Medicaid Alabama

Alabama Medicaid Home Health (HH), UB-04 Hardcopy

Effective March 1, 2010, all claims that do not require attachments or an Administrative Review override by Medicaid must be submitted electronically.

Alabama Home Health is a regular fee-for-service claim.

Adhere to the following specific Alabama Medicaid Home Health (HH), UB-04 Hardcopy rules:

>	Complete all required areas of the UB-04 claim form.

>	Use only original UB-04 claim forms with the red drop-out ink or file electronically.

Note: Do not circle, underline, or highlight any information on the claim. Send original claim forms only, do not send copies.

>	When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>	The value for all check boxes on the form is X.

>	If a field is not completed, the items must be left empty on the form.

>	Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

>	Claims are split into items based on the Revenue/HCPC Codes.

>	Multiple-page claims are not accepted for the paper UB-04 forms.

>	Only the new Medicaid ID number (beginning with a 5) will be accepted for processing purposes for the claims received on or after January 17, 2011.

In Administration>Financial>Insurance Codes>General, define the following items:

>	Type – K (Medicaid)

>	Mode – R (Regular)

>	State – AL (Alabama)

>	Form – UB-04

In Administration>Financial>Insurance Codes>NPI, define the following items:

>	In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

>	In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

In Administration>Financial>Insurance Codes>Liability/ Spend Down, make no selection because Alabama Medicaid captures this information from the Local Representatives and it must not be reported on the claim.

In Administration>Financial>Insurance Codes>Print Variations, define the following items for Alabama Medicaid Home Health (HH), UB-04 Hardcopy.

Locator

Locator Name

Setup

N/A

Specialized formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the following print variations:

>	Make separate claims (with totals) for claims

>	Suppress dots & dashes in ICD codes, dates and insured info

FL 2

Billing Provider's Designated Pay-to Address

If the pay-to name and address is different from the provider's name or address, enter it through the claim constants at the appropriate level. Include the name, address, city, state, and ZIP Code.

FL 4

Type of Bill

The third digit in the type of bill is 1–5. Type 7 and 8 will be generated for voids and replacements. Alabama Medicaid does not accept the 7 and 8 type of bill claims. Use the Alabama Medicaid Adjustment Request Form for corrections.

FL 5

Federal Tax ID

Select the Suppress printing Federal Tax ID print variation.

FL 6

Statement Cover Period From/Through Dates

Select the Use the first and last Dates of Service print variation.

FL 8

Patient Name/Identifier

Enter the recipient's name exactly as it was defined because of the eligibility verification transaction. If a recipient has two initials instead of the first name, enter the first initial and a long space, then the second initial and no periods. For example, for the recipient A. B. Doe, enter the patient's first name as A B.

FL 9

Patient Address

Select the Suppress printing Patient Address print variation.

FL 11

Sex

Select the Suppress printing Patient's Sex print variation.

FL 12

Admission Date

Select the Suppress printing Admission Date print variation.

FL 17

Patient Discharge Status

Select the Suppress printing of Patient Status Code print variation.

FL 18–28

Condition Code

If needed, enter condition codes in Patient>General>Claim Constants.

FL 29

Accident State

If occurrence code from the range of 01–05 is used, enter the two-character accident state in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Code

If needed, enter occurrence codes in Patient>General>Claim Constants.

FL 35ab–36ab

Occurrence Span Codes

If needed, enter occurrence span codes in Patient>General>Claim Constants.

FL 39–41

Value Codes Amounts

Select the Suppress printing Value Code '44' print variation.

Enter value codes and the total charge amount of a claim in Patient>General>Claim Constants. Use the following value codes:

>	73 – Medicare Paid Amount

>	74 – Medicare Allowed Amount

>	80 – Covered Days

>	81 – Non-Covered Days

>	82 – Co-Insurance Days

>	83 – Lifetime Reserve Days

>	A1 – Medicare Deductible Amount

>	A2 – Medicare Co-Insurance Amount

FL 42

Revenue Code

Enter the appropriate revenue codes in the Rev Code column in Administration>Financial>Billing Rates>Rates for this insurance. Ensure that 001 is entered in the Total Rev Code field in Administration>Financial>Insurance Codes>General.

FL 43

Revenue Description

Select the Print 'Page 1 of 1' on line 23 if single-page claim print variation.

FL 44

HCPCS/Rate/HIPPS Code

If needed, enter HCPCS codes in the HCPCS/HIPPS Code field in Administration>Financial>Billing Rates. Also, include any modifiers in positions 6–7, 8–9, and 10–11 of this field.

