Commonwealth of Massachusetts Executive Office of Health and Human Services Division of Medical Assistance 600 Washington Street Boston, MA 02111 www.state.ma.us/dma MASSHEALTH TRANSMITTAL LETTER GAFC-1 January 2002 TO: FROM: Group Adult Foster Care Providers Participating in MassHealth Wendy E. Warring, Commissioner RE: Group Adult Foster Care Manual (Revised Billing Instructions) The Division of Medical Assistance has established a manual for providers of group adult foster care. The Group Adult Foster Care Manual contains sections that apply to all MassHealth providers and sections that apply only to group adult foster care providers. This manual currently contains administrative and billing regulations, billing instructions, and appendices. This manual replaces the adult foster care material that group adult foster care providers have been using. The billing instructions reflect a new rate structure as described in Group Adult Foster Care Bulletin 1. These billing instructions are effective for dates of service on or after October 1, 2001. NEW MATERIAL (The pages listed here contain new language.) Group Adult Foster Care Manual Pages vi, vii, 5.3-1 through 5.3-8, 5.5-1 through 5.5-12, 6-1, and 6-2 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE vi GROUP ADULT FOSTER CARE MANUAL TRANSMITTAL LETTER GAFC-1 DATE 01/01/02 6. SERVICE CODES AND DESCRIPTIONS Service Codes and Descriptions.................................................................... ............................... 6-1 Appendix A. DIRECTORY....................................................................... ......................................... A-1 Appendix B. ENROLLMENT CENTERS......................................................................... ............... B-1 Appendix C. THIRD-PARTY-LIABILITY CODES........................................................................ C- 1 Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE........................................................................ ..... W-1 Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES........................... X-1 Appendix Y. REVS CODES/MESSAGES.................................................................. ..................... Y-1 Appendix Z. EPSDT SERVICES LABORATORY CODES............................................................ Z-1 Commonwealth of Massachusetts Medical Assistance Program Provider Manual Series SUBCHAPTER NUMBER AND TITLE PREFACE PAGE vii GROUP ADULT FOSTER CARE MANUAL TRANSMITTAL LETTER GAFC-1 DATE 01/01/02 The regulations and instructions of the Division of Medical Assistance governing provider participation in MassHealth are published in the Provider Manual Series. The Division publishes a separate manual for each provider type. Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. The Division's regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. Regulations promulgated by the Division of Medical Assistance are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead the Division's effort to give each provider a single convenient source for the essential information providers need in their routine interaction with the Division and with MassHealth members. Part 3. How to Submit Claims All group adult foster care providers must use claim form no. 9 to bill MassHealth for services. Providers can request supplies of claim form no. 9 from the appropriate address or fax number listed in Appendix A of this manual. This section explains how to complete this claim form. Electronic Claims Electronic billing offers an effective and convenient alternative to paper billing. For information on submitting electronic claims on tape, diskette, or in other electronic formats, contact Electronic Claims Services at the address or telephone number listed in Appendix A of this manual. Entering Information on Claim Form No. 9 • Complete a separate claim form, or follow the applicable electronic media claim format, for each member for whom services were provided. • Type or print all required information on the claim form with black ink, using high quality printer ribbons or cartridges. Be sure all entries are complete, accurate, legible, and within the respective claim boxes. • Do not use italicize, bold, or underline characters. • Do not enter negative amounts into any boxes. • For each claim line, enter all required information, repeating if necessary. Do not use ditto marks or words such as “same as above.” • Attach any necessary reports or required forms to the claim form, but be careful not to staple in the bar code printed in the upper-left portion of the claim form. • When the required entry is a date (such as the date of service or the member's date of birth), enter the date in month/day/year order. Example: For a member born on October 8, 1960, the entry in Item 11 should be as follows. 