If a claim was denied (or rejected on a TA1, 997, or 824), do not submit a reversal or replacement claim. Submit a new original claim.

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2 Unisys Electronic Reversal & Replacement Claims. The Health PAS Online web portal ( now offers the ability to submit electronic reversal and replacement claims. You may only reverse or replace claims that are listed on a remittance advice in Paid status. This includes claims marked as Paid with zero dollars paid; but does not include denied claims. If a claim was denied (or rejected on a TA1, 997, or 824), do not submit a reversal or replacement claim. Submit a new original claim. Reversal Claims: c c c c c c c A reversal claim voids a previously paid claim. Use a reversal claim only when you do not need to replace an incorrectly paid claim with a new claim. To submit a reversal claim, enter the CRN (Claim Recognition Number, on your RA) of the original, paid claim in the CRN field of the Claim screen. Change the claim frequency code from 1 Original to 8 Void on Professional (837P) and Dental (837D) claims, or change the third digit of the Type of Bill to 8 on the Claim screen of the Institutional (837I) claim form. Enter the exact service line information of the original, paid claim that is to be voided Submit the claim. The entire claim will be voided. You can not void specific service lines. Replacement Claims: c c c c c c c A replacement claim voids a previously paid claim, and replaces the original claim with a new one. Use a replacement claim only when you need replace an incorrectly paid claim with a new claim. If you do not need to replace a claim with a new one, use the Reversal process above. To submit a replacement claim, enter the CRN (Claim Recognition Number, on your RA) of the paid claim in the CRN field of the Claim screen. Change the claim frequency code from 1 Original to 7 Replacement on Professional (837P) and Dental (837D) claims, or change the third digit of the Type of Bill to 7 on the Claim screen of the Institutional (837I) claim form. Enter the service line information of the new claim. Do not enter service line information for the original claim. Submit the claim. The entire original claim will be voided; and a new claim will be created with the information provided in the replacement claim.

3 West Virginia Medicaid DME Workshop 5 January 2005 Contact Information West Virginia Medicaid Workshops 1

4 Mailing Addresses. HCFA-1500 Claim Form Mailing Address Unisys PO Box 3767 Charleston, WV Mailing Addresses. Provider Services Mailing Address Unisys PO Box 2002 Charleston, WV PO Box 625 Charleston, WV Provider Relations,Member Services, & EDI Help Desk Enrollment 4 2

5 Contact Numbers. Provider Services Monday - Friday am until 5 pm WV and all border states (OH, PA, MD, VA, KY) may access to toll-free numbers All other states and Charleston, WV must call local numbers Access AVRS using same phone numbers 24 hours a day, 7 days a week 5 Billing Information West Virginia Medicaid Transition Workshops 3

6 DME Claim Information. Electronic Submission 837P Paper HCFA HCPCS Codes There is no longer a three month window All new codes are effective January 1, 2005 All terminated codes are closed December 31, 2004 DME Manual New DME Manual will be available on the BMS website Manual will list all procedures and procedure code changes 7 TPL & Medicare Claims. Currently, Unisys is not processing Medicare and TPL primary claims Unisys is in the final stages of testing the processing of these claims BMS is reviewing the test data Administar Federal Unisys has received the first test file from Adminstar Once the file has been approved, Unisys will establish connectivity with them DMERC claims will electronically crossover 8 4

7 Billing Info Continued. Rolling Month Limit Beginning 07/01/2004 many supply codes were moved to a rolling month period A rolling month is defined as a thirty-day period of time There must be 30 days between bills that you submit to Medicaid for these supplies 9 HMO Eligibility. Verification of Files The Health Plan, Carelink, and Unicare have verified all eligibility files through December The Health Plan and Carelink will be reprocessing the denied claims for members they have found eligible in the future Claims that were submitted to Unicare before the member eligibility was updated will need to be resubmitted 10 5

8 Medicaid on the Web West Virginia Medicaid Transition Workshops Web Portal. Web Portal address: Access Internet: through any Internet service provider Instructional Manual Available for download on website Web Portal replaces ASAP-AP software 12 6

