http://maa.dshs.wa.gov/ProvRel/ 

Billing and payment

Question: Why was the requirement to report the National Drug Code (NDC) number on the claim form removed?

Answer:  Except for unlisted drug code J3490 and J9999, you no longer need to report the NDC for drugs administered in the provider's office.  This requirement was removed in an effort to encourage providers to work towards HIPAA-compliant electronic billing.  For more information, please see numbered memo 04-22.

Question:  When I submit a physician (non-institution) claim for drug code J3490 and J9999 administered in a doctor's office and the National Drug Code (NDC) is less than 11 digits (example: 004-0251-01), what do I need to do?

Answer: 11 digits are needed to bill.  MAA's billing format for NDCs J3490 and J9999 is made up of 3 fields: the first with 5 digits, the next field with 4 digits and the last with 2 digits. If there are less than 11 digits in your NDC, often you can add zeros to the beginning of the NDC field to make 11 digits (example: 00004-0251-01). Sometimes you may only have 3 digits in the middle of the NDC. You may need to add a zero beginning of that field (example: 00004-0251-01).

Question: Can I bill electronically through the internet?

Answer: Yes. The Medical Assistance Administration offers providers the opportunity to bill electronically on the internet. 

Question: Where can I find the correct address to send my hardcopy claims to?

Answer: The correct address depends on what claim type you are billing. The addresses that correspond to your particular claim type can be found in the General Information Booklet. Use this link to find page A3 of the General Information billing instructions.

Question: What address do I send a refund check to?

Answer: Mail refund check to: Office of Financial Recovery-MED, PO Box 9501, Olympia, WA  98501-9501

Question: How do I bill the services of a Physician's Assistant?

Answer:  When billing for services performed by a Physician Assistant, the performing ID number of the Physician Assistant should be used in addition to the 7-digit group provider number. To find a Physician or Physician Assistant provider number, use this link to access our Provider Number Reference Web site.  Use this website to look up performing, referring, or attending provider ID numbers.

Question: How do I identify a Medicaid Client?

Answer: You use a 14-digit identifier known as a Patient Identification Code (PIC), which is found on the client's monthly medical ID card. This number is made up of the first initial, the middle initial, the 6-digit birth date, the first 5 digits of the last name and a 1-digit tiebreaker assigned by DSHS.  

Example - AB010101SMITHA  could be for Adam B. Smith, born 01/01/01 with a tiebreaker A.

Question: How do I receive payment when a Washington State Medicaid client has services in an out-of-state facility?

Answer: You must get a provider number from us before billing. Go to the Provider Enrollment page or call 1-800-562-3022. 

Question: How do I find out the status of my claims?

Answer: Start by reviewing your weekly Remittance and Status report. It will contain paid, denied, and in-process claims. If a claim does not appear on your Remittance and Status report within 30 days, it may be necessary to call Provider Inquiry at 1-800-562-3022 or to resubmit your claim.

Question: What information do I need when I call the Provider Inquiry toll-free line?

Answer: You need your provider number, 17-digit claim number, 14-digit patient identification code (PIC), date of service, and dollar amount billed. Providers are encouraged to have their specific billing instructions available.

Question: What is the time limit to bill a claim?

Answer: You have 365 days from the date of service. However, if the client has Part A and/or Part B Medicare, you have only 6 months from the date of the Medicare EOMB in which to bill Medicaid. 

Question: What if I have billed during that year but my claim is now being denied? What do I do?

Answer: You must indicate on your claim or in comments the original 17-digit claim number to show timeliness. You only have 3 years from the original date of service to bill Medicaid on rebills. Pharmacy claims have only 15 months to rebill.

Question: When I am billing a Medicare/Medicaid crossover, which provider number do I put in box 33 of the HCFA-1500 form?

Answer: Bill using your seven-digit Medicaid Provider number.

Question: What do I use to identify the Medicare/Medicaid client on the HCFA-1500 form?

Answer:  You will use the client's Medicaid Patient Identification Code (PIC) in box 1a of the HCFA-1500 form.