FL 51

Health Plan Identification Number

Select the Suppress printing Health Plan ID print variation.

FL 54

Prior Payments – Payer

Select the Only print payments from commercial payer print variation.

FL 61

Insured's Group Name

Select the Print the Insurance Group Name print variation.

FL 70

Patient Reason DX

If needed, submit the diagnosis for the reason a recipient came in for treatment using claim constants at the appropriate level.

FL 76

Attending Physician's License Number

Select the Print physician's State License Number and 0B Qualifier print variation.

Enter the attending physician's state license number in the State License field in Resource>General>Roles.

FL 80

Remarks

If needed, enter remarks in Patient>General>Claim Constants.

Examples include, but are not limited to the following:

>	TPL paid (MM/DD/YY)

>	TPL denied (MM/DD/YY)

>	Retroactive eligibility award date

Alabama Medicaid Home Health (HH), 837I 4010A1 Electronic

Refer to the Alabama Medicaid Home Health (HH), UB-04 Hardcopy instructions for other setup information. The following fields are required for Alabama Medicaid Home Health (HH), 837I 4010A1 Electronic.


Field	Description
Assignment of Benefits and Release of Information	In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.
Carrier Code	Enter the appropriate codes assigned by Alabama Medicaid in Administration>Financial>Insurance Codes>Carrier Codes.
Federal Tax ID -OR- Social Security Number -AND- Provider Taxonomy Code	For the patient's attending physician, enter either the physician's Federal Tax ID or Social Security Number. Enter the physician's taxonomy code. These fields are located in Resource>General>Roles.
Provider Taxonomy Code	Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes.
Receiver ID (File Recipient)	Enter 752548221 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.
Receiver Name (Payer)	Enter Alabama Medicaid in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.
Request for paper EOB	Make sure the Request for paper EOB check box in Administration>Financial>Insurance Codes>General is clear. Alabama Medicaid does not provide paper EOBs.
Submitter ID	Enter the submitter ID assigned by Alabama Medicaid in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.
Test Submission Indicator	Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Alabama Medicaid Home Health (HH), 837I 5010A2 Electronic

Refer to the Alabama Medicaid Home Health (HH), UB-04 Hardcopy instructions for additional setup information.

For Alabama Medicaid Home Health (HH), 837I 5010A2 Electronic, define the following items:

>	In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

Note: If values other than 3 or 1 are required, enter them in Patient>General>Claim Constants or Administration>Financial>Claim Constants.

>	Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

The following fields in the application are required for Alabama Medicaid Home Health (HH), 837I 5010A2 Electronic.


Field	Description
Assignment of Benefits and Release of Information	In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.
Carrier Code	Enter the appropriate codes assigned by Alabama Medicaid in Administration>Financial>Insurance Codes>Carrier Codes.
Federal Tax ID -OR- Social Security Number -AND- Provider Taxonomy Code	For the patient's attending physician, enter either the physician's federal tax ID or Social Security Number. Enter the physician's taxonomy code. These fields are located in Resource>General>Roles.
Provider Taxonomy Code	Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes.
Receiver ID (File Recipient)	Enter 752548221 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.
Receiver Name (Payer)	Enter Alabama Medicaid in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.
Request for paper EOB	Make sure the Request for paper EOB check box in Administration>Financial>Insurance Codes>General is clear. Alabama Medicaid does not provide paper EOBs.
Submitter ID	Enter the submitter ID assigned by Alabama Medicaid in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.
Test Submission Indicator	Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Alabama Medicaid Hospice (HO), UB-04 Hardcopy

Alabama Medicaid Hospice is a benefit claim. Room and board is billed on the same claim as hospice, so the same payer pointer should be used for room and board.

In Administration>Financial>Insurance Codes>General, define the following items:

>	Type – K (Medicaid)

>	Mode – B (Benefit)

>	State – AL (Alabama)

>	Form – UB-04

Important:

>

Alabama Medicaid has different HCPCS codes and/or modifiers when billing for hospice only. Room and board claims use HCPCS code T2046 and appropriate modifiers. Total dollar amount includes both hospice and room and board charges when Medicaid is paying for both charges. Modifier SE is used when a Medicare or a Medicare Advantage company is paying for hospice charges.

>	In Administration>Financial>Billing Rates, set up revenue codes 651–656 as shown in the table below.

>	Set up revenue code 659 with the HCPCS code T2046 only. The application determines if the modifier SC or SE will be reported.