9 Registration. Complete Trading Partner Agreement (TPA), return by mail TPAs are in Form section of Web Portal Unisys assigns Submitter ID, returns EDI form Complete and return EDI form Submit the electronic registration form on Web Portal, choose logon name Unisys receives website registration, access is granted, confirmation is sent with link to set password 13 Registration (cont). Providers may then begin billing direct data entered electronic claims via Web Portal For technical support, contact EDI Helpdesk For user support, contact Provider Relations A signed EDI Agreement form (in addition to TPA), and data testing will be required for providers who will be submitting X12 files via Web Portal 14 7

10 Web Portal Claim Submission West Virginia Medicaid Transition Workshops Web Portal Claim Submission. Direct Data Entry Key individual claims and submit No testing is required for this method Files rejected at two levels (997 and 824) X12 File Upload Create X12 file with your HIPAA compliant software Upload file to Web Portal for processing Testing is required Files and/or claims can reject at three levels (TA1, 997, and 824) 16 8

11 17 Login. Select Login Enter Logon Name, Password Submit 18 9

12 X12 Claim Submission West Virginia Medicaid Transition Workshops Successfully Logged In. Upload File Select Upload File under File Exchange 20 10

13 Upload Claim File. Select 837 Claim file type 21 Browse For Claim File. Select Browse Select Claim File Select Open 22 11

14 Upload File. Select Upload button 23 Confirm Upload. Select Correct, Submit Now to confirm upload Select Incorrect to choose another file 24 12

15 Upload Confirmation. Upload confirmation or rejection will be displayed This does not indicate file was accepted for processing, only that file was received Must check TA1, 997, and 824 responses 25 Direct-Data-Entry Claim Submission Billing Module West Virginia Medicaid Transition Workshops 13

16 Submit Claim By Form. Direct Data Claim Entry Select Claim under Submit By Form 27 Select Claim Type. DME Providers select Professional Health Claim (837P) 28 14

17 Instructions. Form Instructions Display Select Begin 29 Provider Screen. Required Info is in Red Enter Tax ID, WV Medicaid Provider Number, and Name Commit Entries 30 15

18 Member Screen. Enter WV Medicaid Member ID First and Last Names DOB and Gender are optional Commit Entries 31 Claim Screen. Enter Patient Account No. Choose Facility Type Code Enter Diagnosis Code(s) Commit Entries 32 16

19 Service Screen. Enter service line detail information Select Add to create service lines Edit or delete service lines by selecting edit or delete buttons Commit entries when complete 33 Final Page. Select links (Provider, Member, Claim, Service) to view or modify claim information Select Submit when you are sure claim is correct 34 17

20 Confirmation/Tracking Page. Claim submission confirmation is displayed If you do not receive this page, claim was not submitted Save tracking info Select Enter Another Claim or Close This Window 35 Receipt List. Website keeps running total of submissions Select Printable Receipt List to print receipt This page is not available is connection is lost or you logoff 36 18

21 Electronic Reversal / Replacement West Virginia Medicaid Transition Workshops Reversal / Replacement Claims. Only paid claims can be reversed or replaced This includes claims that paid $0, but does not include denied claims, or claims rejected on TA1s, 997s, and 824s Claim must be originally processed by Unisys, can not electronically reverse ACS claims 38 19

22 Reversal Claim. A reversal claim voids a previously paid claim Use a reversal claim only when you do not need to replace an incorrectly paid claim with a new claim To submit a reversal claim, enter the CRN of the original, paid claim on the claim Service screen Change claim frequency code to 8-Void Enter service line information of original, paid claim Submit 39 Replacement Claim. A replacement claim voids a previously paid claim, and replaces the original with a new claim If you do not need to replace a paid claim, use the Reversal claim process To submit a Replacement claim, enter the CRN of the original, paid claim on the claim Service screen Change claim frequency code to 7-Replacement Enter service line information of new claim Submit 40 20

