?

Will you reissue my check?

Checks and RAs are mailed out no later than Wednesday of each week. Allow 7-10 days for the check to arrive at your office. Please begin your inquiry by calling the financial department to determine whether or not the check was cashed.

  • If the check has not been cashed, the financial department will mail you an affidavit that you must sign and notarize in order for the check to be reissued. It takes up to 30 days to receive the re-issued check.
  • If the check was cashed and you need to determine who cashed the check, the financial department will request a copy of the check and endorsements from the State of New Mexico.

If you did not receive your RA, you can access past RAs online at any time.

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We forgot to update our address, what will happen to our check and our RA?

You must update your address information with Provider Enrollment; not the financial department. If your check and RA are returned to ACS, we cannot mail the check until your address is in the system. Refer to the Provider Enrollment FAQs for more information about address changes.

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We would like to pick up our check at ACS, how do we do that?

First call the Financial Department for instructions. You will be directed to mail a letter, signed by your authorized manager, to ACS with your request to release the check to a designated person. The process can be initiated with a fax of that letter. Note that this distribution method will terminate after November 4, 2009 due to the implementation of EFT.

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We found a check that is over one year old and was never cashed; can it be reissued?

No. Due to federal requirements, the state will issue a stop payment directive on any check that is over 6 months old. All claims associated with that payment will be voided. In order to be paid for those claims they must be resubmitted. Please contact the Financial Department so that they can determine whether the check has already been reissued or is in process.

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Can a receivable be transferred from one provider ID to another?

Yes. Contact your Program Manager at MAD for assistance.

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Can I pay back my accounts receivable in installments?

Yes. Contact your Program Manager at MAD for assistance.

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Can I receive an advance payment from Medicaid?

Yes. Contact your Program Manager at MAD for assistance.

 

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Provider Enrollment

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How do I become a New Mexico Medicaid provider?

Go to our Publications Page and download the appropriate New Mexico Medicaid Provider Participation Agreement form - the MAD-312 or MAD-335 and also be sure to download Provider Type and Specialty Listing. You must specify your provider type (and specialty if applicable) to ensure that you are enrolled properly, which will result in proper processing and payment of your claims.

Please remember to sign the forms in blue ink and mail them to ACS.

If you have any questions about enrollment, please call the Provider Enrollment Help Desk for assistance.

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We have a client who is eligible for both Medicare and Medicaid; do we need to do anything special when we enroll with Medicaid?

If you already have a Medicare number, submit your Medicare Welcome Letter or an EOMB with your Medicare provider number on it with your Medicaid provider application. This allows your Medicare number to be associated with your Medicaid number. If Medicaid does not have the correct Medicare number on your Medicaid file, your claims will not electronically crossover.

If you do not have a Medicare number, notify Provider Enrollment as soon as your Medicare number is approved. If Medicaid does not have the correct Medicare number on file, your claims will not electronically crossover.

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We have a provider that is already enrolled as a NM Medicaid Provider with another billing group, how do we get him/her enrolled as a Medicaid Provider under our provider ID?

If the provider is enrolled with NM Medicaid (and has a valid ID #), you must supply the following information on your letterhead:

  • Effective Date for provider's enrollment with your group
  • Signatures of billing group representative and provider

In addition, we require a copy of the following:

  • License/Certification
  • Insurance
  • DEA (if applicable)

Even though our practice is enrolled with Medicaid, one of our claims denied due to 'rendering provider not enrolled' (0422). How can we get this provider enrolled?

If the provider is not already enrolled with NM Medicaid:

You must apply for a provider number for the provider within 120 days of providing the service in order to be paid by NM Medicaid.

Go to our Provider Information page and download the appropriate New Mexico Medicaid Provider Participation Agreement form - the MAD-312 or MAD-335 and also be sure to download Provider Type and Specialty Listing. You must specify the provider type (and specialty if applicable) to ensure that the provider is enrolled properly, which will result in proper processing and payment of claims. Be sure to request that the provider be affiliated with your billing group provider number.

Please remember to sign the forms in blue ink and mail them to ACS.

If you have any questions about enrollment, please call the Provider Enrollment Help Desk for assistance.

If the provider is enrolled with NM Medicaid:

Verify that the rendering provider number (Box 24K on CMS-1500) was correct on the claim. Correct the information and resubmit the claim.

