Billing and Claims Status Frequently Asked Questions
 
1. How can I check the status of my Medical Assistance claims?
 
Response: The Provider Claim Inquiry window in the PROMISe™ Provider Portal is used to search claims, view original claims by ICN, and check the status of one or more claims. Regardless of submission media, you can retrieve all claims associated with your provider number. A search can be narrowed by specifying the ICN, recipient ID number, patient account number, date range, or claim status criteria. You can perform a search only for claims submitted by your provider number and service location(s).
 
Note: When performing a claim inquiry for claims submitted via a media other than the internet, please allow for processing time before the claim appears in the system. For example, if you submit your claims via paper, please allow 7 to 10 business days before performing a claim inquiry. Alternatively, you may also contact the Provider Service Center at 1-800-537-8862 to inquire on the status of claims.
 
2. What is the time limit for submitting claims to Medical Assistance?
 
Response: The original claim must be received by the department within a maximum of 180 days after the date the services were rendered or compensable items provided. Nursing facility providers and ICF/MR providers must submit original claims within 180 days of the last day of a billing period. A billing period for nursing facility providers and ICF/MR providers covers the services provided to an eligible recipient during a calendar month and starts on the first day service is provided in that calendar month and ends on the last day service is provided in that calendar month.
 
Resubmission of a rejected original claim must be received by the department within 365 days of the date of service, except for nursing facility providers and ICF/MR providers. Resubmission of a rejected original claim by a nursing facility provider or an ICF/MR provider must be received by the department within 365 days of the last day of each billing period.
 
3. How do I request an exception to the 180-day or 365-day time limit for submission or resubmission of invoices?
 
Response: The department will consider a request for a 180-day exception if it meets at least one of the following criteria:
 
1. An eligibility determination was requested from the County Assistance Office (CAO) within 60 days of the date the service was provided. The department must receive the provider’s 180-day exception request within 60 days of the CAO’s eligibility determination processing date; and/or
 
2. The provider requested payment from a third party insurer within 60 days of the date of service. The department must receive the provider’s 180-day exception request within 60 days of the date indicated on the third party denial or approval.
 
To submit a 180-day exception request, you must complete the following steps. Also see Medical Assistance Bulletin 99-91-02.
 
     Step 1 - Review the claim to verify that it meets at least one of the above criteria.
 
     Step 2 - Complete a claim form correctly (the claim form must be a signed
     original – no file copies or photocopies will be accepted). If the claim
     form is not signed, please submit a Signature Transmittal form MA-307.  
    
     Step 3 - Include all supporting documentation along with documentation to and
     from the CAO (dated eligibility notification) and/or third party insurer 
     (explanation of benefits statement). 
 
     Step 4 - Complete a 180-Day Exception Request Detail Page and submit it to the
     department with each exception request.
 
Submit a request for a 180-Day exception to the following address:
 
Inpatient and Outpatient Claims:
Attention: 180-Day Exceptions
Department of Human Services
Bureau of Fee-for-Service Programs
P.O. Box 8042
Harrisburg, PA 17105
 
Long Term Care Claims:
Office of Long-term Living
Bureau of Provider Support
Attention: 180-Day Exceptions
P.O. Box 8025
Harrisburg, PA 17105-8025
 
4. If I bill paper invoices, must the physician sign the MA invoice?
 
Response: The provider has the option of signing each invoice individually, using a signature stamp, or submitting the invoices with the Signature Transmittal Form MA-307. If the MA-307 is used, a handwritten signature or signature stamp of a Service Bureau representative, the provider, or his/her designee must appear on the MA-307. When the MA-307 is used, claims must be separated and batched according to the individual provider who rendered the services. Individual provider numbers must be provided in the spaces provided on the MA 307. The MA 307 must be submitted with the corresponding batches of individual provider’s claims (maximum of 100 invoices per transmittal).
 