10 08 60 The period established by state law for the submission of claims is 90 days. For regulations governing time limitations on the submission of claims, see the provider regulations in Subchapter 3 of this manual. The 90-day period is measured from the date of service to the date on which the claim is received. Since the 90-day billing deadline applies to each claim line, the claim must be received within 90 days from the earliest date of service on the claim. When a claim line contains consecutive dates of service, the 90-day period is measured from the last date in the range (the date entered in the column labeled “To” in Item 26 of claim form no. 9). All services listed on a single claim line must have been provided in the same fiscal year. That is, dates of service in the months of June and July should not appear on the same claim line. Claims for Members with Other Health Insurance Coverage Instructions for submitting claims for services provided to members with other health insurance coverage are located in Part 8 of these billing instructions. Further Assistance If, after reviewing the item-by-item instructions in the following section, you need additional assistance, contact MassHealth Provider Services. See Appendix A in this manual for the appropriate address and telephone numbers. This section contains specific instructions for completing each item on claim form no. 9. An example of a properly completed claim form is on page 5.3-8. Item 1 PROVIDER'S NAME, ADDRESS & TELEPHONE NO. Enter the provider's name, address, and telephone number. Item 2 PAY TO PROVIDER NO. Enter the provider’s seven-digit MassHealth number. Item 3 BILLING AGENT NO. If this form is prepared by a billing agent, enter the seven-digit number assigned to the agent, if one was assigned. Otherwise, leave this item blank. Item 4 PRIOR AUTHORIZATION NO. Leave this item blank. Item 5 SERVICING PROVIDER'S NAME Leave this item blank. Item 6 SERVICING PROVIDER NO. Leave this item blank. Item 7 REFERRING PROVIDER'S NAME For members enrolled with a PCC, enter the name of the member’s PCC. For all other members, leave this item blank. Item 8 REFERRING PROVIDER NO. For members enrolled with a PCC, enter the PCC's seven-digit referral number. For all other members, leave this item blank. Item 9 MEMBER'S NAME Enter the member’s name. Item 10 RECIPIENT ID NO. Enter the complete 10-character member identification (ID) number that is printed on the MassHealth card below or beside the member’s name. These characters may be all numbers or a combination of numbers and letters. The member ID on the temporary MassHealth card may include an asterisk as the 10th character. Item 11 DATE OF BIRTH Enter the member’s date of birth in month/day/year order. Item 12 SEX Enter either an M for male or an F for female. Item 13 OTHER INSUR. If the member is covered by other health insurance, enter an X. Item 14 PATIENT ACCOUNT NO. Enter the patient account number or member’s last name (no more than 10 characters). This patient account number or name will be printed on the remittance advice to help identify the claim. Item 15 PLACE OF SERVICE Enter the code from the list below that describes the place in which the service was provided. 01 - Office, facility, or business location 02 - Member's home 03 - Hospital, inpatient 04 - Hospital, outpatient 05 - Emergency department 06 - Nursing facility 07 - Rest home 99 - Other location Item 16A IS MEMBER BEING TREATED AS A RESULT OF AN ACCIDENT? If the service was necessary because the member was involved in an accident, enter an X in the box labeled “Yes” and complete Items 16B and 16C. If the service was not accident-related or if the information is not available, enter an X in the box labeled “No” and leave Items 16B and 16C blank. Item 16B IF YES, TYPE & If the Yes box is checked in Item 16A, enter the code from the list below that describes the type of accident. 