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Professional Billing InstructionsHEALTH SYSTEMS DIVISIONBilling instructions for CMS1500, OHP 505 and ProviderWeb Portal professional claimformats for Oregon MedicaidprovidersJune 2017

ContentsIntroduction . 1Claims processing . 2Before you bill OHA: . 3Professional Web claim instructions . 4When not to submit a Web claim . 4Before you submit a Web claim . 4How to submit a professional Web claim. 5Step 1: Enter claim header information .6Step 2: Enter diagnosis information.7Step 3: Enter third-party liability (TPL) information .8To update a TPL .9Step 4: Enter Medicare information .9Step 5: Enter detail lines.10Step 6: Enter notes about hard copy attachments .13Step 7: Submit claim and review claim status information .13How to resubmit a denied claim . 15To resubmit a denied claim .15How to copy a paid claim . 15Appendix . 17Provider Web Portal resources . 17Quick reference: Submitting a professional claim . 17Quick reference: How to submit a Medicare-Medicaid claim . 18Paper billing instructions . 19Accepted forms.19Important notes about paper claim processing.19CMS-1500 Health Insurance Claim Form (revised 2/12 ).20OHP 505 form (revised 8/15).20Required CMS-1500/OHP 505 fields.21Helpful tips . 25Supplemental information. 27Supplemental information examples .28

IntroductionThe Professional Claim Instructions handbook is designed to help those who bill the Oregon Health Authority(OHA) for Medicaid services submit their claims correctly the first time. This will give you step-by-stepinstructions so that OHA can pay you, the provider, more quickly. Use this handbook with the General Rulesand your provider guidelines (administrative rules and supplemental information), which contain information onpolicy and covered services specific to your provider type.The professional claim is also known as the CMS-1500. Throughout this billing guide you will see the claimtype being referred to as a professional claim.This handbook lists the requirements for completion prior to sending your claim to OHA for paymentprocessing, as well as helpful hints on how to avoid common billing errors.The Professional Claim Instructions are designed to assist the following providers:* Ambulatory Surgical Centers Naturopaths Certified Registered Nurse Anesthetists Nurse Practitioners Chemical Dependency Occupational Therapy Chiropractors Ophthalmologists Doctors of Medicine Optometrists Durable Medical Equipment Physical Therapy Family Planning Clinics Podiatrists Federally Qualified Health Centers Portable X-Ray Providers Home Enteral/Parenteral IV Psychologists Independent Laboratories Public Health Departments Medical Transportation Rural Health Clinics Mental Health School-Based Health Services*This list does not include all provider types that use the professional claim format. If in doubt of which claimformat to use, contact Provider Services at 800-336-6016 for assistance, or refer to your provider guidelines.Professional Billing InstructionsJune 20171

Claims processingThe federal government requires OHA to process Medicaid claims through an automated claim processingsystem known as MMIS - the Medicaid Management Information System. This system is a combination ofpeople and computers working together to process claims.Paper claims submitted by mail are scanned through an OpticalCharacter Recognition (OCR) machine. Each claim is given an InternalControl Number (ICN). The scanned documents are then identified and sorted by form typeand indexed by identifiers such as client name, prime identificationnumber, the date of service, and provider number. Finally, the data is entered in the MMIS and images of thedocuments are stored on an Electronic Document ManagementSystem (EDMS).The ICN is a unique identifier. The first two digits indicate thetype of format of the claim (e.g.,‘22’ Web claim, ‘10’ paper claim,‘20’ electronic). The next two are the year; ‘11’(2011). The next three are the Juliandate; “031” (January 31). The remaining digits are detailsof the claims regarding how theyare ‘batched’ within the MMIS.Data from Web claims directly enter the MMIS if all information isentered correctly. Electronic data interchange (EDI, or electronic batchsubmission) claims are reviewed for compliance and translated from the HIPAA standard formats for MMISprocessing.Once the data enters the MMIS, staff can immediately access submitted claim information by checking certainMMIS screens.The system performs daily edits for presence and validity of data as each claim is processed. Once a week, thesystem audits all claims to ensure that they conform to medical policy. Every weekend, a payment cycle runs,and the system produces checks for claims that successfully pass all edits and audits.If MMIS cannot make a payment decision based on the information submitted or if policy determines manualreview is needed, the claim is routed to DMAP staff for specific manual, medical or administrative review. Thistype of claim is a suspense (suspended) claim.OHA does not return denied claims to providers in this process. Instead, OHA sends a listing of all claims paidand/or denied to the provider (with payment if appropriate). The listing is called a Remittance Advice (RA). The RA comes in paper and electronic formats. The paper format will list suspended claims while theelectronic does not. If you aren’t already receiving the electronic RA, contact EDI Support at 888-690-9888 for moreinformation.Professional Billing InstructionsJune 20172