Question: When billing Medicare/Medicaid crossovers, I am required to put an "XO" in box 19 of the HCFA-1500 form and circle it. Should I do this in red ink?

Answer: No, not since HRSA began using an optical scanner to process claims. The scanner is programmed to drop off red ink and will not be able to register your "XO" if red ink is used. Please use black or blue ink on your claims.

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Core Provider Agreement

Question: Is the Core Provider Agreement required for fee for service and Healthy Option providers?

Answer: The Core Provider Agreement is required for providers who see fee for service Medical Assistance clients with respect to services included in the scope of the client's Medical Assistance program.

The Core Provider Agreement is not required for providers who see clients enrolled in Healthy Option. However, the provider should have an agreement with the client's Healthy Option plan(s). If the provider chooses to treat the Healthy Option client without such an agreement, but has a Core Provider Agreement, the provider is bound by the Core Provider Agreement to seek reimbursement from the plan for services included in the plan's contract with the department. See WAC 388-502-0100(6); WAC 388-538-070(3).

If the provider does not have a Core Provider Agreement or a contract with a HO plan, the provider should not be seeing the client. However, an individual, whether receiving medical assistance or not, has the right to obtain medical services from providers that do not accept the patients insurance/Medical Assistance, as long as the individual is willing to accept financial responsibility. A Medical Assistance client who seeks services from a provider that does not have a Core Provider Agreement or a contract with a HO plan may do so, but MAA expects the provider to inform the client that the provider does not accept Medical Assistance and if the client still chooses to have the provider treat him/her, he/she will be billed.

Question: How does a provider "opt out" of Medical Assistance?

Answer: Medical Assistance, unlike Medicare, does not have an "opt out" provision. However, the provider may terminate their Core Provider Agreement. The Core Provider Agreement includes provisions related to termination. In general, providers may terminate their Core Provider Agreements at any time by providing written notice to the department. See Core Provider Agreement; WAC 388-502-0030(5)(e).

The provider is considered "inactive" if there has been no billing activity in a 24 month period. In these cases MAA notifies the provider his/her CPA will be terminated, unless we are notified that the provider wants to remain active. See WAC 388-502-0030(5)(b).

Termination of the CPA does not assume termination of HO provider participation. If a provider chooses to terminate their contract with a HO plan, they must abide by the procedures in their contract with the plan.

Question: I want to become a provider.  How do I get a Medicaid Provider number?

Answer: You must complete the Core Provider Agreement. To get more information on this, use this link to sign up to become a provider or call 1-800-562-3022.

Question: How do I add a new provider to my existing group number?

Answer: You must complete the Core Provider Agreement. Use this link to add a new provider or call 1-800-562-3022.

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Eligibility

Question: How do I rebill a claim that has been denied stating the client is in a Healthy Options plan and I have a client medical ID card that does not show that?

Answer: You must send in a claim with a copy of the client's medical ID card showing there is nothing in the HO column for the month of service attached. Indicate in box 19 on HCFA-1500's and in the comment field on UB-92's, "ID card attached".

Question: I don't know if a client is eligible for the services they are in my office for. How do I find out if they are eligible?

Answer: You must get a copy of the client's medical ID card to prove the client is eligible for the date of service. This is your proof of eligibility.  NOTE: To help with medical eligibility, Medical Eligibility Verification (MEV) is available. There are several MEV vendors available. To find out more about MEV, refer to the General Information Booklet, page C-2. To find this Booklet, use this link General Information.  After you accept the agreement, select the Billing Instructions tab and then find the General Information Booklet .

Question: What do I do when my claim is denied for a client who is not eligible and I have a copy of the client's medical ID card showing they are eligible?

 Answer: You must send a copy of the client's medical ID card for the month of service on the card with your claim when you resubmit the claim.

Question: Is eligibility verification available through the internet?

Answer:  Yes, provider can get free client medical eligibility verification on-line.  For more information on this service, use this link for details and registration or call 1-800-833-2051.

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Policy

Question: Can a provider limit the number of fee for service Medical Assistance clients they see?