1 - Automobile related 2 - Employment related 3 - Other Item 16C DATE OF ACCIDENT If the Yes box is checked in Item 16A, enter the date of the accident in month/day/year order. Item 17 IS MEMBER BEING TREATED AS A RESULT OF EPSDT SCREENING? Leave this item blank. Item 18 L.O.F. Leave this item blank. Item 19 PATIENT STATUS Leave this item blank. Item 20 DISCHARGE DATE Leave this item blank. Item 21 DIAGNOSIS CODE Leave this item blank Item 22 DIAGNOSIS NAME Leave this item blank Item 23 DIAGNOSIS CODE Leave this item blank Item 24 DIAGNOSIS NAME Leave this item blank Item 25 LINE Each letter (A through J) refers to one of the 10 claim lines contained on the claim form. This letter will appear as the last character of the claim's transaction control number (TCN) listed on the remittance advice. Item 26 DATES OF SERVICE For single dates of service, in the From column, enter, in month/day/year order, the date the service was provided. Leave the To column blank. Use a separate claim line for each date of service, except for consecutive dates. For consecutive dates of service, enter the first date of service in the From column and the last date of service in the To column. Indicate the number of days billed during this span of dates in Item 31. Item 27 DESCRIPTION OF SERVICE No entry is required. To complete this item for your records, enter a brief description of the service provided. Item 28 PROCEDURE CODE-MODIFIER Enter the service code that corresponds to the service provided. Obtain the service code from Subchapter 6 of this manual. Item 29 TREAT. REL. TO DIAG. Leave this item blank. Item 30 TREAT. REL. TO FAM. PL. Leave this item blank. Item 31 UNITS OF SERVICE Enter the number of days or units billed. Item 32 USUAL FEE Enter the usual and customary fee (the amount you charge a person who is not a MassHealth member) for each service provided. When billing for more than one unit, multiply the number of units in Item 31 by the usual and customary fee. Enter that product as the usual and customary fee. Item 33 OTHER PAID AMOUNT Enter any amount received for the service from a source other than MassHealth, and attach to the claim form a copy of the notice of final disposition from the other payment source. Do not enter any previous payment received from MassHealth. See Part 8 of these billing instructions for submitting claims for services provided to members with other health insurance coverage. Any amount entered in Item 33 will be deducted from the MassHealth payment. Item 34 EMERG. SERV. Leave this item blank. Item 35 REMARKS Leave this item blank. Item 36 TOTAL USUAL FEE No entry is required. To complete this item for your records, calculate and enter the sum of the amounts entered in Item 32 (“Usual Fee”). Item 37 TOTAL OTHER PAID AMOUNT No entry is required. To complete this item for your records, calculate and enter the sum of the amounts entered in Item 33 (“Other Paid Amount”). Item 38 AUTHORIZED SIGNATURE The form must be signed by the provider or by the individual designated by the provider to certify that the information entered on the form is correct. Signatures other than handwritten signatures (for example, stamped, typewritten, or computer- generated) are also acceptable. Item 39 BILLING DATE Enter in month/day/year order the date on which the claim form is completed. The billing date may not precede any of the dates of service entered on the claim form. Item 40 ADJUSTMENT/RESUBMITTAL Enter an X in the Adjustment or Resubmittal box only when an entry is required by the instructions for correcting a claim. See the section on correcting claims elsewhere in these billing instructions. Do not make any entry in this item without completing Item 41. Item 41 FORMER TRANSACTION CONTROL NO. When an entry is required in this item, enter the 10-digit transaction control number (TCN) assigned to the original claim. The TCN appears on the remittance