>	Medicare Advantage companies are identified by using the HM insurance type code in Administration>Financial>Insurance Companies.

Payment of hospice services is limited to the following codes (for more information, refer to the Alabama Medicaid Hospice Billing Manual).

Revenue Code

Procedure Code

Description

651

T2042

Routine home care, per day.

652

T2042SC

Continuous home care, per hour.

655

T2044

Inpatient respite care, per day.

656

T2045

General inpatient care, per day.

659

T2046

Nursing facility room and board, routine care, per day.

T2046SC

Nursing facility room and board, continuous care, per hour. This modifier must be reported for continuous care unless the SE modifier is being used.

T2046SE

Nursing facility room and board, per dually eligible recipient, per day. This modifier must be reported when Medicare or any of the 5 pre-approved Medicare Advantage programs are the primary payer:

>	HealthSpring's Seniors First

>	United HealthCare's Medicare Complete

>	Viva Health's VIVA Medicare Plus

>	Blue Cross/Blue Shield of Alabama's Blue Advantage

>	Windsor Health

In Administration>Financial>Insurance Codes>Print Variations, define the following items for Alabama Medicaid Hospice (HO), UB-04 Hardcopy.

Locator

Locator Name

Setup

N/A

General Rules

Select the following print variations:

>	Suppress dots & dashes in ICD codes, dates and insured info

>	Print 9 digit zip codes without dashes for all addresses

FL 4

Type of Bill

Select the Print the bill type as X1X for Inpatient Claims and X3X for Outpatient Claims (hospice patients) print variation.

FL 5

Tax ID

Select the Suppress printing of Federal Tax ID print variation.

FL 6

Statement Cover Period From/Through dates

Select the Use the first and last Dates of Service for each separate claim print variation.

FL 9

Patient Address

Select the Suppress printing Patient Address print variation.

FL 11

Patient Sex

Select the Suppress printing Patient's Sex print variation.

FL 12

Admission Date

Select the Print Admit Date from Admissions & Status screen as of the claim from date print variation.

FL 13

Admission Hour

For room and board claims, enter the admission hour in Patient>General>Claim Constants.

FL 15

Admission Source

If the default values of 3 for admission type and 1 for admission source are acceptable, select the Print '3' and '1' Admission Type/Srcprint variation.

FL 17

Admission Status

The application automatically calculates patient status codes of 01 (routine discharge), 20 (expired), and 30 (still a patient). If status codes of 04 (discharged to an ICF facility) or 07 (Discontinued care) are appropriate, enter them in Patient>General>Claim Constants.

FL 18–28

Condition Codes

If needed, enter condition codes in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Codes

If needed, enter occurrence codes in Patient>General>Claim Constants.

FL 35ab–36ab

Occurrence Span Codes

If needed, enter occurrence span codes in Patient>General>Claim Constants.

FL 39–41

Value Codes Amounts

Select the following print variations:

>	Print Value Code '80' with the number of days covered on the claim (Claim Through Date – From Date)

>	Suppress printing Value Code '44'

N/A

Benefit and Hybrid Claims

Select the following print variations:

>	Summarize same type of services which have contiguous dates of service. Print earliest date in FL45

>	Itemize Continuous Care services by date of service

>	Grouping rules for Alabama Medicaid Hospice

FL 51

Health Plan Identification Number

Select the Suppress printing Health Plan ID print variation.

FL 54

Prior Payments – Payer

Select the Only print payments from commercial payer print variation.

FL 59

Patient's Relationship to Insured

Select the Suppress printing of Patient Relationship print variation.

FL 61

Insured's Group Name

Select the Print the Insurance Group Name print variation.

FL 64

Document Control Number

If your agency needs to report a void or a replacement claim, enter the Document Control number in Patient>General>Claim Constants.

FL 66

ICD indicator

Enter 9 (Ninth revision) or 0 (Tenth revision) in Administration>Financial>Claim Constants.

FL 70

Patient Reason DX

For Outpatient claims only, enter a diagnosis in Patient>General>Claim Constants for the reason the recipient came in for treatment.

Note: This diagnosis is not always the same as the primary diagnosis.

FL 76

Attending

Select the Print physician's State License Number and 0B Qualifier print variation.

FL80

Remarks

If needed, enter remarks in Patient>General>Claim Constants.