Before you bill OHA:1. Verify the client is eligible on the date of service for the services rendered. Services for clients enrolled inan OHP managed care organization (MCO) or coordinated care organization (CCO) must be billed to theappropriate MCO/CCO.2. Medicaid is always the payer of last resort. If the client has Medicare or third-party insurance, bill thembefore billing Medicaid.Professional Billing InstructionsJune 20173

Professional Web claim instructionsWhen not to submit a web claimDo not submit a web claim when: You need to submit hard-copy attachments (e.g., consent forms or op reports). If you submit a Webclaim for a procedure that requires attached documentation, the claim will suspend, then deny for missingdocumentation. Always bill on paper for claims that require attachments. You need to bill for services more than a year after the date of service. Claims past timely filing limitsmust be sent on paper.Before you submit a web claimTo use the Web portal for the first time, use the provider Personal Identification Number (PIN) from OHA. Ifyou do not have your PIN, contact Provider Services at 800-336-6016 for assistance.The following list will help you to better understand what needs to be done prior to submitting a Web claim.1. Verify that you are logged in as and acting on behalf of the correct provider. OHA will pay the provider youare logged in under.2. You must complete and submit the claim in its entirety in order to save the data entered. Partially completedclaims data cannot be saved.3. The session will end after 20 minutes of inactivity. Any work orchanges that have not been submitted will be lost.4. The professional claim has 7 screens. In some screens you simply movefrom field to field while in others you must select the “Add” button toadd information. Make sure you review all screens and enter all requiredand/or applicable data in each screen.Professional Billing InstructionsJune 20171.2.3.4.Professional Claim HeaderDiagnosisThird-Party Liability (TPL)Medicare Information (ForMedicare-Medicaid claims)5. Detail6. Hard Copy Attachments7. Claims Status Information4

How to submit a professional web claim“Claims” menu, click “Professional.”Professional Billing InstructionsJune 20175

Step 1: Enter claim header informationThe professional claim header is the main screen including basic information for the entire claim.Professional claim fieldsShaded boxes are always mandatory. Non-shaded boxes are mandatory if applicable.FieldDescriptionICNClaim's internal control number (ICN).Provider IDNational Provider Identifier (NPI) or Billing Provider number.Client ID*Recipient identification number. Review the name fields under this field to makesure you have entered the correct ID number.Last NameLast name of the recipient. (This field will auto populate with the name associatedwith the client ID you entered.)First Name, MIFirst name and middle initial of the recipient. (This field will auto populate with thename associated with the client ID you entered.)Date of BirthThe recipient's date of birth. (This field will auto populate with the DOB associatedwith the client ID you entered.)Patient Account #Identification for a recipient assigned by a provider. If a patient account number isprovided in this field it will print on the Remittance Advice (RA).Referring PhysicianNPI or Medicaid Provider ID of the Referring Provider. The referring physician must be enrolled with DMAP to comply withAffordable Care Act requirements.Insurance DeniedThis is the field that indicates if the TPL was denied or not. Valid options are Yesor No.From Date*Beginning date on which service was provided. Must be before today’s date.To Date*Ending date on which service was provided. Must be after “from date” of service.Expected Delivery Date Pregnancy due date.Accident Related ToIndicates whether service was performed as result of an accident.Total ChargesTotal dollar amount charged for the claim. Total charges are the sum of all chargesand are derived from the detail Line Items. This field will not populate with totalcharges until the detailed line is completed.TPL AmountDollar amount paid by any third-party resource (third-party liability, or TPL). Thisamount is the total payment received.Plan Payment AmountDollar amount paid by recipient’s OHP managed care plan. Displays for managedcare plan submissions only.Co-Pay AmountAmount recipient is to pay for services rendered. (This will auto populate based onthe client’s benefit plan.)Professional Billing InstructionsJune 20176