23 Claim Screen. Change Claim Frequency Code to 7 for Replacement or 8 for Void Enter Original CRN (on your RA, from the original paid claim) 41 Web Portal Claim Responses West Virginia Medicaid Transition Workshops 21

24 Rejection & Transaction Responses. A variety of responses provide feedback to transaction submissions It is imperative to check claim submission responses! Claims rejected on TA1, 997, and 824 responses will not appear on remittance advices These transactions were not accepted for processing, therefore you must correct and resubmit the claims Responses are available under Download File in file exchange area Responses generally available within 5-10 minutes of transaction submission 43 Submission Responses. Response Description TA1 (X12) The TA1 acknowledges that the inbound 837 (claim file) was received. 997 (X12 & PDF) 824 (X12 & TXT) The 997 acknowledges that the 837 is syntactically correct. The entire file or specific claims can be rejected depending upon the error. Contact your software vendor or the EDI Helpdesk for more information. The 824 rejects claims based on WV Medicaid business rules, i.e., invalid diagnosis codes, invalid procedure codes, etc. Unlike the TA1 and 997, the 824 will only display claim rejections. 835 (X12 & PDF) RA (PDF) (ERA) Information in the 835 Remittance Advice transaction is generated by the WV MMIS adjudication system. This is an X12 transaction and requires a software program to be translated. The 835 is generally used to electronically post payments to your practice management or accounting software package. Contact your software vendor for more information Standard Remittance Advice. In Adobe PDF Format 44 22

25 Submission Responses (cont). Direct Data Entry X12 File Upload TA1 (X12) Not Generated ISA14 I13 (Acknowledgment Requested Element) must be set to "1" to generate a TA1. A value of "0" indicates you do not want to receive a TA (X12) Rejected Only Rejected and Accepted 997 (PDF) Rejected Only Rejected and Accepted 824 (X12) Rejected Only Rejected Only 824 (TXT) Rejected Only Rejected Only 835 (X12) Determined by EDI Registration Determined by EDI Registration RA (PDF) Determined by EDI Registration Determined by EDI Registration 45 Download Responses. Select Download File Choose dataset type 46 23

26 TA1 Interchange Acknowledgment. Available Transaction Sets 47 TA1 - WinZip. Select file link File will open in WinZip, double click file name 48 24

27 TA1 Example. Open the TA1 with any text reader: NotePad WordPad MS Word UltraEdit The TA1 acknowledges that the inbound 837 was received Only one format is available (X12) 49 TA1 Accepted. Accepted ISA*00**00*ZZ*WV_MMIS_4UNISYS*ZZ*WVSUBID00821*040616*17 51*U*00401* *0*P*:~ TA1* * *1742*A*000~ IEA*1* ~ A indicates file was accepted (received) (Claim may still reject on 997 and 824) 50 25

28 TA1 Rejected. Rejected ISA*00**00*ZZ*WV_MMIS_4UNISYS*ZZ*WVSUBID00821*040616*1751* U*00401* *0*P*:~ TA1* * *1742*R*025~ IEA*1* ~ R indicates Rejection Number following R indicates rejection Reason 51 TA1 Most Common Rejection Codes. Code Reason Remedy 008/009 Invalid/Unknown Interchange Receiver ID Valid value is: WV_MMIS_4UNISYS Contact your software vendor for assistance entering/configuring this value 020 Invalid test indicator value You have not been approved to submit production claims Contact the EDI Helpdesk at , prompt Duplicate interchange control number You either uploaded the same file more than once, or your software program is not incrementing the ISA control number value Be sure you are uploading a new claim file. If you are, contact your software vendor for assistance

29 997 Functional Acknowledgment. The 997 acknowledges that the 837 (claim filed) is syntactically correct The entire file and / or specific claims can reject depending on the error Two versions are available: X12 (open with your HIPAA-compliant software program) PDF (open with Adobe Reader) Functional Acknowledgment