advice that listed the original claim as paid or denied. When resubmitting or adjusting a claim, include all attachments that were required for the original claim. Item 42 FOR OFFICE USE ONLY Leave this item blank. This example shows a claim for a daily rate for group adult foster care services. XYZ Foster Care, Inc. 1 Main Street Anytown, MA 02222 617-555-1234 1 2 3 4 5 6 7 Michelle Belmont 0 1 2 3 4 5 6 7 8 9 12 12 70 F BelmontM 99 X 10 01 01 10 31 01 Personal Care & Admin X9877 31 1116 00 Robert Lynch 11 07 01 Part 5. How to Read the Remittance Advice The remittance advice is sent to providers to explain the disposition of MassHealth claims. The remittance advice lists claims in the following order: paid claims, denied claims, and suspended claims. Items within each category of claims are sorted by date of service, patient account number, and then by member last name. Three-digit errors for denied and suspended claims, amounts paid, and claim identification information are also listed. See the section on errors and descriptions elsewhere in these billing instructions for an explanation of the errors. The first page of each remittance advice is a message page. This page provides timely information from the Division about MassHealth billing, regulation, and payment, as well as other topics. These updates must be communicated to all applicable staff, and should be kept for future reference. Sample Remittance Advice Pictured below is a claim form no. 9 remittance advice. An item-by-item explanation begins on the next page. (09) PROVIDER NAME ATTENTION LINE STREET ADDRESS CITY, STATE ZIP 1 MEDICAL SERVICES (9) REMITTANCE ADVICE COMMONWEALTH OF MASSACHUSETTS DIVISION OF MEDICAL ASSISTANCE MEDICAL ASSISTANCE PROGRAM RUN MM/DD/YY 5 6 PROVIDER NUMBER 4 PROVIDER PAGE REPORT PAGE 2 3 PATIENT ACCOUNT NUMBER 7 RECIPIENT NAME 8 RECIPIENT ID 9 TCN 10 FROM DATE 11 TO DATE 12 SERV- ICING PROV NO 13 PROC CODE/ MOD 14 PLACE OF SERV 15 UNITS 16 AMOUNT REQUEST 17 OTHER PAID AMOUNT 18 AMOUNT PAID BY MEDICAID 19 STATUS 20 REMARKS 21 DIAG 22 PA 23 OTH INS 24 ERRORS 25 The following list explains the items found on the remittance advice as depicted in the sample on the previous page. 1 TO This is the provider’s name and address. 2 PROVIDER PAGE This is the page number of the remittance advice. 3 REPORT PAGE This is the page number of the entire claims processing pay cycle for all MassHealth providers. 4 PROVIDER NUMBER This is the pay-to provider number that was entered in Item 2 on the claim form. 5 RUN This is the number identifying the specific pay cycle. The first digit of the run number designates the claim type: 1 - MassHealth 3 - CommonHealth 5 - Massachusetts Commission for the Blind. 6 DATE This is the date the remittance advice was printed. 7 PATIENT ACCOUNT NUMBER This is the patient account number that was entered in Item 14 on the claim form. 8 RECIPIENT NAME This is the member’s name. If the member identification (ID) number is not on the MassHealth member eligibility file, or if the ID entered on the claim form was incorrect, this item states that the name is not available (NM NOT AVAIL). 9 RECIPIENT ID This is the ID number entered on the claim form. 10 TCN This transaction control number (TCN) is a unique 10- character number assigned to each claim line. The TCN is assigned when a claim is received. It is used to identify a claim for adjustments, resubmittals, and research. The following chart details each character of the sample TCN 130902744A. Last Digit of Current Calendar Year Julian Date Received MMIS Batch Number Claim Number Within Batch Line on Claim Form 1 309 027 44 A (2001) (November 5) (Batch #27) (Claim #44) (Claim Line A) 11 FROM DATE This is the date on which the service was provided. 12 TO DATE The To date entered on the claim form appears here, if applicable. Otherwise, this is the same as the From date. 13 SERVICING PROV NO. This is the MassHealth provider number entered in Item 6 of the claim form. 14 PROC CODE/MOD This is the code for the service that was provided. 15 PLACE OF SERV This is the code indicating where the service was provided. 16 UNITS This is the number of service units (days, items, number of times performed, or time increments) that were billed. 