5. If I bill paper invoices, must the patient sign the MA invoice?
 
Response: Providers must obtain applicable recipient signatures either on the claim form or must retain the recipient’s signature on file using the Encounter Form (MA 91). The purpose of the recipient’s signature is to certify that the recipient received the service and that the person listed on the PA ACCESS Card is the individual who received the services provided.
 
A parent, legal guardian, relative, or friend may sign his or her own name on behalf of the recipient. The provider or an employee of the provider does not qualify as an agent of the recipient; however, children who reside in the custody of a County children and youth agency may have a representative or legal custodian sign the claim form or the MA 91 for the child. The following situations do not require that the provider obtain the recipient’s signature: 
  • When billing for inpatient hospital, short procedure unit, ambulatory surgical center, nursing home, and emergency room services.
  • When billing for services which are paid in part by another third party resource, such as Medicare, Blue Cross, or Blue Shield.
  • When billing for services provided to a recipient who is unable to sign because of a physical condition such as palsy.
  • When billing for services provided to a recipient who is physically absent, such as laboratory services or the interpretation of diagnostic services.
  • When resubmitting a rejected claim form.
  • When billing on computer-generated claims. In this instance, you must obtain the recipient’s signature on the Encounter Form (MA 91).
In all of the above situations, print “Signature Exception” on the recipient’s signature line on the invoice.
 
6. Can physicians bill for medications dispensed to their patients?
 
Response: All physicians licensed in the state of Pennsylvania may bill and be reimbursed for the actual cost of medications administered or dispensed to an eligible recipient in the course of an office or home visit. There is no reimbursement to a physician for medical supplies or equipment dispensed in the course of an office or home visit. Payment for medical supplies and equipment is made only to pharmacies and medical suppliers participating in the Medical Assistance program.
 
Physicians must bill drug claims using the electronic 837 Professional Drug transaction if using proprietary or third party vendor software, or the 837 Professional transaction if using the Provider Electronic Solutions (PES) software, or on the PROMISe™ Provider Portal using the pharmacy claim form. Physicians are required to use the 11-digit National Drug Code (NDC) and assign a prescription number for the medication. For additional information, please refer to the Pharmacy Services website at http://www.DHS.state.pa.us/provider/pharmacyservices/index.htm,
 
7. I have not seen my claim(s) on a remittance advice – what should I do?
 
Response: A claim which has been submitted to the department not appearing on a remittance advice within 45 days following that submission, should be resubmitted by the provider.
 
If you submit paper claim forms, please verify that the mailing address is correct. Refer to Provider Quick Tip #41 MEDICAL ASSISTANCE (MA) DESK REFERENCE http://www.DHS.state.pa.us/publications/forproviders/QuickTips/index.htm to verify the appropriate PO Box to mail paper claim forms based upon claim type.
 
8. Are “J” codes compensable under Medical Assistance?
 
Response: No, “J” codes are not compensable under Medical Assistance.
 
9. Can I print out the ADA 2012 Dental Claim Form from the Department of Human Services website?
 
Response: No. The ADA Dental Claim form (2012 version) must be ordered from the American Dental Association or associated forms vendors. The ADA Dental Claim form may also be available as part of your office practice software program.
 
10. How do I submit claim adjustments on PROMISe™?
 
Response: The Provider Claim Inquiry window is used to make an adjustment to a claim on PROMISe™. Regardless of submission media, you can retrieve all claims associated with your provider number. A search can be narrowed by specifying the ICN, recipient ID number, patient account number, date range, or claim status criteria. Claim records that match your search criteria are displayed in the lower portion of the Claim Inquiry window. Note that all ICNs and Recipient IDs are hyperlinked. Click on the ICN link for which an adjustment is to be made. The original claim is displayed. Scroll down the claim window to the Adjustments for Service Line: 1 group. In the Adjustment 1 row, select a value from the Adjustment Group Code drop-down box. Select a value from the Reason Code drop-down box. Enter the amount of the adjustment for this claim in the Amount box at the end of the Adjustment 1 row. Select a value from the Carrier Code drop-down box. To add another adjustment to the claim, click the Add Adjustment button to activate the Adjustment 2 row. Up to eleven additional adjustments can be added. When finished adding adjustment rows, click the Submit button to submit the adjustment to PROMISe™.
 
