Kentucky Medicaid - Kymmis.com

Kentucky Medicaid 

Spring 2009 

Billing Workshop 

CMS 1500

Agenda 

• Representative List 

• Reference List 

• CMS Claim Form 

• Detailed Billing Instructions 

• Forms 

• Timely Filing 

• FAQ’s 

• Did You Know 

• Top Denials 

• Questions 

• Evaluation 

Cabinet for Health and Family Services 

2

Representative List 


3

Representative List 


4

Reference List 

Helpful Phone Numbers 

EDI Helpdesk 

800-205-4696 

ky_edi_helpdesk@eds.com 

Provider Billing Inquiry 

800-807-1232 

ky_provider_inquiry@eds.com 

Web Addresses 

EDS Website 

www.kymmis.com 

KyHealthnet 

http://home.kymmis.com 

KY Medicaid 

www.chfs.ky.gov/dms 


5

Top Half CMS Claim Form 


6

Required Information 

FIELD NUMBER NAME AND DESCRIPTION 

2 Patient’s Name 

Enter the member’s last name and first name exactly as it appears on 

the Member Identification card. 

3 Date of Birth 

Enter the date of birth for the member. 

9A Other Insured’s Policy Group Number 

Enter the 10 digit Member Identification number exactly as it appears 

on the current Member Identification card. 

10 Patient’s Condition 

Check the appropriate block if applicable. 


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10D 

Reserved for Local Use 

Enter the Physician Assistant’s NPI Number, if applicable. 

11 Insured’s Policy Group or FECA Number 

Required only if member is covered by Commercial Insurance and 

ONLY if a payment is made, otherwise leave blank. 

11C 

Insurance Plan Name or Program Name 

If an insurance company other than Medicaid has issued payment on a 

claim, enter the name of the other insurance company. 


8

Bottom Half of CMS Claim Form 


9



14 Date of Current (Accident Indicator Only) 

Enter the appropriate date, if you marked “Yes” in the fields 10A- 

10C. (Accident indicator only) 

17B 

Referring Provider 

Enter the KenPAC NPI number. 

21 Diagnosis or Nature of Illness or Injury 

Enter the required, appropriate ICD-9-CM diagnosis code. 

23 Prior Authorization Number 

Enter the PA number assigned for these procedures, if 

applicable. 

24A 

24B 

Date(s) of Service (Non Shaded Area) 

Enter the date or dates of service (s) in month, day, year 

numeric format (MMDDYY). 

Place of Service (Non Shaded Area) 

Enter the appropriate two digit place of service code which 

identifies the location where services were rendered. 


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24C 

24D 

24D 

24E 

24E 

EMG (Shaded Area) School Based Providers only 

Enter number of students in the group on the shaded area above EMG. Valid entry is 1-6 

Procedures, services or Modifiers 

(Shaded Area) 

Enter EI for employee ID followed by the three digit employee ID # (School Based Providers) 

(Shaded Area) 

Enter EI for employee ID followed by the four digit employee ID # (Community Mental Health) 

(Shaded Area above modifier) 

Enter the appropriate EPSDT Referral code if applicable 

(Non-Shaded Area) 

Enter appropriate procedure code (non-shaded area) 

Modifier (Non-Shaded Area) 

Enter appropriate Modifier to identify the procedure. 

Diagnosis Pointer (Shaded Area) 

Enter Military Time of Pickup (Transportation only) 

Diagnosis Pointer (Non-Shaded Area) 

Diagnosis Code Indicator Enter 1, 2, 3, or 4 


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24F 

24G 

Charges 

Enter detail charges. 

Days or Units 

Enter units. 

For Anesthesia Billing, Enter the total number of minutes (shaded area, above the units) 

24I 

EXCEPTION: 

24I 

24J 

EXCEPTION: 

24J 

ID Qualifier (Shaded area) 

Enter ZZ to indicate Taxonomy 

ID Qualifier (Shaded area) 

Enter a 1D to indicate Medicaid Provider (Provider types ONLY: Hands, Commission for 

Handicapped Children, Title V, First Steps, Impact Plus and Non Emergency 

Transportation) 

Rendering Provider ID # (Shaded Area) 

The Rendering Provider’s Taxonomy Code 

(Non-Shaded Area) 

Enter the Rendering Provider’s NPI’s Number 

Rendering Provider ID # (Shaded Area) 

Enter the Medicaid Provider number (Provider types ONLY: Hands, Commission for 

Handicapped Children, Title V, First Steps, Impact Plus and Non Emergency 

Transportation) 


12



26 Patient’s Account No. 

Enter the office account number you have assigned to this member, if 

desired. 

28 Total Charge 

Enter the total of all individual charges entered in column 24F. Total 

each claim separately. 

29 Amount Paid 

Enter the amount paid, if any, by a private insurance not Medicare. 

30 Balance Due 

Enter the balance due if applicable. 