How can I change information on my provider file? If it is just my address or phone number can I change it over the phone?

Providers cannot change any information over the phone. The procedure for changing information is different depending on your enrollment status:

o       Billing Only / Servicing Only providers

o       Unrestricted Providers (Billing and Servicing)

o       PCO and Waiver Providers

Billing only and servicing only providers:

You must mail the change(s) to ACS:

  • On letterhead
  • Signed
  • Indicating which address/information you want to change:
    • Location
    • Billing
    • Mailing

 

Unrestricted providers (billing and servicing):

In addition to the letter mentioned above, you must also include an updated business license with the new address/information.

PCO and Waiver Providers

The state (MAD) must approve any changes to your enrollment. Send your request to ACS first; we will track your request in Omnicaid and forward it to the state for approval.

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When do I need to re-enroll with NM Medicaid?

Re-enrollment is not required, unless your eligibility with Medicaid has been terminated for more than 90 days.

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What is a reverification Turn Around Document and what do I do with it?

Providers are required to verify the information on file with Medicaid every two years. Sixty days prior to the date the reverification is due, a form called a reverification turn around document (TAD) is mailed to providers to confirm that NM Medicaid has the correct information on file. Providers are required to complete/correct this document in a timely fashion. The TAD should be returned prior to the reverification date, but there is a grace period. If the TAD is not returned within two months after the reverification date, the provider number is terminated.

If your provider number has been terminated due to failure to complete the reverification Turn Around Document, please contact the Provider Enrollment Help Desk.

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Why did I receive a letter stating that my licensure or certification is about to expire?

Any license or certification that you are required to have as a NM Medicaid provider must be up-to-date in order to be a valid provider. You must send in any new/updated licenses by the expiration date. Failure to submit the appropriate documentation will result in termination of your participation in the New Mexico Medicaid program and denial of claims payments.

A letter will be sent 90 days prior to the expiration of license or certification, reminding the provider to send in their updated license or certification. A reminder letter will be sent every 30 days thereafter until the license or certification has been expired more than 60 days. At that time the provider number will be terminated.

If your provider number has been terminated due to failure to supply an up-to-date license or certification, please contact the Provider Enrollment Help Desk.

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Now that I am enrolled with NM Medicaid, can I see SALUD! patients?

Although the SALUD! MCOs offer services to NM Medicaid clients; enrollment with Fee-for-Service Medicaid does not automatically result in MCO participation. You must enroll directly with each managed care organization in which you choose to participate.

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My billing group and I decided to part ways last month, am I still a NM Medicaid provider?

Servicing only providers must be affiliated with at least one billing group. If you have become disaffiliated with all NM Medicaid billing groups, then you are terminated as a NM Medicaid provider until you become affiliated with another billing group.

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How soon after a change of ownership should we report the change to NM Medicaid?

As soon as possible and not less than 30 days after the change in ownership. Otherwise NM Medicaid has the right to withhold or recoup payments.

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Children's Medical Services (CMS) Prior Authorizations

Do all claims for CMS clients need a prior authorization?

Yes. All claims for Children's Medical Services (CMS) clients must have the CMS prior authorization number entered on the claim. The CMS prior authorization number is 8 digits, so when you include it on the CMS-1500 form (box 23), you must put 2 zeros in front of the 8-digit PA number to make a 10-digit number.

ACS recommends that the paper authorization issued by CMS be attached to the claim form as well. This is either the CMS 309 form or the Healthier Kids Fund card.

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Medicare

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How long will it take for Medicaid to process my Medicare crossover claim?

Medicaid has electronic crossover agreements with the Medicare carriers and intermediaries that most commonly process Medicare claims for New Mexico residents. Most claims will electronically cross over from these Medicare claims processors. Allow 4 weeks after Medicare pays for the claim to automatically cross over to Medicaid and show up on your Medicaid RA.

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What should I do if the claim was processed by Medicare but did not cross over to Medicaid?

If the claim does not appear on your RA as paid, denied or pending 4 weeks after Medicare paid the claim, submit the crossover on paper to Medicaid. Note: If your claims consistently do not cross over electronically from Medicare, it could mean that your Medicare number is missing or incorrect in your file in Omnicaid. Contact Provider Enrollment Help Desk that your correct Medicare number is in Omnicaid.