17 AMOUNT REQUEST This is the usual and customary fee entered on the claim form. 18 OTHER PAID AMOUNT This is the amount entered on the claim form that was paid by other health insurance. 19 AMOUNT PAID BY MEDICAID Positive amounts are paid by the Division resulting from the approval of a claim for payment or from an approved adjustment of a previously paid claim. Negative amounts are owed by the provider to the Division resulting from an adjustment or void of a previously paid claim. 20 STATUS This reports the status of the claim, adjustment, or void. PAID - claim is paid DENIED - claim is not paid SUSPEND - claim must be reviewed prior to payment determination ACCEPTED - void claim is accepted 21 REMARKS This contains additional information about the claim. CRADJ - on an adjustment claim, the amount previously paid is recalculated DBADJ - on an adjustment claim, the amount previously paid is debited FISCPEND - payment is pending for fiscal reasons ORIG - original claim PRRUXXX - indicates action taken by postpayment and provider review (PPRU) pend (“XXX” indicates the log number assigned to the case) RECOUP - payment amount subtracted to satisfy an amount owed to the Division RELFISC - claim is released from fiscal pended status RELXXX - released from postpayment and provider review unit pend (“XXX” indicates the sanction log number) RESUB - resubmittal of a previously denied claim TAPE - claim was submitted electronically TPL-INS - collection from other health insurance VOID - void to a previously paid claim An additional character may appear in the last position in the Remarks section under the following conditions. M - claim was manually reviewed and adjudicated P - claim was pended S - claim was suspended 22 DIAG This is the ICD-9-CM diagnosis code that was entered on the claim form. 23 PA This is the prior-authorization number that was entered on the claim form. 24 OTH INS If an explanation of benefits (EOB) from a primary insurance carrier was attached to the claim form, the third-party-liability (TPL) carrier code corresponding to that insurer appears in this field. 25 ERRORS The error(s) that caused the claim to suspend or deny appears here. See the section on errors and descriptions elsewhere in these billing instructions for an explanation of the error(s). Pictured below is a sample remittance advice total page. An item-by-item explanation begins on the next page. 9) (0 PROVIDER NAME ATTENTION LINE STREET ADDRESS CITY, STATE ZIP MEDICAL SERVICES (9) REMITTANCE ADVICE COMMONWEALTH OF MASSACHUSETTS DIVISION OF MEDICAL ASSISTANCE MEDICAL ASSISTANCE PROGRAM REMITTANCE ADVICE TOTAL PAGE RUN MM/DD/YY PROVIDER NUMBER PROVIDER PAGE REPORT PAGE PAYMENT STATUS 1 2 3 4 5 NUMBER OF CLAIMS PROVIDER BILLED AMOUNT UNITS OTHER PAID AMOUNT MEDICAID PAID AMOUNT PAID CLAIMS ADJUSTED CLAIMS VOIDED CLAIMS DENIED CLAIMS SUSPENDED CLAIMS PENDED CLAIMS 6 TOTALS PROVIDER VOUCHER AMOUNT $ 7 VOUCHER NUMBER 8 RETURN CHECK AMOUNT $ PROVIDER RETURNS $ OTHER RETURNS $ ECOUPMENT ACTIVITY R NT RECOUPME ACCOUNT 9 DESCRIPTION 10 G CASE LONUMBER 11 OPENING BALANCE 12 IONS TRANSACTAPPLIED 13 CLOSING BALANCE 14 ANCTION ACTIVITY S G CASE LONUMBER 15 OPENING BALANCE 16 IONS TRANSACTAPPLIED 17 CLOSING BALANCE 18 The following explains the items found on the remittance advice total page. Payment Status 1 NUMBER OF CLAIMS These are the total number of claims within each of the six categories of claim status. .. paid claims .. adjusted claims .. voided claims .. denied claims .. suspended claims .. pended claims 2 PROVIDER BILLED AMOUNT These are the totals of the amounts billed by the provider for each of the six categories of claims. 3 UNITS These are the totals of the number of payable units for each of the six categories of claims. 4 OTHER PAID AMOUNT These are the totals of the amounts paid by other health insurers for each of the six categories of claims. 5 MEDICAID PAID AMOUNT These are the totals of the amounts paid by the Division for each of the six categories of claims. 6 TOTALS These are the totals for Items 1 through 5 listed above. 7 PROVIDER VOUCHER AMOUNT This is the amount of the payment. 8 VOUCHER NUMBER This is the payment reference number of the check or deposit issued by the state treasurer’s office. 