Information For Certified Family Home Providers Information

Certified Family Homes Billing Tips Information for Certified Family Home Providers Certified Family Home (CFH) providers have the ability to bill claims electronically or on paper. An overview for each process is provided in this packet, as well as links to additional information. Information The Idaho Gainwell Technologies Medicaid website at http://www.idmedicaid.com contains valuable information for providers. Hover over the Reference Material tab to access: Announcements that are posted with information about system updates and critical information about billing. Information Releases (IRs) to access all the IRs from DHW. DHW Forms or DXC Technology Forms to find all the forms you need. MedicAide Newsletters containing information about Medicaid policy, important dates, and resources for Idaho Medicaid providers. User Guides to find instructions. Provider Handbook These documents are located on the website and contain general information for all providers and specific billing information for CFHs. Select the Provider Handbook link under the Reference Material menu to find the following documents that will be helpful to you as a CFH provider: General Information o Overview o Directory o General Billing Instructions o General Information and Requirements for Providers o Remittance Advice Analysis Reference o Glossary Provider Guidelines o Adult Residential Care, Certified Family Homes 03/02/2021 Page 1

Certified Family Homes Billing Tips Prior to Billing Please check participant eligibility and retrieve your prior authorization (PA) number. Refer to the Trading Partner Account User Guide for additional information on finding Prior Authorizations and checking eligibility. To retrieve your prior authorization number use the View Authorization tile on the far left. You will get a list of authorizations; use the PA that matches the dates of service you are billing for. Figure 1: View Authorizations Billing Electronically To bill claims electronically, sign into your Trading Partner Account (TPA). On the Form Entry tab, select the View Patient Roster (Figure 2) title. From this screen you may create a patient roster, and use this feature to Submit Claims. You may also use the View & Submit Claims and Verify Member Eligibility tile. Select your Billing Provider and select Submit Claim (Figure 3). Refer to the Trading Partner Account User Guide for helpful information on creating patient rosters, filling out forms, finding members, and adding attachments. Figure 2: View Patient Roster Figure 3: View & Submit Claims The Trading Partner Account User Guide will also explain how to copy the last claim and create a patient roster for a participant so you do not have to complete the same information each time you need to submit a similar claim. 03/02/2021 Page 2

Certified Family Homes Billing Tips Edit/Adjudicate Options After you have submitted your claim, the Claim Confirmation page will display (Figure 4). Figure 4: Claim Confirmation The claim ID displays in the upper left corner of the confirmation page. Select the Claim View link to see the detail of claim. Select Edit Claim to modify this claim. (For example, if you realize the dates of service are incorrect, you can immediately fix the claim.) Select Adjudicate Claim to identify any outstanding edits. Paper Billing If you would prefer to submit your claims on paper, page 5 shows the CMS 1500 claim form. An explanation of the fields that need to be completed are described in the table that follows the claim form. In the Provider Handbook under General Billing Instructions there are Claim Form Instructions for the CMS 1500 has complete information for billing on the professional form. Some of the tips and instructions are included in this document. MAIL ALL 1500 CLAIM FORMS TO: Gainwell TECHNOLOGY PO BOX 70084 BOISE, ID 83707 Instructions and Tips for Completing the CMS 1500 A maximum of six-line items per claim can be accepted. If the number of services performed exceeds six lines, prepare a new claim form, and complete all the required elements. Total each claim separately. Enter all dates using the 2-digit month, day, and year (MM/DD/YY) format (except the Patient’s Birth Date must be entered MM/DD/CCYY) You can bill with a date span (From and To Dates of Service) only if the service was provided every consecutive day within the span. Do not enter any data or documentation on the claim form that is not listed as required below. All paper claims are electronically scanned for processing. The printed versions of the claim forms are machine readable. As such, they are printed using special paper, special color inks, and within precise specifications. For this reason, only original, color forms can be used for scanning. Forms that cannot be scanned are returned to the provider. 03/02/2021 Page 3

