Medicaid Delaware

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

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

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

>	Submit paper claims on the Red UB-04 claim forms. Computer-generated forms are not allowed.

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

>	Split services into items. Services are reported in 15-minute increments and must be rounded to the nearest 15-minute unit per service.

>	Maximum 22 line items for a claim can be accepted. If the number of performed services exceeds 22 lines, prepare a new claim form and complete the required data elements. Calculate the total of each claim separately.

>	Commas are optional within the fields with amounts.

>	Enter the cents of a monetary amount without the decimal point.

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

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

>	Type – K (Medicaid)

>	Mode – R (Regular)

>	State – DE (Delaware)

>	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 Delaware 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 Delaware 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

>	Print in upper case letters only

>	Print 9 digit zip codes without dashes for all addresses

FL 4

Type of Bill

Select the Print the bill type as 33X 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 8

Patient Name

Select the Print Insurance ID 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 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 38

Responsible Party Name

Select the Print insured name & address print variation.

N/A

Fee-for-service Claims

Select the following print variations:

>	15 minute increment reporting

>	Suppress printing of summary; print visit detail only

FL 43

Revenue Description

Select the Suppress printing page numbers on line 23 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 45

Service Date

Select the Suppress printing of the bill date on line 23 print variation.

FL 50

Payer Name

Select the Coinsurance only: print the primary payer info in FL 50A and the coinsurance payer in FL 50B print variation.

FL 51a–51c

Health Plan ID A–C

Select the Coinsurance only: print the provider ID only for the coinsurance payer print variation.

FL 54a–54c

Prior Payments A-C

Select the Only print payments from commercial payer print variation.

FL 61a–61c

Group Name A–C

Select the Print the Insurance Group Name print variation.

FL 80

Remarks

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

All other locators are standard.

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

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

For Delaware 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 the Delaware Home Health (HH), 837I 5010A2 Electronic.


Field	Description
Authorized Signature	Complete the Authorized Signature field in Administration>Financial>Insurance Codes>EMC.
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 Delaware Medicaid-assigned ID codes for each insurance carrier in Administration>Financial>Insurance Codes>Carrier Codes.
Federal Tax ID -OR- Social Security Number NPI	For the patient's attending physician, enter either the physician's federal tax ID or Social Security Number. Enter the physician's NPI. Enter the physician's Delaware Medicaid Provider ID in the State License field. 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>General.
Receiver ID (File Recipient)	Enter 345724166 for production claims, and 445296158—for testing.
Receiver Name (Payer)	Enter Delaware 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. Delaware Medicaid does not provide paper EOBs.
Submitter ID	Enter the Electronic Transmitter Identification Number (ETIN) assigned to the submitter. It is the same as your ECMS Bulletin Board ID.
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.
Void or Replaced Claims	If this is a voided or replaced claim (third digit of the type of bill is a 7 or 8), enter the document control number or the ICN of the original claim in Claims>Process>Annotate Claims. Note: If your organization uses electronic remittances, the system will automatically provide this number.

Delaware Medicaid Hospice (HO), UB-04 Hardcopy

Delaware Medicaid Hospice is a benefit claim.

Adhere to the following specific Delaware Medicaid UB-04 Hardcopy rules:

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

>	Print legibly using black ink or use a typewriter.

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

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

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

>	Type – K (Medicaid)

>	Mode – B (Benefit)

>	State – DE (Delaware)

>	Form – UB-04

>	Ensure that the Authorized Signature field is blank because DMAP currently only accepts handwritten signatures.

>	In the Max Lines field, enter 001.

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

>	Under Spend Down, make sure no options are selected.

>	Under Specialized Formats, make sure no options are selected.

>	Under Printer, select the appropriate printer.

>	Under General Rules, select the following print variations:

•	Make separate claims (with totals) for claims needing multiple pages

•	Suppress dots & dashed in ICD codes, dates and insured info

•	Print upper case letters only

Separate service codes and billing rates are defined for each type of service provided. Refer to the Delaware Medicaid Provider Handbook for the appropriate Revenue Codes to be billed under this program.

In the Other Physician field in Resource>General>Roles, enter the Medicaid provider ID assigned to the attending physician. This ID prints in FL 82a on the claims.

In the Coverage Description field in Administration>Financial>Insurance Companies>Plans, enter the name of the group or plan providing the insurance to the insured. This value prints in FL 61 (Group Name) on the claims.

In the IDs to include in EMC files and IDs to include in Paper Claims sections in Administration>Financial>Insurance Codes, select the National Provider IDs (NPI) radio button.

Room and board charges must be on a separate claim from other hospice services. To separate claims, define one insurance code for both per diem and room and board charges using the standard setup procedures.