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How do we resubmit crossover claims?

Allow 4 weeks after Medicare pays for an electronic crossover to show up on your Medicaid RA. If it does not, then submit the crossover claim on paper with the EOMB attached. The EOMB must be legible and include all required information.

For CMS-1500 claims:

Submit the exact same claim you submitted to Medicare. This means:

  • All codes billed to Medicaid must match the EOMB
  • Same # of lines billed to Medicaid as on the EOMB
  • Billed amounts on the claim must match the EOMB

For UB-04 claims:

Be sure that the dates on your Medicaid claim match the EOMB

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Our client has exhausted her Medicare Part A benefits, how do we bill to Medicaid?

Contact the Provider Relations Help Desk for assistance with claims for this client.

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How many Medicare numbers can be associated with a Medicaid provider number?

Multiple Medicare numbers can be associated with one Medicaid provider number.

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Can one Medicare number be associated with multiple Medicaid provider numbers?

No, a Medicare number cannot be associated with multiple Medicaid provider numbers.

What constitutes a valid EOMB

Since many Medicare EOBs are transmitted electronically, it can be difficult to tell which information to include when sending the claim to Medicaid.

A valid EOMB includes the following information:

  • Must say 'Medicare' or have HIC Number
  • Allowed amount
  • Paid amount
  • Date Issued
  • For UB-04 Only: Coinsurance or Deductible amount
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How has Medicare Part D impacted Medicare/Medicaid dual-eligible clients?

On January 1, 2006, dual-eligibles began receiving their prescription drug benefits from Medicare rather than Medicaid.

Dual-eligibles were auto-enrolled into a Part D plan if they did not choose a plan by December 31, 2005. Click here for the MAD supplement regarding Medicare Part D.

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If a client's Medicare Prescription Drug Plan (PDP) does not cover a Medicare covered drug, will Medicaid cover it?

No.

Will Medicaid pay for the dual-eligible's Medicare D copayment?

No.

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Our client is enrolled in SALUD!, but becomes eligible for Medicare next month; how does the transition from SALUD! to fee-for-service Medicaid work?

Clients who are enrolled with SALUD! will become fee-for-service eligible on the 1st of the month that their Medicare eligibility begins. Medicaid often does not find out that the client has been enrolled in Medicare for 2 or 3 months after the enrollment takes effect. For many clients, this means a retroactive Medicare eligibility span that will cover months for which a client has a SALUD! lock in.

Example: Client becomes Medicare eligible on 11/10/2006. Once Medicare eligibility is in Omnicaid, the client will be made fee-for-service retro-eligible back to 11/01/2006. This means that at the beginning of the client's Medicare enrollment, the information inonline eligibility inquiry will likely contradict what you know about the client's enrollment. Claims submitted for dates of service when the client had Medicare and a SALUD! enrollment will deny for the follow reason:

You must attach any and all RAs to your claim in order to 'tell the whole story' of the denied claim. Remember that a human being reviews these attachments and needs to understand the chain of events in order to process your claim correctly.

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I received a denial for timely filing (EOB 0345, etc), but I already submitted this claim two months ago and it was denied. What do I need to do to get the claim processed?

If you have proof of timely filing, simply resubmit the claim to Medicaid with an attachment that indicates proof of timely filing. If you do not have proof, but you are sure that you submitted the claim within time limits, please contact the Provider Relations Help Desk. A representative will attempt to locate a record of the original claim and our research department will reprocess the claim.

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Why is the final limit on claims 2 years (EOB 0496)?

The federal government partially reimburses Medicaid for claim expenditures. Once 2 years have passed, the federal government will no longer reimburse for Medicaid claims. Only state funds are used to pay claims more than two years old.

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What are the most common timely filing denials?


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TPL (Third Party Liability)

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What is Third Party Liability (TPL)?

  • All commercial/private insurance
  • Another payer, such as an absent parent or court settlement
  • Medicare is not considered TPL
  • Medicaid is the payer of last resort, except for clients covered by Indian Health Service (IHS).
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How do I bill TPL and Medicaid?

For further assistance, please contact the Provider Relations Help Desk.

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Is a Medicare Replacement plan TPL Medicare

A Medicare Replacement (Medicare Advantage) plan is considered Medicare coverage but must be processed like an HMO co-payment claim.