Step 2: Enter diagnosis informationClick “add” to add a diagnosis. You may enter up to ten (10) diagnosis codes. Do not use decimals whenentering diagnosis codes. Use ICD-9 codes for services on or before 9/30/2015. Use ICD-10 codes for services on or after 10/1/2015.Field descriptionsFieldDescriptionSequenceThe sequence of the diagnosis (1 for primary, 2 for secondary, etc.). Used for the DiagnosisCode Pointer on the Professional Claim-Detail screen.DiagnosisCode indicates the diagnosis. Use the “search” hyperlink next to this field to look up thediagnosis.Present onThis field does not apply to professional claims.AdmissionDescriptionThis field does not apply to professional claims.ICD VersionIndicates whether the code selected is ICD-9 or ICD-10. (Read-only)To add a diagnosisStepAction1Click the Add button.2Enter the Sequence and Diagnosis. Or, use thediagnosis search.To delete a diagnosisStepAction1Choose the line item to be deleted.2Click the Delete button.Note: The delete button deletes selected data onthe current screen. It does not delete the claim.3Click OK.ResponseDiagnosis field is activated for data entry.Diagnosis displays.ResponseData populates fields in the Diagnosis screen.Dialog displays to confirm deletion.The system will indicate the deletion with a “D”on the line item. It will be removed from theclaim once the claim is resubmitted or adjusted.To update a diagnosisNOTE: To update the sequence, you will need to delete line items and re-add them in the correct order.Professional Billing InstructionsJune 20177

Step1ActionChoose the line item to be updated.2Enter updated data in the Diagnosis field.ResponseData populates detail fields in the Diagnosisscreen.Diagnosis will display.Diagnosis Search screenThis screen allows you to verify and look up a diagnosis code.To look up a diagnosis via the search screenStepAction1Click the Add button.2Click the “search” hyperlink.3Enter either a diagnosis code or a diagnosisdescription, then select ICD Version 9 or 10.Then click search.4Click on the line item that displays the mostappropriate diagnosis.ResponseSearch hyperlink is activated for selection.Diagnosis search screen displays.Search display diagnosis options.Diagnosis code and description displays.Step 3: Enter third-party liability (TPL) informationThis screen allows you to add third party liability (TPL, or third party resource) information. Click “add” to addTPL information. You can enter a line of TPL information for each payer other than OHA.This includes Medicare supplement plans.Do not enter Medicare as TPL; enter Medicare information in the Medicare information section of the Webclaim.If applicable, TPL must be entered on each claim. If a third-party or other insurance did not make payment or made a partial payment, you must enter theappropriate HIPAA Adjustment Reason Code (ARC). This code identifies the detailed reason the otherpayer(s) did not make a payment. For a complete list of HIPAA ARCs, go to the Washington Publishing website at www.wpc-edi.com.Note: Do not enter client liability (e.g., copayments) on the claim.Professional Billing InstructionsJune 20178