EXCEPTION: (If you are a certified Primary Care or Rural Health provider, or 

Community Mental Health provider, this field is only used for Medicare 

payments) 


13



33 Physician/ Supplier’s Billing Name, Address, Zip Code and Phone Number 

Enter the provider’s name, address, zip code and phone number (including area 

code). 

33A 

EXCEPTION: 

33A 

NPI 

Enter the appropriate Pay to NPI Number. 

Provider types ONLY: Hands, Commission for Handicapped Children, Title V, First 

Steps, Impact Plus and Non Emergency Transportation, LEAVE BLANK 

33B 

EXCEPTION: 

33B 

(Shaded Area) 

Enter ZZ and the Pay to Taxonomy Number. 

Enter 1D and the Pay to Provider Number. (Provider types ONLY: Hands, 

Commission for Handicapped Children, Title V, First Steps, Impact Plus and Non 

Emergency Transportation) 


14

Forms 

• Third Party Liability 

• Adjustment and Claim Credit 

• Cash Refund 


15

TPL Lead Form 


16

TPL Helpful Hints 

• When to use the TPL Lead Form: 

• When there is no response within 120 days from the insurance 

carrier. 

When the other health insurance has not responded to a provider’s 

billing within 120 days from the date of filing a claim, a provider may 

complete a TPL Lead Form. 

Mark “no response in 120 days” on the TPL Lead Form. 

Attach it to the back of claim and submit it to EDS. 

EDS overrides the other health insurance edits and forwards a copy of 

the TPL Lead form to the TPL Unit. The TPL staff contacts the 

insurance carrier to see why they have not paid their portion of liability. 

• Used for Commercial Insurance Only 

• Not to be used for Medicare 

• Other section is obsolete 

• Contact name and phone number is person and phone 

number at Commercial Insurance 


17

Adjustment Claim Credit 


18

Adjustment, Claim Credit/Void Hints 

An adjustment/void is a change to be made to a “PAID” claim. 

Please keep the following points in mind when filing an adjustment 

request: 

• Attach a copy of the corrected claim and the paid remittance 

advice page to your adjustment form. 

• Do not send refunds on claims for which an adjustment or void 

has been filed. 

• Be specific. Explain exactly what is to be changed on the claim. 

• Claims showing paid zero dollar amounts are considered paid 

claims by Medicaid. 

• If the paid amount of zero is incorrect, the claim requires an 

adjustment. 

• Do not do a adjustment/void on KyHealth Net and paper. Do one 

or the other. 

• A claim credit is on paper, a void is on the KyHealth Net. They are 

the same. 

• Only a void/claim credit will re-set a Prior Authorization 


19

Cash Refund 


20

Cash Refund Hints 

The Cash Refund Documentation Form is used when refunding 

money to KY Medicaid. 

Please keep the following points in mind when refunding: 

• Attach to the Cash Refund Documentation Form a check for 

the refund amount made payable to the KY State Treasurer. 

• Attach applicable documentation, such as a copy of the 

remittance advice showing the claim for which a refund is 

being issued. 

• Do not send a refund and an adjustment/void on the same 

claim. 


21

Timely Filing 

Aged claims (those older than within 12 months from date of service or 6 months 

from the Medicare payment or denial date) may be considered for payment only 

when documentation is submitted behind the claim to support timely filing. 

The ONLY Acceptable documentation will include a copy of one or more of the 

following: 

• Remittance advices to verify timely filing within each 12 months from date of 

service. 

• A Screen Print from KYHealth-Net to verify issue date of the eligibility. (this is 

the card issuance screen) 

• A Screen Print from KYHealth-Net Summary Page, to verify timely filing within 

each 12 months from date of service. 

• Medicare explanation of benefits (EOMB) 

• Commercial Insurance EOB 


22

Timely Filing Examples 

1 Year From Issue Date 


23


KyHealth Net 

Search Criteria 

Screen 

Not Acceptable 

for timely filing 


24


KyHealth Net 

Header Screen 

Not Acceptable 

for timely filing 


25


KyHealth Net 

Summary 

Screen 

Acceptable for 

timely Filing 


26

FAQ’s 

If you bill Medicare and drop your claim to paper, remember to attach 

your coding sheet when Medicare allows a charge. If Medicare denies 

a charge, this must be billed paper with the denial EOB attached. 

Medicare Replacements follow the same rules as Medicare claims. 

The sequence to submit is; Claim, Coding sheet then any other 

attachments. 

When billing Medicare electronically, you may bill with NPI and 

taxonomy and the claim will cross via 837. Medicare’s website about 

taxonomy is: www.cms.hhs.gov/manuals/ 

When submitting a paper claim with attachments, the claim must 

always be on top of any attachments. Except, when submitting paper 

adjustments, the adjustment form is to be on top of the claim. 


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FAQ’s Cont. 