Answer: A provider may limit the number of Medical Assistance clients they see as long as they do not limit the practice based on the clients age, race, sex, disability, etc. See WAC 388-502-0020(1)(h). A provider may limit the practice to established clients and not accept new clients. The provider may also limit their practice based on their specialty (e.g. OB/GYNs may restrict their practices to womens health care.)

We expect that the provider will abide by this limit and not use the limit as a method to bill clients. For example, if the Medical Assistance practice is limited to 30 percent of the providers total patient load, he/she cannot continue to treat Medical Assistance clients above the 30 percent and bill these clients for their care.

Question: Can a provider limit the number of HO clients he/she sees?

Answer: The provider and his/her HO plan(s) should include in their contract any agreements regarding limitation of HO members. The department is not a party to such decisions.

Question: Are there situations when the nonparticipating provider can bill Medical Assistance clients for their care?

Answer: MAA assumes that nonparticipating providers do not treat Medical Assistance clients. If a provider wishes to treat Medical Assistance clients, the provider needs to enroll with MAA. 

However, if a Medical Assistance client seeks care from a nonparticipating provider, is informed and understands that the provider does not accept Medical Assistance, and the client still chooses to receive services from that provider with the understanding that the services are available at no cost to the client from a Medical Assistance provider, then the client will be financially responsible for the services. See also WAC 388-502-0160 regarding when participating providers may bill Medical Assistance clients.

Question: When is it ok to bill the client?

Answer: Refer to WAC 388-502-0160, WAC 388-538-095(5), Memo 01-13 or the General Information Booklet for specific information on billing the client. This also includes a waiver for a client to sign. Use this link for MAA memos.

Question: Who is responsible for payment of professional services when a medical assistance client is treated in the hospital and the provider does not have a Core Provider Agreement?

Answer: We expect that hospitals have provisions in their provider contracts to address the treatment needs of the Medical Assistance population and payment mechanisms for any provider that does not have a Core Provider Agreement or contract with a Healthy Options plan (non-participating provider). Each hospitals approach may be different, but in general the following policies are applicable.

In the case of emergency treatment, the client cannot be told to wait until a Medical Assistance provider is available to treat him/her. The client must be treated timely. The hospital may bill MAA for the facility costs, but not for the professional fee. The non-participating provider cannot bill MAA either, and the client cannot be billed for the professional fee. The hospital may choose to pay the non-participating provider.

In the case of non-emergent services, the client can only be billed for professional services if the client understands that the provider does not accept Medical Assistance and he/she has agreed to accept financial responsibility even though he/she understands that the services can be obtained at no cost to the client from a Medical Assistance provider. . If the client does not consent to treatment by a non-participating provider, the hospital and the non-participating provider are responsible for the professional fees and neither can bill MAA for them.

Question: Can a nonparticipating provider bill a Medical Assistance client who is also eligible for Medicare for amounts above what Medicare pays that typically would be paid by Medical Assistance?

Answer: No. If a nonparticipating provider treats a client eligible for both Medicare and Medical Assistance, the provider must make arrangements with MAA to get paid for any amounts not paid by Medicare that typically would be paid by Medical Assistance. The provider may not bill the Medical Assistance client or any other person.

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Authorization

Question: I have received a denial on my claim for "no authorization", but I have 2 authorization numbers on my claim. Why was this claim denied?

Answer: Only one authorization number is allowed per claim. If you have services with multiple authorization numbers, you must break those services into two separate claims.

Question: What is expedited prior authorization (EPA)?

Answer: Expedited prior authorization is a series of self-assigned authorization numbers that you build according to specific criteria. Please refer to your billing instructions to find out the specifics of your particular treatment. To go to the billing instruction link, click here. 

Question: Who do I call when I have a client having elective out-of-state surgery?

Answer: The first contact is the Out-of-State Medical Request Program Manager at (360) 725-1577. 

Please see numbered memo 01-71 for specific information on this process. Use this link and go to memo 01-71. 

Question: Who do I call for authorization questions?

Dental - Request must be submitted by mail to: Quality Utilization Section-Dental, PO Box 45506, Olympia, WA  98504-5506

DME/Prosthetics & Orthotics - 1-800-292-8064

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