Field descriptionsFieldLast NameFirst Name, MIDate of BirthRelationshipPolicy NumberPlan NameAdjustment Reason Code*Adjustment Group CodeAdjustment AmountDescriptionThe TPL insured’s last name.The TPL insured’s first name and middle initialThe TPL insured’s date of birth.The TPL insured’s relationship.The TPL insured’s policy number.The TPL insured’s plan name.HIPAA Adjustment Reason Code (ARC) identifying how TPL processed theclaim. Use the “search” link to find the most appropriate ARC.Review primary EOB for use of appropriate Adjustment Group Code.Amount adjusted off based on primary payment.To add a TPLStepAction1Click the Add button.2Enter the last name, first name, MI, DOB,Relationship, Policy number, and plan name.3Select the Add button again (only when there ismore than one TPL).To delete a TPLStepAction1Choose the TPL line item to be deleted.2Click the Delete button.Note: The delete button deletes selected data onthe current screen. It does not delete the claim.3Click OK.To update a TPLStepAction1Choose the TPL line item to be updated.2Type updated data in the TPL fields.ResponseTPL fields are activated for data entry.The TPL data displays as a line item.Line item displays.ResponseData populates fields in the TPL screen.Dialog displays to confirm deletion.ResponseData populates fields in the TPL screen.TPL information displays.Step 4: Enter Medicare informationMedicare information is only required when you bill for a client who is eligible for both Medicare and Medicaidservices. Normally, when you submit your Medicare Part B (outpatient health care expense including provider fees)claim to Medicare, Medicare transmits the billing information to OHA electronically. This transmission iscalled a “crossover.”Professional Billing InstructionsJune 20179

If the claim does not automatically crossover, you must bill OHA separately and indicate what Medicarepaid. Enter the Medicare information for the entire claim in the Medicare Information screen. This includesinformation on Medicare replacement plans.You must complete this section when: Medicare transmits incorrect information to OHA; or OHA did not receive a crossover claim from Medicare; or You billed an out-of-state Medicare carrier or intermediary.Medicare information screenThis screen is used to report the total amount paid by Medicare for the entire claim. This information can befound on the Medicare EOMB.Field descriptionsFieldMedicare Paid DatePsychiatric AmountPaid AmountCoinsurance AmountDeductible AmountDescriptionThe date Medicare paid for the services.The Medicare psychiatric charge.The dollar amount paid by Medicare for the services.Amount that represents the member’s coinsurance payment.The amount a Medicare client with no Medicaid benefits would have to pay beforeMedicare pays anything.Step 5: Enter detail linesThis screen allows you to enter multiple detail lines. Enter information for the first detail line. Click the “add”button for each additional detail line.Professional Billing InstructionsJune 201710

Field descriptionsShaded boxes are always mandatory. Non-shaded boxes are mandatory if applicable.FieldDescriptionItemThe number of the detail line. Read-onlyFrom DOS*Beginning date on which service was provided.To DOS*Ending date on which service was providedUnits*Number of units billed for the service For anesthesia codes (00100-011996), bill time in minutes whenappropriate. OHA will convert minutes to units.Charges*Total dollar amount charged for the services.Rendering PhysicianNPI or Medicaid Provider ID of the rendering provider.(required for claimsThis field is required when you need to indicate who in the clinic, group orsubmitted by clinic, group or OHA-approved mental health or chemical dependency facility actuallyOHA-approved facilities for performed/rendered the service.services rendered by When the rendering provider is under direct supervision (e.g.,enrolled OHA providers)resident at a teaching hospital), enter the supervising physician’sinformation. For medical claims, the rendering provider must be enrolled withOHA and have their ID number reported in this field to ensureappropriate claim processing. For chemical dependency or mental health claims, only renderingproviders who meet OHA’s certification or enrollment criteria arerequired to enroll with OHA and have their ID numbers reported inthis field.StatusClaim status on the detail line. Read-onlyDiagnosis Code PointerIndicates the sequence number(s) of diagnosis (referring to the ClaimDiagnosis screen) for which services were provided.ModifiersCode used to further define a procedure provided. You can use the [search]link next to this field to search for a modifier by code or description.POS*2-digit place of service code (POS) is used for the location where servicewas rendered. You can use the [search] link next to this field to search for aPOS code by code or description.Procedure*Code that identifies the service provided. You can use the [search] link nextto this field to search for procedure codes by code or description.NDCNational Drug Code (NDC) that identifies the drug administered (foroutpatient services only). You can use the Drug Search screen to find a drugby NDC or name. The “N4” qualifier is not required on Web portal claims. Enter NDC in 5-4-2 format (add leading zeroes as needed), withoutdashes. OHA only pays for drugs that are rebateable (i.e., part of the federalMedicaid Drug Rebate Program). To verify that an NDC isrebateable, search for it in the CMS rebate drug product data file onthe CMS Medicaid Drug Rebate Program Data page. If the NDC ison file, it is rebateable.NDC UOMCode that identifies the NDC Unit of Measure.NDC QuantityNumber that identifies NDC quantity (fractional units limited to 3 digitsafter the decimal)TPL amountEnter the amount paid by third party for the individual procedure codes.Professional Billing InstructionsJune 201711

