Maryland medicaid cms-1500 paper



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MARYLAND MEDICAID

CMS-1500

PAPER

BILLING INSTRUCTIONS



A Comprehensive Guide Focusing on Maryland Medicaid Billing Procedures and Other Useful Information




Effective April 2013
Dept. of Health and Mental Hygiene

Office of Systems, Operations & Pharmacy

Medical Care Programs
TABLE OF CONTENTS
I. GENERAL INFORMATION PAGE

A. Introduction 1

B. HIPAA 1

C. NPI 1



II. HEALTHCHOICE

A. Health Choice (MCO) 2

B. Payments to Managed Care Organizations 3

C. MCO Excluded Services 4

D. Self-Referral Services 5



III. BILLING INFORMATION

A. General Instructions 6

B. Timely Filing Statutes 6

C. Paper Submission & Claims Address 6

D. Electronic Submission 7

IV. EVS 8



V. CMS-1500 BILLING INSTRUCTION

A. CMS-1500 Billing Instructions 10 B. Third Party Billing 18

C Medicare/Medical Assistance Crossover Claims 20

D. Claims Troubleshooting 23

E. How to File an Adjustment Request 27

F. Medical Assistance Payments 28




VI. FRAUD AND ABUSE 29



VII. MARYLAND MEDICAID PROGRAM SERVICES INFORMATION

A. Emergency Service Transporter 32




VIII. EPSDT/HEALTHY KIDS

A. EPSDT/Newborn Billing 33/34

B. Audiology 35

C. IEP/IFSP Health Related Services 36

D. PT, OT, Speech & Chiropractic Services 37

E. Substance Abuse Services 38

F. Therapeutic Behavioral Service 41

G. Vaccine for Children Program 42

H. Vision Care Services 43
IX. HEALTHY START PROGRAM FOR PREGNANT WOMEN 44
X. DMS/DME

A. DMS/DME 45

B. Oxygen and Related Respiratory Equipment Services 46




XI. LABORATORY AND PATHOLOGY 47
XII. MEDICAL DAY CARE 48
XIII. PHYSICIANS’ SERVICES

A. Physicians’ Services 49

B. Modifiers 50

C. Podiatry 53

D. Radiology 54

E. Abortion 56

F. Hysterectomy 57

G. Sterilization and Tubal Ligation 58

H. Trauma Billing 60
XIV. PRIVATE DUTY NURSING 63
XV. IMPORTANT TELEPHONE NUMBERS AND ADDRESSES

  1. Websites, Important Telephone Numbers and Addresses 64

  2. Directory of Local Department of Social Services 67


XVI. FREQUENTLY ASKED QUESTIONS 69
XVII APPENDIX – DHMH FORMS

A. CMS-1500 Form 71

B. Adjustment Form - DHMH 4518A 72

C. Abortion Form - DHMH 521 73

D. Hysterectomy Form – DHMH 2990 74

E. Sterilization and Tubal Ligation Consent Form – DHMH 2989 75


INTRODUCTION
This manual was prepared to provide proper billing procedures and instructions for Maryland Medicaid providers who bill using the CMS-1500 form. This includes Certified Nurse Midwives, Certified Nurse Practitioners, Certified Registered Nurse, Anesthetists, Free-Standing Clinics, Physicians, Podiatrists and DME/DMS providers.
The Medical Assistance Program has made numerous revisions to the billing procedures for all Medicaid Programs in order to adhere to the standards created under the Health Insurance Portability and Accountability Act (HIPAA). As a result of the requirement for standardization of code sets and forms, Maryland Medicaid has replaced all local procedure codes to nationally accepted codes. This includes standardization in the way providers transmit claims electronically.


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