In Patient>General>Payers, perform the following setup:

>	In the Pay Source section, set up two pay sources for Medicaid.

>	In the Pay Control section, set up Payer A as the primary (per diem charges) and Payer B for room and board charges as shown in the image.

For Delaware Medicaid Hospice (HO), UB-04 Hardcopy, 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.

In Administration>Financial>Insurance Codes>Print Variations, select the following print variations.


Locator	Locator Description	Setup
FL 1	Provider Name, Address and Telephone Number	Select the Print associated facility name & address, if blank print patient name & address print variation.
FL 2	Unassigned Data Field	Select the Print the agency name & address print variation.
FL 3b	Patient Control Number	Select the Print Patient ID print variation.
FL 4	Type of Bill	Select the Print Type of Bill on Last three spaces print variation.
FL 6	Statement Covers	Select the Print the first last Dates of Service for each separate claim print variation.
FL 8a	Patient ID Number	Select the Print Insurance ID print variation.
FL 10	Patient Date of Birth	Select the Print Birth Date in MMDDYY format print variation.
FL 12	Admission Date	Select the Print Admit Date form Admission & Status screen as of the claim from date print variation.
FL 14 -15	Type of Admission	Select the Print '3' and '1' Admission Type/Src print variation.
FL 31 -34	Occurrence Codes and Dates	Enter the appropriate occurrence code and date in Patient>General>Claim Constants.
FL 35	Occurrence Span Code and Dates	Select the Print "M2" occurrence span code with from/through date of Inpatient Respite Care print variation.
FL 38	Responsible Party Name	Select the Print the commercial insurance company address print variation.
FL 39-41	Value Codes	Select the Print Value Code '80' with the number of days covered on the claim (Claim Through Date - From Date+1) print variation.
FL 42	Revenue Codes	Select the Print total line on line 22 in revenue section print variation.
FL 45	Service Date	Select the Print date in MMDDYYYY print variation.
FL 50	Payer	Select the Coinsurance only: print the primary payer info in FL 50A and the coinsurance payer in FL 50B print variation.
FL 51	Health Plan ID	Select the Only print value for current claim payer line print variation.
FL 54	Prior Payment	Select the Only print payment form commercial payer print variation.
FL 59	Patient's Relationship to Insured	Select the Print NUBC Relationship Codes effective as of 10/16/03 print variation.
FL 61	Insurance Group Name	Select the Print the Insurance Group Name print variation.
FL 62	Insurance Group Number	Select the Print the payers assigned Carrier code print variation.
FL 63c	Treatment Authorization Code	Select the Print secondary physician's Additional Physician No print variation.
FL 69	Admitting Diagnosis	Select the Print the patient's diagnosis code as of the patient's admission date print variation.
FL 76	Attending	Select the Print R&B facility's NPI print variation.
FL 77	Operating	Select the Print secondary physician's information with NPI, Other Phys No and 1D Qualifier print variation.
FL 80	Remarks	If needed, enter remarks in Patient>General>Claim Constants.

All other locators are standard.

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

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

>	In the Locator 14-15 section in Administration>Financial>Insurance Codes>Print Variations, select the Print '3' and '1' Admission Type/Src check box to ensure compliance with the ANSI 5010 Billing Template.

Note: To report the values other than 3 or 1, go to Patient>General>Claim Constants or Administration>Financial>Insurance Codes>Print Variations.

>	Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor column in Patient>General>Payers>HIPAA.

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


Field	Description
Authorized Signature	Complete the Authorized Signature field in Administration>Financial>Insurance Codes>EMC.
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	For Payer (Locator 50), enter the appropriate Delaware Medicaid-assigned ID codes for each insurance carrier. This field is located in Administration>Financial>Insurance Codes>Carrier Codes.
Federal Tax ID -OR- Social Security Number NPI	For the patient's attending physician, enter either the physician's federal tax ID or Social Security Number. Enter the physician's NPI in the NPI field. Enter the physician's Delaware Medicaid Provider ID in the State License field. 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>General.
Receiver ID (File Recipient)	Enter 345724166 for Production claims, and 445296158—for Testing.
Receiver Name (Payer)	Enter Delaware 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. Delaware Medicaid does not provide paper EOBs.
Submitter ID	Enter the Electronic Transmitter Identification Number (ETIN) assigned to the submitter. It is the same as your ECMS Bulletin Board ID.
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.
Void or Replaced Claims	If this is a void or replaced claim (third digit of type of bill is a 7 or 8), enter the document control number or the ICN of the original claim in Claims>Process>Annotate Claims. Note: If your organization uses electronic remittances, the system automatically provides this number.