FieldEmergencyDescriptionIndicates whether service was provided as result of emergency situation.Valid values: Yes, No.PregnancyIndicates whether service is related to condition of being pregnant.EPSDT RefNot usedEPSDT Family PlanningNot usedAllowed AmountAmount approved to pay for services provided. Read-onlyCopay AmountAmount paid by recipient for services performed. Read-onlyAdjustment Reason CodeEnter ARC to describe why Medicare did not make payment.(only when Medicare is the ARC codes are used in place of the unique 2-digit code on paperprimary payer)claims. A complete list of ARC codes can be found by using theWeb claims search feature or at www.wpc-edi.com. If entering an ARC for multiple payers, select the code that is mostappropriate.Adjustment AmountAmount adjusted for the reason code entered above.The following information is required for Medicare-Medicaid claims only. Amounts entered for the claimdetails should correspond to the total amount entered on the Medicare Information screen.Medicare Paid DateThe date Medicare paid for the services.Deductible AmountThe amount a Medicare client with no Medicaid benefits would have to paybefore Medicare pays anything.Coinsurance AmountAmount that represents the member’s coinsurance payment.Medicare Paid AmountThe dollar amount paid by Medicare for the services.Medicare Psych AmountThe Medicare psychiatric charge.To add a detail line itemStepAction1Click the Add button.2Enter data in the required fields (From DOS, ToDOS, Units, Charges, Rendering Physician,POS, and Procedure).3Enter data in the remaining fields that areapplicable (Diagnosis Code Pointer, Modifier,Emergency, Pregnancy, EPSDT Ref).To delete a detail line itemStepAction1Choose the line item to be deleted.2Click the Delete button.Note: The delete button deletes selected data onthe current screen. It does not delete the claim.3Click OK.To update a detail line itemStepAction1Choose the line item to be updated.2Enter updated data in the From DOS, To DOS,Units, Charges, Rendering Physician, POS, andProfessional Billing InstructionsJune 2017ResponseDetail screen activates fields for data entry.ResponseData populates fields in the Detail screen.Dialog displays to confirm deletion.(The system will indicate the deletion with a“D” on the line item. It will be removed whenthe claim is resubmitted or adjusted.)ResponseData populates detail fields in the Detail screen.12