11. Will modifiers continue to be used after local codes are eliminated?
 
Response: Yes. Refer to the appropriate fee schedule and billing guides for your provider type for correct usage of modifiers on the DHS website @
 
OR
 
12. When billing for services provided in a hospital setting, where can I find facility numbers?
 
Response: Facility provider numbers are available on the PROMISe™ provider portal @ https://promise.DHS.state.pa.us. After logging on with your unique user ID, challenge question answer and password, click on the Claims tab, then Submit Professional. You will see a hyperlink for Facility Provider Numbers and clicking the hyperlink will allow you to view a list of provider numbers for Acute Care Hospitals, Ambulatory Surgical Centers, Psych and Rehab Hospitals and Short Procedure Units.
 
13. How do Outpatient Hospital providers bill MA secondary to Medicare?
 
Response: Outpatient Hospital providers may bill MA secondary charges when Medicare applies payment to deductible or coinsurance. The charges may be billed on the PROMISe™ Provider portal using the institutional claim form, on the UB-04 paper claim form or via Provider Electronic Solutions (PES) or other third party software.
 
To bill MA secondary charges via the institutional claim form on the PROMISe™ Provider portal, follow these steps:
 
StepAction
  
1.In Other Insurance section, press ADD
2.In Carrier Code field - Select 100-Medicare Part B from the drop-down
3.In Policy Holder ID Code field - enter the Policy Holder ID
4.In Individual Relationship field - select recipients relationship with insured
5.In Release of Medical Data field – make selection from the drop down box
6.In Benefit Assignment field – make selection from the drop down box
7.In Claim Filling Code field - select MB- Medicare Part B
8.Scroll to the SERVICE ADJUSTMENTS for Service Line 1 Section
9.In Adjustment field - from drop-down select why MA is being billed
10.In Amount field - enter the amount being billed
11.

In Adjustment Group Code field - from drop-down select PR-Patient Responsibility

12.In Paid Date field - enter the date of Medicare EOB or check
13.In Paid Amount field - enter how much Medicare Paid. If Medicare did not pay, leave blank
14.In Carrier Code field - select 100-Medicare Part B
15.In Medicare Approved Amount field - enter the Medicare Approved amount
 
To bill MA secondary charges via the UB-04 paper claim form, follow these steps:
 
Example - if billing for deductible:
Form Locators 39-41          A1 – deductible Payer A
Form Locator 54                  Report the Medicare approved If Medicare applied the entire 
                                                payment to the recipient’s deductible, 
 
Example - when there is Medicare Coinsurance/copayment:
If Medicare applied part of the payment to the Deductible and assessed coinsurance or copayment towards the same service or assessed co-insurance or copayment only
 
Form Locators 39 though 41 list the following value codes:
 
          A1 deductible Payer A (if applicable) 
          A2 coinsurance payer A (if applicable)
          A7 Copayment payer A (if applicable)
 
Locator 54 Report the Medicare Paid
 
Form Locators 50 through 65
 
          Line A – 2(represents MED B)
          Line B- MAPA(represents Medical Assistance)
 
To bill MA secondary charges via Provider Electronic Solutions (PES) software, follow these steps:
 

HEADER 3

Other Insurance Indicator -
Used to activate the O/I screen, which is used to record a recipient’s other insurance information. Select the other insurance code from the drop down list, or enter an appropriate value as specified:

Crossover Indicator -
Used to activate the Crossover screen, which is used to record a recipient’s Medicare information. Select the crossover code from the drop down list, or enter the appropriate value, as described below: 

 
STEPACTION
1.In Other Insurance Indicator field enter Y – Yes-Recipient has other insurance
2.In Crossover Indicator field enter Y – Yes-Recipient has Medicare
3.In Payer Responsibility field enter P – Payer 1
4.In Claim Filing Indicator Code field enter MB – Medicare Part B
5.In Paid Date/Amount field enter the date on which the other insurance company paid
against the claim. Enter the amount paid by the Other Insurance carrier. An amount of zero
(0) may be entered.
 
