Timely Filing

All claims must be submitted within 9 months from the date of service. There are an additional 60 days from the date of the denial in which a denial may be appealed.

There are a few circumstances in which MHA will waive these timely filing rules:

• Retro MA eligibility -- Provider has 9 months from the date of MA eligibility in which to submit a bill.
• Retro review/appeal -- Provider has 9 months from the date of service or 60 days from the date of notification of the review or appeal in which to submit a bill.
• Retro opening of an LTC span -- Provider has 9 months from the date or service or 60 days from the date of notification of the Long Term Care (LTC) span being opened in which to submit a bill.
• Resubmission of a corrected claim -- Provider has 9 months from the date or service or 60 days from the date of notification (denial) in which to submit a bill.

FAQ

Q. If we check the Gray Zone website and see that the consumer is already registered, do we still need to submit a DCW (data collection worksheet)?

A. No, If the consumer is registered, the DCW has already been submitted. However, you should check to see if the income verification has been submitted. If it has not, you may not receive payment if the first two visits have been used. Remember that the first two visits are per consumer, not per provider.

Q. Are there specific guidelines for determining Gray Zone consumers' co-pay amounts? Is it the last two checks or year to date income?

A. The last two consecutive paychecks are sufficient, however, if the paychecks are not consecutive, the previous year's tax statements can be submitted.

Q. How can we get reimbursement for services where income verification was not submitted for a consumer who has used his two covered visits, comes to us and we have provided services not knowing the first two visits have been used?

A. You can contact your CSA to find out if they can offer assistance in helping you get paid. To avoid this situation, you should check the Gray Zone website to see if the consumer has been registered as plan 00 by another provider. You may also ask the consumer.

Data Collection Worksheets

Q. When the DCW (Data Collection Worksheet) information is submitted, but not the income verification, will we still get paid?

A. Only the first two visits will be covered. Prior to the third visit, the income verification must be submitted if continued payment is expected. Remember that the first two covered visits are per consumer, not per provider.

Q. Should we send DCW (Data Collection Worksheet) information to the CSAs (Core Service Agency)?

A. No. This should always come to MAPS-MD.

Q. Should I submit the income verification with the treatment plan?

A. No. The income verification should be submitted with the DCW (Data Collection Worksheet) or shortly thereafter, but must be submitted before the third (3rd) visit.

Name Changes

Q. When a consumer gets married, how do we bill when the consumer's name changes but MAPS-MD does not have the name change in the system?

A. If the consumer has Medicaid or Medicare, the name change must be done through Medicaid / Medicare and the new information would be transferred to MAPS-MD via eligibility information updates. If the consumer is a Gray Zone only consumer, the provider must submit legal documentation of the name change to MAPS-MD @ 410-953-1857. Until the name change is confirmed, continue to bill with the name in the system.

Q. How do we handle claims submissions when there has been a name change due to marriage, divorce, etc.?

A. DSS must be contacted and the changes must be made at the State level. If the consumer is registered as Gray Zone, you must submit official documentation to of the correct information to P.O. Box 3190, Columbia MD. 21046

Q. How do we get consumer demographic information corrected when we have different information on file than is entered into the MAPS-MD system?

A. If the consumer is registered as Gray Zone, you must submit official documentation to of the correct information to MAPS-MD, P.O. Box 3190, Columbia MD. 21046. If the consumer is a Medicaid consumer, the provider must submit documentation to DSS to have the information updated in the Medicaid system.

Social Security Numbers

Q. Will MAPS-MD accept the consumer's social security number as an identification number?

A. Yes. The consumer's medical assistance number or social security number can be used to submit a claim. MAPS-MD will not accept a "T" number for a consumer who is registered as Gray Zone.

Homelessness

Q. If a consumer is homeless, how will we be paid for services?

A. If the consumer is homeless, the provider should indicate "homeless" on the Data Collection Worksheet. Decisions regarding the co-pay amount will be determined on a case by case basis depending on income verification.

Q. Is there a form for re-certification?

A. No. A new DCW and income verification must be submitted.

Eligibility Verification

Q. If a consumer says that he / she does not have Medical Assistance (MA), do I still need to check EVS (Eligibility Verification System)?

A. You should check EVS to verify that the consumer is not covered under MA. You should then check the Gray Zone website to verify if the consumer is registered as Gray Zone. If the consumer is not already registered as Gray Zone, you should begin the registration process.

Denials

Q. When we get a denial for "other insurance", whom can we contact to get the other insurance information?

A. You should contact the consumer. If you are receiving denials for other insurance, this indicates that the consumer has supplied MA or MAPS-MD with information of a primary insurance carrier. If this is incorrect or the primary insurance carrier no longer covers the consumer, the consumer must supply MA / MAPS-MD with updated information.

Q. Should a denial for exhausted benefits be submitted with every claim?

A. Yes. A copy should be submitted with each claim along with the corresponding occurrence codes in form locator 32 and the date benefits exhausted. (The code used will depend on whether the benefits were Medicare or commercial insurance- see list of occurrence codes in training handout or Provider Manual chapter 16).