Submit the claim with the EOB from the Medicare replacement payer. Bill the claim so the total billed less the previous payment amount entered equals the co-payment amount you want to collect. Write 'Medicare Replacement Plan - Copay Due' on the claim.

My client has Medicare, a Medicare supplement plan and Medicaid. How do I bill Medicaid?

In this case, Medicaid is the payer of last resort. The claim must be submitted with the Medicare EOMB and the supplement plan's EOB attached. Enter ONLY the amount the supplement plan paid on the claim in the previous payment box on the claim form.

If the TPL payment is received after receiving payment from Medicaid, there are two options for correcting the payment:

Fill out an Adjustment/Void Request

  • Attach the corrected claim reflecting the third party payment
  • Attach the TPL EOB
  • Attach the Medicaid RA

OR

Refund the lower amount of either the third party payment or Medicaid payment.

For more information, please contact the TPL Help Desk.

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Our client's primary insurance carrier denied the claim for timely filing (or another administrative reason). Will Medicaid pay as primary?

No. Medicaid will not pay as primary if the claim has denied due to an administrative error. You must follow the guidelines of the TPL policy in order to receive payment from Medicaid.

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Our client has a TPL HMO insurance carrier. However, we are not an in-network provider so the HMO denied the claim. Will Medicaid pay as primary?

No. This is considered an administrative error.

Can I bill Medicaid for the difference between the discounted TPL payment (from participating in an HMO) and the actual charges for services?

No. Medicaid does not pay the difference between the provider-agreed TPL discount and the actual charge. Medicaid will only pay for the co-payment or up to the Medicaid allowed amount, whichever is less.

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What if I need more information on TPL?

Review the TPL Provider Responsibilities in the Medicaid General Provider Policies.

Contact the Provider Relations Help Desk for assistance with claims submission or denied claims. If necessary, they can refer you to the TPL Help Desk for further assistance.

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Why did my claim deny for no prior authorization on file even though my case manager gave me the MAD-046 with the PA number on it and I put the PA number on the claim?

It is possible the PA number you entered on your electronic claim was incorrect. Please check the number on the claim to the PA number on the MAD-046. The number on the 046 may be difficult to read. Check the PA online to find the correct PA number.

If you submitted a paper claim, it is possible that you entered the wrong PA number on the claim or the PA number was not keyed correctly at ACS. Check the PA number you entered on the copy of the claim you sent to ACS. If you entered the wrong PA number, correct it and resubmit the claim. If you believe ACS made a data entry error, please contact the Provider Relations Waiver Help Desk.

It is possible that the PA has not yet been entered in Omnicaid by BCBS. You can check your PAs online to see if it is there. Click here to learn more about being able to look up PAs on line. Or, you can call the Provider Relations Help Desk and they will look up the PA.

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When should I call the case manager regarding a budget/prior authorization?

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When should I call Blue Cross/Blue Shield regarding a budget/prior authorization?

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Why did my claim deny for auth/service date conflict?

You have billed a PA number that does not cover some or all of the dates of service on your claim.

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Why did my claim for the first half of the month deny for not enough units (exception 9617) but the claim for the second half of the month paid?

Used units are updated on the prior authorization based on the order that claims are paid, not based on which dates of service came first. It is possible for a claim for dates of service later in the month to pay and use up authorized units prior to a claim with dates of service from earlier in the same month.

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How often do I need to submit my level of care abstract?

For the majority of waiver providers, you must submit to Medicaid UR annually.

For DD (96) managers, submit every third year.

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Where can I find the allowed procedure codes for Waiver billing?

Refer to Attachments A-D of the Waiver billing instructions for allowed procedure codes for each waiver COE.

What are the changes that are going to be implemented for waiver services provided to children?

Certain services provided to children and paid for through the HCBS waiver programs will be paid for out of the Early Periodic Screening Diagnostic and Treatment (EPSDT) benefit of the regular Medicaid program as described in the State Plan. This is to avoid duplication of services under the EPSDT benefit and the HCBS Waiver program. Please see the chart below:

SERVICE

CHILDREN*

ADULTS

Speech Language Pathology

X

 

Occupational Therapy

X

 

Physical Therapy

X

 

Behavior Therapy, Counseling/Psycho Therapy component**

X

X

Private Duty Nursing

X

 

Personal Care/Homemaker

X

 

Home Health Aide (Medically Fragile Waiver)

X

 

* 'Children' are defined as eligible individual's age birth until their twenty-first (21) birthday.