30 997 PDF Files in WinZIP PDF

31 997 (X12) Accepted. Accepted 997 ISA*00**00**ZZ*WVMMIS4UNISYS*ZZ*WVSUBID99999*040611*1442*U*004 01* *0*P*:~ GS*FA*WVMMIS4UNISYS*WVSUBID99999* *144220*1*X*004010~ ST*997*0001~ AK1*HC*6~ AK2*837*0010~ AK5*A~ AK9*A*2*2*2~ SE*8*0001~ GE*1*1~ IEA*1* ~ (X12) Rejected. Rejected 997 ISA*00**00**ZZ*WVMMIS4UNISYS*ZZ*WVSUBID99999*040610*1347*U*00401* *0*P*:~ GS*FA*WV_MMIS_4UNISYS*WVSUBID99999* *134716*1*X*004010~ ST*997*0001~ AK1*HC* ~ AK2*837*0001~ AK3*SV1*17*2400*8~ AK4*1:1*235*7*ZZ~ AK5*R*5~ AK9*R*1*1*0~ SE*8*0001~ GE*1*1~ IEA*1* ~ 58 29

32 824 Application Advice. The 824 rejects claims based on WV Medicaid business rules i.e. invalid diagnosis codes, revenue codes, bill types, etc The 824 only displays / indicates claim rejections If you receive an 824, a claim file has been rejected Correct and rebill the claim(s) Two formats available: X12 (open with your HIPAA-compliant program) TXT (open with any text editor, NotePad, MSWord) Download

33 824 File in WinZIP TXT. 824 text file will list errors in Human Readable format Correct errors and rebill claims 62 31

34 824 X12. Open X with your software program, if supported ISA*00**00**ZZ*WV_MMIS_4UNISYS*ZZ*WVSUBID00821*040611*1442*U*004 01* *0*P*:~ GS*AG*WV_MMIS_4UNISYS*WVSUBID00821* *144220*1*X*004010~ ST*824*0001~ BGN*11*0010* *1442~ OTI*TR*F8*0010*WVSUBID99999*WV_MMIS_4UNISYS* *165001*6*0 010*837*004010X098A1~ TED*012*E The Transmission Type Identification (REF02) mu*ref*3*2*127*004010x098da1~ NTE*DEP*st be X098A1 when the ISA15 is equal to P.~ SE*9*0001~ GE*1*1~ IEA*1* ~ 63 Remittance Advices. 835 (Claim Payment Advice) Information in the Remittance Advice (835) transaction is generated by the West Virginia Medicaid adjudication system. This is a X12 transaction, and will require a software to be translated. A PDF version is also available. Remittance Advice Report (PDF) This report is a print image of the paper remittance Claims-in-Process Lists claims not finalized in adjudication system (not paid, denied or reversed) Only available on Web Portal Check or EFT List either check number or authorization code of payments Only available on Web Portal 64 32

35 Web Portal Claim Status Inquiry West Virginia Medicaid Transition Workshops Claim Status Inquiry. Select Claim Status under Submit By Form Claim Status Requests will be processed within 5-10 minutes Responses available in download area 66 33

36 Claim Status Intro Screen. Introduction screen displays Select Enter Claim Status Request 67 Claim Status Instructions. Instructions display, select Begin 68 34

37 Claim Status Provider Screen. Enter provider number and organization name Select Commit These Entries 69 Claim Status Request Screen. Enter Required Info, including Bill Type for Institutional Claims, commit entries 70 35

38 Claim Status Final Page. Submit on final page, or select links Provider or Claim Status Request to correct or add additional information. 71 Claim Status Confirmation. Select Finished Entering Request 72 36

39 Claim Status Responses. Two formats available 277 Claim Status Response (X12) 277 Claim Status Report (PDF) Open X12 with your HIPAA compliant software Open PDF with Adobe Reader Retrieve responses by selecting Download File under File Exchange 73 Claim Status Report (PDF). Select 277 Claim Status Report (PDF) dataset type Select Display Available Dataset Inventory Click on file link to download ZIPped file 74 37

40 Claim Status Report (277). 75 Questions and Answers 38

41 Thank You For Your Attendance 39