Q. If a consumer has commercial primary coverage and the benefits have exhausted, will services be eligible for reimbursement by MAPS-MD?

A. If the consumer has only commercial insurance, MAPS-MD will not consider the claim for payment. If the consumer has commercial insurance and Medicaid as secondary, the claim will be considered for payment.

Q. When Medicare is primary, can we attach one EOMB (Explanation Of Medical Benefits) to multiple claims?

A. No, each claim must have a copy of the EOMB attached.

HCFA

Q. On the HCFA- 1500 in form locator 11, should there be anything listed other than occurrence codes?

A. No, this space has been designated by MHA to list occurrence codes only.

Q. On the HCFA -1500 in form locator 33, does the rendering provider # go there?

A. No, For group billers only, the rendering provider's MA# would be entered in form locator 19.

Q. Can you bill more than one date of service on a HCFA 1500 claim?

A. Yes, there are six (6) lines for entry on the HCFA 1500. You may not span dates of service. Each line must reflect only one date of service. Spend Downs & 216s

Q. When a consumer has a spend down amount, do we have to attach a copy of the form 216?

A. No. However the information must be listed in the appropriate form locators. Form locator 36 must contain the occurrence code 80 and the date listed on form 216 showing spend down date span. Form locator 39 must contain D3 and the spend down amount listed on form 216.

Q. If a claim is billed without the information listed on the form 216, what will happen to the claim?

A. The claim will be denied for improper billing.

Q. What if we don't know that the consumer has a spend down amount?

A. Once you receive the denial the not having the spend down information on the claim, you should check the consumer's records for the form 216 and re-bill with the added information.

Q. If we receive a denial because spend down information is not listed, we add the information and re-submit, is this considered a corrected bill?

A. No, this is not a corrected bill. This claim was originally denied; therefore no previous payment has been made.

Q. Must we always show the estimated amount due on the claim?

A. No, only if it differs from the total charges. If the total charges is different than the estimated amount due, there must be corresponding information listed on the claim: i.e.: spend down amount information, leave of absence information, non-covered charge information, etc.

Q. If a consumer has a spend down amount, will the amount be automatically deducted from the claim?

A. No. It is the responsibility of the provider to list the spend down information from form 216 on the claim. Claims submitted without the required spend down information will be denied. (Refer to Provider Manual Chapter 16 or your training packet for UB92s for instructions)

Q. If a claim is denied for spend down information not being listed on the claim and the dates of service fall outside of the dates listed for consumer spend down, how do we get the claim denial over turned?

A. Contact customer service @ 1-800-565-9688. They will verify the spend down eligibility dates and send the claim for correction if the dates of service are not within the spend down date span.

Web Site Authorizations

Q. How soon after getting authorization will it be available to view on the authorization web site?

A. Please allow five (5) business days before looking for the authorization on the web site. Certification Period

Q. In chapter 3.5 - Certification Period, what is considered extraordinary change?

A. An extraordinary change would be if there has been a change in the consumer's income that would affect the consumer's co-pay amount.

Pharmacy-Only Consumers

Q. If a pharmacy only consumer cannot pay the co-pay, what should the provider do?

A. MAPS-MD has been directed to inform the provider that in a situation as this, the provider should contact their CSA (Core Service Agency) for directives.

Q. How will we know if the consumer is registered with one of the new pharmacy only coverage groups? (S08, S09, S11 and S12)

A. When you check the Gray Zone Website, for verification of eligibility, the coverage group will be listed as S08; S09; S11 and S12 for pharmacy only consumers who fall into the above categories.

PRPs & MA #s

Q. If a clinic is billing for PHP (Partial Hospitalization Program) services, what MA# should we use?

A. Use the Medicaid number given to you by the State for PHP services.

RTCs

Q. How should RTCs submit bills with corrections?

A. If a payment has been made to a claim, and you now wish to make changes to that claim, you must submit a corrected claim. This will be submitted with the bill type 167 and must include all charges that you wish to have considered for payment.

Q. What if the claim has already been retracted? Do we still need to submit a corrected claim?

A. Yes. Although the claim has been retracted, there was once a payment made and this would still be considered a corrected claim.

UB 92

Q. Why do we have to bill only one date of service for each UB92 claim?

A. This is State mandated.

Bill Type 115

Q. Is bill type 115 a valid bill type?

A. Yes, this is a late bill for ancillary charges only and cannot include room and board charges. If room and board charges are billed on a late bill, the claim will be denied for use of an inappropriate bill type.

Q. How should additional room and board charges be billed?

A. If additional room and board charges need to be billed after the payment of an original claim, the claim must be billed as a corrected bill. (bill type 117, 157 or 167)

Medicaid Cross Overs

Q. If we are a not Medicare cross over provider, do we still have to wait six weeks to submit a claim with EOB?

A. Yes. MAPS-MD will not process a Medicare claim unless the date of submission is six (6) weeks past the date on the Medicare EOB.

EOPs & Web MD

Q. Who do I contact if I am having problems getting my electronic EOP?

A. Contact Web MD for possible posting issues @ 1-888-305-3756

Q. What if we make changes to our software?

A. You must contact Web MD to let them know of any changes you make on your system. The smallest of changes could cause problems with your claim submissions resulting in non-payment of claims.