9 RECOUPMENT ACCOUNT This is the code for the recoupment account with activity this pay cycle. Recoupment Activity 10 DESCRIPTION This is a description of the recoupment account with activity this pay cycle. 11 CASE LOG NUMBER This is the case log number assigned to the recoupment account with activity this pay cycle. 12 OPENING BALANCE This is the balance of the recoupment account at the beginning of this pay cycle. 13 TRANSACTIONS APPLIED This is the amount of claims activity applied to the recoupment account this pay cycle. 14 CLOSING BALANCE This is the balance of the recoupment account at the end of this pay cycle. 15 CASE LOG NUMBER This is the case log number assigned to the provider review activity during this pay cycle. Sanction Activity 16 OPENING BALANCE This is the balance of the provider review account at the beginning of this pay cycle. 17 TRANSACTIONS APPLIED This is the amount of claims activity applied to the provider review account this pay cycle. 18 CLOSING BALANCE This is the balance of the provider review account at the end of this pay cycle. A Paid Claim In this example, group adult foster care services (Service Code X9877) were provided to eligible MassHealth member John Doe from October 1, 2001 to October 31, 2001. The provider's usual fee is $1,116.00. The remittance advice claim line identifies the claim line by the transaction control number 130902744A, and lists the claim as paid and the amount paid as $1,116.00. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0123456789 TCN 130902744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 11116.00 STATUS PAID REMARKS (ORIG) DIAG PA OTH INS ERRORS A Denied Claim In this example, group adult foster care services (Service Code X9877) were provided to eligible MassHealth member Helen Doe from October 1, 2001 to October 31, 2001. The claim is denied with error 103, meaning “Duplicate Claim,” because a claim for the same service provided to the same member on the same date was already paid. This previously paid claim appears on the following line with the message “Conflicting Claim” and the run number of the remittance advice on which the claim was paid. PATIENT ACCOUNT NUMBER DOEH85 RECIPIENT NAME DOE HELEN RECIPIENT ID 0123456789 TCN 132302744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 1234567 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID STATUS DENIED REMARKS (ORIG) DIAG PA OTH INS ERRORS 103 DOEH85 DOE HELEN 0123456789 130902744A 100101 103101 1234567 X9877 99 31 1116.00 (ORIG) DIAG PA OTH INS CONFLICTING CLAIM RUN 1460 A Suspended Claim In this example, group adult foster care services (Service Code X9877) were provided to John Smith from October 1, 2001 to October 31, 2001. The claim was suspended with error 246, meaning “Member Ineligible on Service Date.” The claim was suspended because the MassHealth member eligibility file did not list the member as eligible for the date of service. The claim will remain suspended for a period of up to 60 days, to allow for possible updates to the MassHealth member eligibility file. PATIENT ACCOUNT NUMBER SMIJ85 RECIPIENT NAME SMITH JOHN RECIPIENT ID 0123456789 TCN 130902744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID STATUS SUSPEND REMARKS (ORIG) DIAG PA OTH INS ERRORS 246 Adjustments An adjustment is indicated on a remittance advice by a debit-credit transaction. The debit (DBADJ) line reflects the original claim information, and the corresponding status field contains the amount originally paid. The credit (CRADJ) line reflects the current claim information, and the corresponding status field contains the amount that has now been paid. The amount in the “Amount Paid by Medicaid” column represents the difference between these two amounts. This amount will be zero if the adjustment did not change the original payment. If the amount is negative, it will be deducted from current and future payments made to the provider until collected in full. If the amount is positive, it will result in an additional payment for the claim. A Positive Adjustment In this example, a change in the number of days billed resulted in a payment increase of $36.00. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0185133789 TCN 132302845A FROM DATE 100301 TO DATE 101001 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 8 AMOUNT REQUEST 28800 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 3600 STATUS 28800 REMARKS (CRADJ) DIAG PA OTH INS ERRORS DOEJ85 DOE JOHN 0185133789 130902744A 100301 100901 0123456 X9877 99 7 25200 25200- (DBADJ) DIAG PA OTH INS ERRORS A Negative Adjustment In this example, a change in the number of days billed resulted in a payment decrease of $36.00. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0185133789 TCN 132302845A FROM DATE 100401 TO DATE 100901 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 6 AMOUNT REQUEST 21600 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 3600- STATUS 21600 REMARKS (CRADJ) DIAG PA OTH INS ERRORS DOEJ85 DOE JOHN 0185133789 130902744A 100301 100901 0123456 X9877 99 7 25200 25200- (DBADJ) DIAG PA OTH INS ERRORS A Zero Adjustment Claim In this example, the claim was adjusted to show the correct dates, resulting in no change in payment by the Division. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0185133789 TCN 132302845A FROM DATE 100401 TO DATE 101001 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 7 AMOUNT REQUEST 25200 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID STATUS 25200 REMARKS (CRADJ) DIAG PA OTH INS ERRORS DOEJ85 DOE JOHN 0185133789 130902744A 100301 100901 0123456 X9877 99 7 25200 25200- (DBADJ) DIAG PA OTH INS ERRORS A Pended Claim In this example, it was determined that $1,116.00 was payable for this claim; however, payment is being withheld as a result of a sanction initiated by the Division’s Program Review Recoveries Unit (PRRU). A sanction inhibits the release of current payments to a provider. This claim may be released for payment when a resolution is reached between the provider and the PRRU. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0123456789 TCN 130902744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 1116.00 STATUS PAID REMARKS (PRR123) DIAG PA OTH INS ERRORS A Void A void transaction is reported on a remittance advice to return incorrect payments, including, but not limited to, any one of the following situations: .. payment to wrong provider; .. payment for wrong member; .. payment for overstated services; and .. payment for services for which payment has been received from third-party payers. A void transaction always results in a negative payment. These amounts are overpayments and are deducted from current and future payments made to the provider until collected in full. See the section on correcting claims for information on how to request a void to paid or pended claims. PATIENT ACCOUNT NUMBER SMITHJ RECIPIENT NAME SMITHJ RECIPIENT ID 0123456789 TCN 132302744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 1116.00- STATUS ACCEPTED REMARKS (VOID) DIAG PA OTH INS ERRORS A Recoupment When a claim adjustment, or a void, results in an amount due to the Division, a negative amount appears in the “Amount Paid by Medicaid” column on the remittance advice. These negative amounts are subtracted from the provider's current payment. If a negative balance is still outstanding, after the current pay cycle, the balance is carried forward as an outstanding recoupment account. In this example $1,116.00 is applied toward the outstanding balance. PATIENT ACCOUNT NUMBER DOEJ85 RECIPIENT NAME DOE JOHN RECIPIENT ID 0123456789 TCN 130902744A FROM DATE 100101 TO DATE 103101 SERV- ICING PROV NO 0123456 PROC CODE/ MOD X9877 PLACE OF SERV 99 UNITS 31 AMOUNT REQUEST 1116.00 OTHER PAID AMOUNT AMOUNT PAID BY MEDICAID 1116.00 STATUS 1116.00 REMARKS (RECOUP) DIAG PA OTH INS ERRORS This page is reserved. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 GROUP ADULT FOSTER CARE MANUAL TRANSMITTAL LETTER GAFC-l DATE 01101102 601 SERVICE CODES AND DESCRIPTIONS Service Code Service Description X9873 Adult foster care short-term alternate placement; per-member, per-diem payment for caregiver services X9874 Adult foster care personal care service and agency administrative fee; per member per diem Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 GROUP ADULT FOSTER CARE MANUAL TRANSMITTAL LETTER GAFC-l DATE 01/01/02 THIS PAGE IS RESERVED.