** Be advised that Behavioral Support Consultation services will continue to be available through the Developmental Disabilities and Medically Fragile waivers.

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When do these EPSDT/Waiver changes go into effect?

This change will not happen all at once. The change of waiver services to EPSDT service will be implemented as client's current budgets/ISPs expire and new budgets and ISPs are developed, beginning with budgets that expire in July 2006. So, it will take a year for these changes to be fully implemented.

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Will I still need authorizations to be paid for the services covered by EPSDT?

Yes, except for PT, SLT and OT evaluations.

Where will I get these authorizations?

If the client is enrolled in SALUD!, you will request prior authorizations from the SALUD! organization. If the client is fee-for-service (exempt), you will request prior authorizations from the NM Medicaid Utilization Review Contractor, Blue Cross/Blue Shield.

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Will I end up with more than one prior authorization? One for the waiver services and one for the EPSDT services.

Yes, this will happen if you are providing services covered by EPSDT and other services covered by the waiver program. Depending on how you apply for the authorizations, you could end up with more than 2 PAs.

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Will I have to show the services are medically necessary in order to get the service authorized?

Yes.

Will I have to have a doctor's order for the services?

Yes.

What if the services are denied for not medically necessary?

Discuss it with the agency that denied the request. Perhaps they just need more documentation. Also, appeal processes are in place with the SALUD! MCOs and Blue Cross/Blue Shield.

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Will I need prior authorizations for behavioral therapy services?

Please contact ValueOptions for information on when they require a prior authorization.

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Can I bill the MCOs and fee-for-service Medicaid with my waiver provider number that I currently use?

If you provide services that are currently covered under the waiver but will be covered under the EPSDT benefit, you will need to become an enrolled provider with the SALUD! MCOs and you will need an EPSDT fee-for-service Medicaid provider number to bill for clients not in SALUD!. Most children are enrolled in one of the SALUD! MCOs.

Please note that some providers already have a fee-for-service Medicaid provider number in addition to a waiver provider number. If you are unsure if you do, call the ACS Provider Enrollment Help Desk.

If you are a behavioral therapy provider who delivers direct therapy services, you will need to be credentialed with Value Options to be reimbursed for your services but you will also need to be enrolled with fee-for-service Medicaid in order to be credentialed by Value Options.

Click here for information about provider enrollment with ACS. Click here for provider enrollment forms available for download on this web site.

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Does this mean I will have one provider number to bill waiver services not covered by EPSDT and another provider number to bill the EPSDT services?

Yes.

Can I bill the EPSDT services and the waiver services on the same claim?

No. For a client enrolled in SALUD!, you will bill the EPSDT services to the SALUD! MCO following the MCO's billing requirements and using your MCO provider number. For the waiver services, you will bill another claim to ACS using your waiver provider number.

If the client is fee-for-service Medicaid, you will bill the EPSDT services to ACS using your EPSDT fee-for-service provider number and you will bill the waiver services on a different claim using your waiver provider number.

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If I am billing both the EPSDT and waiver services to ACS, can I use Payerpath to submit both claims, or only the waiver claims?

You can use Payerpath to bill both claims.

How do I bill ACS for EPSDT services that are provided by contractors?

This depends on what provider type you are enrolled as with ACS. Home health agencies and private duty nursing agencies do not have to bill their claims indicating the provider who performed the services. If you provide PT, OT or SLT services and are enrolled as a group, all of your contracted direct-service providers must have a fee-for-service provider number with ACS, must be affiliated with your group on ACS' files and you must enter their provider number as the 'rendering' provider at the line level. Some types of therapy facilities do not have to have their rendering providers enrolled or affiliated. Click here for the Provider Enrollment applications, instructions and the provider type/specialty listing for more information.

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Which procedure codes do we use to bill services covered by EPSDT to ACS? The waiver procedure codes we use now, or other codes?

You will not be using the same codes you use to bill waiver services. You will use the appropriate CPT codes the describe the physical therapy, occupational therapy or speech/language therapy services you perform. Home health agencies will use the appropriate revenue codes and private duty nursing agencies will bill with the appropriate HCPCS code.