Certified Family Homes Billing Tips CMS 1500 Form 03/02/2021 Page 4

Certified Family Homes Billing Tips CMS 1500 Form Descriptions Only fields that are required for billing the Idaho Medicaid program are shown on the following table. There is no need to complete any other fields. Claims will be rejected when information is not entered into a required field. The numbered items below correspond to the CMS-1500 (2/2012) claim form. Box No. Field Name Notes 1a Insured’s ID (Required) Enter the Participant’s Idaho Medicaid ID number (Three zero prefix plus seven digit ID number.) 2 Patient’s Name 3 Patient’s Birth Date Sex (Required) Enter the participant’s name exactly as it appears on the Participant’s Idaho Medicaid ID card. Enter as last name, first name, middle initial. (Required) Enter the patient’s date of birth. Formatted as MMDDCCYY 3 5 5 5 5 10 10a Patient’s Address City State Zip Is patient’s condition related to: Employment? 10b 10b Auto Accident? Place (State) 10c Other Accident? 10d Claim Codes 14 Date of Current Illness, Injury or Pregnancy (LMP) Name of Referring, Ordering, or Supervising Provider Referring, Ordering, or Supervising Physician NPI Additional Claim Information Diagnosis or Nature of Illness or Injury 17 17b 19 21 (A-L) (Required) Female (Required) (Required) (Required) (Required) Check the appropriate box indicating the patient’s gender. M – Male, F Enter Enter Enter Enter Patient’s Street Address the patient’s city the patient’s 2 character state code. patient’s 5 or 9 digit zip code. (Not required) If any are yes, then required. Indicate yes or no if this condition is related to the client’s employment (Not required) Indicate yes or no if this condition is related to an auto accident. (Required if auto accident) Enter 2 digit state abbreviation of the state where auto accident occurred. (Not required) Indicate yes or no if this condition is related to an accident other than an auto accident. (Not required) When applicable, enter the two-digit valid condition claim codes. A maximum of six two-digit alphanumeric codes may be entered. Ensure there is a space between each two-digit code. (Required if any related cause in box 10 is marked Yes) Enter Date of Accident or the date the illness or injury first occurred, or the date of the last menstrual period (LMP) for pregnancy. Formatted MMDDYY (Required for certain specialties) Enter the referring, ordering, or supervising physician’s name formatted: Last Name, First Name, Middle Initial Enter a qualifier of DN for referring provider, DK for ordering provider, or DQ for supervising provider. (Required for certain specialties) Enter the referring, ordering, or supervising physician’s 10-digit NPI. (Not required) Use as a “remarks” field to indicate information helpful for claims processing, e.g. injury/accident – how, where, and when injury/accident happened. (At least one required) Enter the appropriate ICD-9-CM/ICD-10 codes (up to 12). Enter the primary diagnosis in 21(A). If applicable, B, C, and other diagnosis in 21 (AL). Always enter the entire diagnosis code including the decimal point. 22 Resubmission Code Enter a 9 for ICD-9 or a zero for ICD-10 codes in the ICD Ind. field. (Required if a claim is a resubmission) Enter “7” if claim is a replacement claim. Enter “8” if this claim voids a previously submitted claim. Only enter a value in this field if sending a replacement or void to a previously submitted claim, otherwise leave blank. 03/02/2021 Page 5

Certified Family Homes Billing Tips Box No. Field Name Notes 22 Original REF. NO. 23 Prior Authorization Number Date of Service From/To NDC code (Required if a claim is a resubmission) Enter the claim ID number of the original claim to be voided or replaced. Only enter a value in this field if sending a replacement or void to a previously submitted claim, otherwise leave blank. (Required if services need a PA) Enter the PA number exactly as it appears on the Notice of Decision. 24A (unshaded) 24A (shaded top) 24B (unshaded) (Required) Enter the from and to date(s) the service was provided, using the following format: MMDDYY (Required if appropriate) Enter N4 followed by the 11 digit NDC code Place of Service (Required) Enter the appropriate 2 digit numeric code 24B (shaded top) NDC Unit of measure 24C (unshaded) EMG (Required if NDC code is present in 24A) Enter appropriate 2 digit NDC unit of measure. Valid values: F2 - International Unit GR – Gram ME - Milligram ML - Milliliter UN - Unit (Required, if applicable) If the services performed are related to an emergency, mark this field with an X. 24C-D (shaded top) NDC number of Units 24D (unshaded) Procedures, Services, or Supplies Modifier 24D (unshaded) (Required if NDC code is present in 24A) Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may precede the decimal point and three numbers may follow the decimal. (Required) Enter the appropriate five-character HCPCS procedure code to identify the service provided. (Desired) If applicable, add the appropriate HCPCS 2 digit modifier(s). Enter as many as four. Otherwise, leave this section blank. 24D (shaded top modifier section) 24E (unshaded) 24F (unshaded) 24G (unshaded) NCD Unit Price (Required if NDC code is present in 24A) Enter unit price corresponding to NDC code. Diagnosis Pointer 24H (unshaded) EPSDT Family Plan 24I (shaded) ID. Qualifier for service line rendering provider Rendering Provider ID Number (Required if diagnosis code in block 21 is present) Use A-L for the corresponding diagnosis code entered in field 21. (Required) Enter the usual and customary fee for each line item or service. Do not include tax. (Required) Enter the quantity or number of units of the service provided. Maximum value of 9999999. If there is a zero leading a value, you need to remove it (IE. 01 will be 1). (Required if applicable) Not required unless applicable. If the services performed constitute an EPSDT program screen, refer to the instructions for EPSDT claims in the provider handbook. (Required) Enter Service line rendering provider id only if provider rendering the service is different than billing provider. Enter qualifier 1D followed by Idaho Medicaid provider number in 24J, only if Rendering Provider is not registered with an NPI. (Required if rendering provider is billing with Idaho Medicaid ID) Enter Service line rendering provider id only if provider rendering the service is different than billing provider. Enter Rendering Provider Medicaid ID only if Rendering provider is not registered with an NPI. (Required if rendering provider is different from billing provider) Enter Service line rendering provider NPI only if provider rendering the service is different than billing provider. 24J (shaded top) 24J (unshaded) 03/02/2021 Charges Days or Units Rendering Provider NPI Page 6