 

Member Program Codes to watch for 

Z-QMB Only-Medicaid only allows after Medicare, so if Medicare 

denies, Medicaid will deny. 

ZJ, ZK, ZL, ZQ Buy-In Member-Medicaid is only paying the 

Medicare Premiums. No Medicaid coverage. 

 

 

 

For Ambulatory Surgery Centers only: 

The 59 modifier is ONLY for implants. These must be billed on 

paper with the invoice attached and the billed amount must match 

the invoice dollar amounts. 

Rendering ARNP/CRNA cannot be billed along with the 

physician group. 

Billing for a Physician Assistant: In field 10d, enter the PA’s NPI 

number. In field 24d enter the U1 modifier. In field 24j, enter the 

supervising Physician’s NPI. 


28

FAQ’S Cont. 

Internal Control Number (ICN) 

All claims, adjustment and Voids are given a unique number. 

First two digits are the Region, Second 2 digits is the Year the 

claim was received and the 3 rd three digits are the Julian Date 

of receipt. 

*Example 2009061123456-Claim received as an electronic claim, 

March 2, 2009. 

If the ICN begins with: 

10-Paper claim with no attachments 

11-Paper claim with attachments 

20-Electronic claim 

22-KyHealth billed claim 

50-Adjustment 

56-Claim Void 


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FAQ’s Cont. Physicans ONLY 

• Recently the Department for Medicaid Services (DMS) requested a review of the 

medical necessity of CT scans performed for Medicaid members. The review 

revealed that many diagnoses appear unrelated to the medical conditions/reasons for 

CT scans. Inaccurate diagnosis coding may result in the denial or recovery of 

services because the medical necessity of the scan can not be determined. Medicaid 

funds can only be used for services that are medically necessary. 

• Examples of inappropriate brain CT diagnoses include cellulitis of the toe, sunburn, 

osteoarthritis, lumbago, trigger finger, joint pain of the shoulder, cough, chest pain, 

screening mammogram, removal of sutures, varied fractures and sprains of the 

patella, wrist, tibia, fibula, hand and foot. 

• Examples of inappropriate spine CT diagnoses include malaise, convulsions, 

generalized pain, altered mental status, abdominal pain, ankle and foot fractures and 

sprained ankle. 

• Examples of inappropriate chest CT diagnoses include panic disorder, anxiety, 

hyperlipidemia, appendicitis, pain in the limb, memory loss, headache and diarrhea. 

• DMS is requesting all providers review their radiology billing process and bill claims 

with the appropriate diagnoses that supports the medical necessity of the procedure 

being performed. Future restrictions may be imposed if the medical necessity of CT 

scans continues to be unsupported by the diagnosis codes. 


30

Did You Know 

* Coming Soon--Paper checks are going to be mailed from the 

KY State Treasurer. Remittance Advices will continued to be 

mailed by EDS. 

* GO GREEN--Did you know that you can opt not to receive 

paper RA's. You can download the RA from the KyHealth Net 

and keep an electronic copy. 


31

Top Denials 

 

 

 

 

 

EOB 0482-Exact duplicate 

Resolution: The claim has already paid, a duplicate will not hit against a previously 

denied claim. 

EOB 1010-Rendering Provider not a member of billing group. 

Resolution: Contact provider enrollment at 877-838-5085. Invalid billing NPI and 

taxonomy may result in this denial code. 

EOB 1955-The billing provider NPI submitted on the claim cannot be used to 

uniquely identify the billing provider. 

Resolution: Verify billing provider number NPI and taxonomy number billed. 

EOB1908-NPI IS NOT ON FILE 

Resolution: Contact provider enrollment at 877-838-5085 to update provider file. 

EOB2003-Member not eligible for Medicaid 

Resolution: Always check member eligibility. 


32

KY MMIS Project 

Provider Evaluation – Provider Workshop 

Date: 

Thank you for attending this session. We’d appreciate your feedback, as well as suggestions on how we can 

improve future sessions. 

Please answer the following questions, rating them on a scale of 1-5, with 1 being strongly disagree and 5 being 

strongly agree. 

Strongly 

Disagree 

Somewhat 

Agree 

Strongly 

Agree 

Question 1 2 3 4 5 

1. Material was appropriate for the audience. 

Comments: 

2. Presentation was well-organized and easy to follow. 

Comments: 

3. Session leader was easy to hear/understand. 

Comments: 

4. The Session leader was well-versed in their subject area and presented information 

in a clear, understandable manner. 

Comments: 

5. I was given appropriate material/handouts. 

Comments: 

6. Questions were answered to my satisfaction. 

Comments: 

7. I was able to see/hear the audiovisual portion with no trouble. 

Comments: 

If you would like to receive information via e-mail, please provide address below. 

Comments: 

Optional: if you would like a member of the KY MMIS team to contact you, please provide your contact information below. 

Name: Department/Branch: 

Phone Number: Email:

Kentucky Medicaid - Kymmis.com

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