Long Term Care

Q. What is Long Term Care (LTC)?

A. Long term care is a specialized treatment setting where "institutionalized individuals" are treated. These settings include Residential Treatment Centers, nursing homes, and private psychiatric hospitals. Medical Assistance defines the time when an individual becomes institutionalized differently for different age groups. Individuals under the age of 21 become institutionalized on the first day of the first full calendar month of their stay in a long-term care facility. All other individuals become institutionalized after staying 30 calendar days in a long-term care facility.

Q. Do you have to wait a full month before submitting the paper work for Long Term Care?

A. No. For RTCs, the paper work must be submitted immediately since the LTC span must be opened from the date of admission, except for non-community eligible consumers whose LTC span will be opened when the recipient becomes an institutionalized person. For IMDs, you must submit the disenrollment form as soon as possible if the consumer is in your facility for a period over thirty (30) calendar days. The admit month only will be paid without an established Long Term Care span, however, if the Long Term Care span is not opened by the fourth (4th) month, the paid claim for the month of admission will be retracted. Revenue Code 949

Q. Does revenue code 949 (IOP) include physician charges? Can the physician bill his / her services separately?

A. When delivered in a non-hospital-based program, physician charges are included in the rate. When delivered by a hospital-based program, physician charges may be billed separately. Physician charges must be billed on a HCFA -1500 form.

Claims

Q. To which address should I send claims?

A. MAPS-MD, P.O. Box 624, Owings Mills, MD 21117-0624

Q. If a claim has been paid, then retracted, will that authorization be available again?

A. Yes.

ICD-9 Discharge

Q. Will MAPS-MD accept the updated discharge ICD-9 codes? (Updated October 2001)

A. To date, MAPS-MD has not been instructed by MHA (Mental Hygiene Administration) to accept the new codes.

Partial Eligibility

Q. Can we bill non-eligible dates of service as non-covered days when only part of the consumers' stay is MA eligible?

A. No. The entire claim will be denied for lack of membership. You can only bill MAPS-MD for days that the consumer has MA eligibility. If the non-eligible dates of service fall in the middle of the stay, you must submit two (2) bills. If you need a denial from MAPS-MD, you may submit the non-covered days on one claim for a denial and the covered days on a second claims for payment consideration.

Treatment Plan Faxing Program

In response to the increased fax volume MAPS-MD has added two additional secure fax lines to receive clinical information. Please fax clinical information only to fax 410 953-1903.

New Claims Address

Effective June 1, 2002, all claims should be sent to the following address:

PO Box 3000
Columbia, Maryland 21046

This address will be replacing P.O. BOX 624, Owing Mills, Maryland 21117

Reminder: Preauthorization of all clinical and rehabilitative services

Effective January 1, 2002, all clinical and rehabilitative services authorized in the PMHS with the exception of the initial twelve (12) traditional outpatient services, emergency room visits, labs, hospital consultations and nursing home consultations must be pre-authorized. Maryland Health Partners care managers will not authorize any requests for services once the services have already been rendered.

The initiation of the twelve (12) traditional outpatient services is considered a registration which should occur before treatment begins or as soon thereafter as possible. If the consumer has been in treatment with another provider, it is possible that claims will reject for lack of authorization if the consumer has not been registered prior to the submission of the claim.

Authorization Website Reminder

Each provider, who has a Medicaid provider number, will receive a login name and password for the authorization website. The purpose of this website is to verify authorizations that have already been issued. Once a provider has received his/her password, he/she should refer to the MAPS-MD website (mdhp.com) for instructions on accessing and utilizing the site. Please allow at least one business day for authorizations obtained over the phone and ten working days for the authorizations received via fax or mail to be posted on the website.

If you are having trouble accessing the site please send an email to: Info@GZMD.com, and address all inquires to "Team G".

Friendly Reminder Regarding Other Insurance Coverage and Crossover Billing

"When a consumer is enrolled in other insurance, an Explanation of Benefits from the other carrier must be attached to the claim." (Provider Manual sec. 16.6)

"A separate HCFA-1500 must be submitted for each claim listed on the Explanation of Medicare Benefits (EOMB). Codes and dates of service should exactly match the EOMB when payment has been made by Medicare. When Medicaid denies, MAPS-MD becomes primary and all submission guidelines for Medicaid should be followed. Failure to follow these guidelines will result in denied claims." (Provider Manual sec. 16.7.3)

Diagnosis Code Update

Download a list of the valid diagnosis codes accepted in the Public Mental Health System. All codes must be billed up to the fourth or fifth digit when applicable.

New EX Code

MAPS-MD has identified claims that were paid by both MAPS-MD and Medicaid which have similar or conflicting services and the same dates of service. We have been instructed by MHA to retract the claim paid by MAPS-MD.

EX Code 9S "CLAIM RETRACTED. SIMILAR OR CONFLICTING SERVICE PAID BY MEDICAID" is the code currently being used to identify these rejections. If you have any questions, please contact Medicaid claims directly at 410/767-5503 for medical claims, and 410/767-5457 for hospital claims.

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