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What are the procedure codes that should be used for billing homemaker services, therapy services and private duty nursing services?

Waiver Service

FFS Code

FFS Code Description

EPSDT Personal Care

S5125 is used for EPSDT Personal Care Attendant

Attendant care services: per 15 minutes billed by a Private Duty Nursing Agency

Private Duty Nursing, RN

T1000 modifier TD (use the modifier for billing but not when requesting prior authorization)

Private duty/independent nursing service(s) - licensed, up to 15 minutes

Private Duty Nursing, LPN

T1000 modifier TE (use the modifier for billing but not when requesting prior authorization)

Private duty/independent nursing service(s) - licensed, up to 15 minutes

Physical Therapy

97001, 97002, 95831-95904 range & the 97010-97799 range

Physical Medicine and Rehabilitation (not covered - 97005, 97006, 97537, 97545, 97546).

Physical Therapy - Home Visit

G0151 (used by fee-for-service furnishing home services to clients with COE 096 - DD Waiver - under 21 years of age)

Services of Physical Therapist in home health setting, each 15 minutes

Occupational Therapy

97003, 97004, 95831-95904 range & the 97001-97799 range

Physical Medicine and Rehabilitation (not covered - 97005, 97006, 97537, 97545, 97546).

Occupational Therapy-Home Visit

G0152 (used by fee-for-service furnishing home services to clients with COE 096 - DD Waiver - under 21 years of age)

Services of Occupational Therapist in home health setting, each 15 minutes

Speech Therapy

92506 (Speech Evaluation), 92507 (Speech Treatment - Individual) & 92508 (Speech treatment group, two or more individuals)

See descriptions with codes in previous column

Speech Therapy - Home Visit

G0153 (used by fee-for-service furnishing home services to clients with COE 096 - DD Waiver - under 21 years of age)

Services of Speech and Language Pathologist in home health setting, each 15 minutes

Home Health Aide

0571 (billed by Home Health Agency)

Revenue Code 0571 Home Health Aide (Home Health) - Visit Charge

Click here for the complete ACS presentation about ACS provider enrollment and billing under the EPSDT/Waiver changes.

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Common Waiver Provider Denials

0141 - Client ID not on file

Special notes for Waiver Providers:

The waiver client's eligibility depends on receiving services for 30 days. Once that occurs, they are made eligible back to the month when their services began.

However, eligibility doesn't get to ACS until at least a month after receiving services, which can lead to eligibility denials in the meantime.

If you have provided assessment services as part of the waiver enrollment process, click here to learn how to bill for a client who has not yet gotten waiver eligibility.

For all other claims for services provided during the first 30 days of waiver eligibility, it is up to you to determine whether you want to go ahead and submit the bills knowing the denial will occur or waiting until after eligibility gets in the system to submit. Once the client has received 30 days of services, you should check with eligibility to determine if the eligibility is on file. If so, submit or resubmit the claim.

Remember, for newly added eligibility, the filing limit is 120 days from the date the eligibility was added to Omnicaid. Click here for more information about the filing limit and retroactively added eligibility.

0436 - Authorization Required/PA is missing/invalid

0502 - PA / Client Conflict

0504 - Authorization/Modifier Conflict

Special note for Waiver Providers:

Check theonline PA Inquiry to make sure that the procedure and modifiers you used are valid for the PA number that you are using.

0510 - Authorization/Provider Conflict

Special note for Waiver Providers:

If the PA's information doesn't match the approved MAD-046, contact BCBS to get the PA corrected

0511 - Authorization/Service Conflict

Special note for Waiver Providers:

If the PA's information doesn't match the approved MAD-046, contact BCBS to get the PA corrected.

0518 - Authorization Line Status Denied

0546 - Procedure Requires Price

0605 - Authorization / Service Date Conflict

0727 - Prior Authorization Required / No PA Number on File

0958 - Client not eligible for Waiver services

9617 - Prior Authorization Used or Units Billed Greater than Remaining PA

9727 - Prior Authorization Not on File

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Unique Waiver Denials

0783 Suspect Dup, Long Term Care and Waiver Claim

0955 Invalid Client ID Number for Waiver Assessment

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