Step3ActionResponseProcedure fields.Enter updated data in the remaining fields that areapplicable or select the most appropriate datafrom the drop-down lists (Diagnosis Code Pointer,Modifier, Emergency, Pregnancy, EPSDT Ref).Step 6: Enter notes about hard copy attachmentsThis screen is not currently used by Medicaid. If you need to send hard copy attachments (e.g., sterilizationconsent form) for a claim, submit the claim on paper with the attached documentation, or use the EDMSCoversheet to fax the documentation to OHA. See Appendix for paper claim instructions.Field descriptionsFieldControl NumberTransmissionReport TypeDescriptionDescriptionAttachment/Paperwork Identifier selected by the user to identify a document that theyintend to send in. This identifier is not used by the system. Attachments are associated to aclaim through the EDMS coversheet by the claim ICN.Code defining timing, transmission method or format of attachment/paperwork.Code describing the type of attachment /paperwork.Additional notes about the attachment /paperwork.Step 7: Submit claim and review claim status informationBefore you click “Submit,” claim status information displays as follows:Click the “Submit” button at the bottom of the screen to submit the claim. If the claim encounters an error (i.e.missing information), a message will display at the top of the claim.Claim status informationClaim processing is real-time, and you can immediately view the status of the claim: The Claim Status Information screen displays information regarding the claim status after the claim hasbeen processed. For example, the claim status may show that the claim has been 1) paid, 2) denied, or 3)suspended (pending).“Cover Sheet for Supporting Documentation” buttonIf you need to send hard copy attachments (e.g., sterilization consent form) for a claim, this button allows you toprint off an EDMS coversheet use as the coversheet for the supporting documentation you mail or fax in. Thesystem will populate the ICN and mark the “Supporting documentation” checkbox for you.Professional Billing InstructionsJune 201713

HIPAA Adjustment ReasonsIf there are Adjustment Reason Codes, they will also display on this screen.Field descriptionsFieldClaim StatusClaim ICNPaid DateAllowed AmountCoversheet forsupportingdocumentationDetail NumberCodeDescriptionDescriptionThe detailed description of the status of the claim.Internal control number that uniquely identifies a claim.The date that the claim was paid.The dollar amount allowed for the claim.Link to the coversheet used when submitting claim attachmentsThe claim detail on which the EOB posted.The Explanation of Benefit code.The description of the EOB code.Paid claimThe claim status, ICN, paid date, allowed amount, and HIPAA Adjustment Reason Codes (ARCs) display on allpaid claims. The “cancel,” “adjust,” “void,” and “copy claim” buttons at the bottom of the claim will activate.See the Claim Adjustment Handbook for more information about adjust and void. The claim will not show the amount paid, only OHA’s allowed amount. You will need to refer to theRemittance Advice for the paid amount.Denied claimThe claim status, ICN, denied date, allowed amount and HIPAA Adjustment Reason Codes (ARCs) display onall denied claims. The “re-submit” button at the bottom of the claim will activate. “Re-submit” allows you tocorrect the denied claim and re-submit it as an original, new claim.Professional Billing InstructionsJune 201714

Suspended claimSuspended means the claim is still in process. The claim status, ICN and allowed amount display on suspendedclaims. Suspended claims can ONLY be viewed. No action buttons display at the bottom of the claim until afterthe claim is processed (paid or denied) by an OHA Adjustment Analyst.How to resubmit a denied claimAfter a claim has denied, two (2) buttons will be displayed at the bottom of the screen: 1) Re-submit and 2)Cancel.To resubmit a denied claimStep Action1Enter data in all required and/or applicable fields. Professional Claim Header Diagnosis Third-Party Liability (TPL) Medicare Information Detail Hard Copy Attachments2Click the resubmit button.ResponseNew claim status information displays with newICN, status, and EOB Information.How to copy a paid claimThe copy button allows you to make an exact duplicate of an existing claim. Once copied, you can update theclaim data and submit the copied claim as a new claim. This feature saves time because you do not have to enter all new data, but you must make sure to update allrelevant data. Once the new claim is processed, a new ICN will display.Professional Billing InstructionsJune 201715

Step1ActionSelect the copy button.2Update all required and/or applicable fields. Professional Claim Header Diagnosis Third-Party Liability (TPL) Medicare Information Detail Hard Copy AttachmentsClick the submit button.3Professional Billing InstructionsResponseThe screen will refresh and display an exactcopy of the claim. Data fields are activated toupdate pertinent information. You will now see“submit” and “cancel” in the lower right of theclaim.June 2017The claim ICN, status, and/or error code isreturned.16

AppendixProvider Web

Introduction The Professional Claim Instructions handbook is designed to help those who bill the Oregon Health Authority (OHA) for Medicaid services submit their claims correctly the first time. This will give you step-by-step instruct