Examples include, but are not limited to the following:

>	TPL paid (MM/DD/YY)

>	TPL denied (MM/DD/YY)

>	Retroactive eligibility award date

Alabama Medicaid Hospice (HO), 837I 4010A1 Electronic

Refer to the Alabama Medicaid Hospice (HO), UB-04 Hardcopy instructions for additional setup information. The following fields in the application are required for Alabama Medicaid Hospice (HO), 837I 4010A1 Electronic.


Field	Description
Assignment of Benefits AND Release of Information	In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.
Carrier Codes	Enter 752548221 for each insurance carrier including Alabama Medicaid in Administration>Financial>Insurance Codes>Carrier Codes. These codes can be found in the Appendix K of the Provider's Manual.
Federal Tax ID -OR- Social Security Number -AND- Provider Taxonomy Code -AND- Provider Number -AND- NPI	For the patient's attending physician, enter either the doctor's Federal Tax ID or Social Security Number in the Resource>General>Roles window. Enter the Provider's Taxonomy Code in this window or through Administration>General>Resource Types. The provider number of the physician must also be entered in the License Number field. The NPI must be entered. These fields are located in Resource>General>Roles.
Provider No.	Enter your Alabama Medicaid Provider number in the Provider No. field located on the General tab in Administration>Financial>Insurance Codes.
Provider Taxonomy Code	Enter the agency's provider taxonomy code. This field is located in Administration>Financial>Insurance Codes>Provider Taxonomy Code.
Receiver ID (File Recipient)	Enter the Alabama Medicaid receiver ID of 752548221 into the Receiver ID (File Recipient) field located on the EMC tab in Administration> Financial>Insurance Codes.
Receiver Name (Payer)	Enter 'AL Medicaid' in the Receiver Name (Payer) field located on the EMC tab in Administration> Financial>Insurance Codes.
Request for Paper EOB	Do not select the Request for paper EOB check box on the EMC tab in Administration>Financial>Insurance Codes.
Submitter ID	Enter the submitter ID (Trading Partner ID) assigned to you by Alabama Medicaid in the Submitter ID field located on the EMC tab in Administration>Financial>Insurance Codes.
Test Submission Indicator	Indicate if this is a test file sent by selecting or clearing the check box on the EMC tab in Administration> Financial>Insurance Codes.

Alabama Medicaid Hospice (HO), 837I 5010A2 Electronic

Refer to the Alabama Medicaid Hospice (HO), UB-04 Hardcopy instructions for additional setup information.

For Alabama Medicaid Hospice (HO), 837I 5010A2 Electronic, define the following items:

>	In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

Note: If values other than 3 or 1 are required, enter them in Patient>General>Claim Constants or Administration>Financial>Claim Constants.

>	Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

The following fields in the application are required for Alabama Medicaid Hospice (HO), 837I 5010A2 Electronic.


Field	Description
Assignment of Benefits AND Release of Information	In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.
Carrier Codes	Enter 752548221 for each insurance carrier including Alabama Medicaid in Administration>Financial>Insurance Codes>Carrier Codes. These codes can be found in the Appendix K of the Provider's Manual.
Federal Tax ID -OR- Social Security Number -AND- Provider Taxonomy Code -AND- Provider Number -AND- NPI	For the patient's attending physician, enter either the doctor's federal tax ID or Social Security Number in Resource>General>Roles. Enter the provider's taxonomy code in Resource>General>Roles or in Administration>General>Resource Types. Enter the provider number of the physician in the License Number field. Enter the NPI in Resource>General>Roles.
Provider No.	Enter the Alabama Medicaid Provider number in the Provider No. field in Administration>Financial>Insurance Codes>General.
Provider Taxonomy Code	Enter the agency's provider taxonomy code in Administration>Financial>Insurance Codes>Provider Taxonomy Code.
Receiver ID (File Recipient)	Enter 752548221 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.
Receiver Name (Payer)	Enter AL Medicaid in the Receiver Name (Payer) field in Administration> Financial>Insurance Codes>EMC.
Request for Paper EOB	Make sure the Request for paper EOB check box in Administration>Financial>Insurance Codes>General is clear. Alabama Medicaid does not provide paper EOBs.
Submitter ID	Enter the submitter ID (trading partner ID) assigned by Alabama Medicaid in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.
Test Submission Indicator	Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Alabama Medicaid Remittance, 835 4010A1 Electronic

Homecare currently supports the ANSI 835 format for Alabama Medicaid. In order to apply this version of the remittance file, claims must have been submitted to Alabama Medicaid in the ANSI X12 837 4010A1 Institutional and/or Professional format from Homecare.