6.In Carrier Code (Policy Holder) field select the carrier code associated with the other insurance coverage from the drop down list.
7.In Group Number (Policy Holder) field enter the Group number associated with the other insurance coverage.
 Crossover
8.In Release of Medical Data field select the release code from the drop down list,
9.In Benefits Assignment field select the assignment code from the drop down list
10.In Reason Codes/Amts field identifies the reason the adjustment is being made (why is
MA being billed); enter the amount of the adjustment(amount billing for)
 
11.In Claim Filing Indicator Code field enter MB – Medicare Part B
12.In Adjustment Group Code field enter PR –Patient Responsibility
13.In Paid Amount field enter the Medicare amount paid
14.In Carrier Code field select the carrier code from the drop down list,
 
14. Is there a revenue code table for inpatient and outpatient? 
 
Response: Yes, the inpatient and outpatient revenue codes can be found @
 
15. Are emergency room services still billed with “W” codes?
 
Response: No, refer to Medical Assistance Bulletin 01-06-05 and the outpatient fee schedule for the correct codes.
 
16. Can we bill for services provided to a newborn using the mother’s Recipient ID number?
 
Response: Yes. If you are billing via the CMS-1500 paper claim form, in order for PA PROMISe™ to process your claim, the newborn invoice must be completed with the following modifications:
 
1. Block 1a (Insured’s I.D. Number) - Use the mother’s 10-digit ID number found on her ACCESS Card or by accessing EVS. 
 
2. Blocks 2 (Patient’s Name (Last Name, First Name, and Middle Initial) and 3 (Patient’s Birth Date) - Use the newborn’s identifying information (i.e., name, birthdate, sex, etc.). 
 
3. Block 19 (Reserved for Local Use) - Enter Attachment Type Codes AT26 (which indicates that you are billing for a newborn using the mother’s ID number) and AT99 (which indicates that you have an 8½ by 11 sheet of paper attached to the claim form). Enter the mother’s name, social security number, and date of birth on the 8½ by 11 sheet of paper. Include your provider name, 9-digit provider number and
4-digit service location on the attachment.
 
If you bill via the PROMISe™ Provider portal, you must complete the Newborn section of the claim form and enter the mother’s 10-digit ID number in the Patient ID field. Additionally, you must complete the billing notes with the mother’s name, date of birth and SSN.
 
For more detailed information on billing without the Newborn’s Recipient Number, institutional and professional providers may refer to the provider handbooks and billing guides located at:
 
17. For second digit bill classification, do we use a “4” when we bill for special treatment room “X” codes? What if other services are on the same bill type?
 
Response: Yes, Special Treatment Room (STR) support components must be billed using bill type 141. Please refer to Medical Assistance Bulletin 01-06-01.
 
If other outpatient services are performed on the same date of service for which you are billing, you must separate the charges and bill the outpatient charges using bill type 131.
 
18. Does PROMISe™ accept the MD license number or the UPIN number for the physician format?
 
Response: Medical Assistance does not accept UPINs on any claim submission media. The medical license number must be used when appropriate.
 
19. What are the options for submitting claims electronically?
 
Response: Providers may submit electronic 837 claim transactions through clearinghouses and certified third-party software. If you submit claims through a clearinghouse, you are covered under the clearinghouse's certification. If you submit your claims through a third party software vendor, they have to certify with PROMISe™ on your behalf. Providers may also download the Provider Electronic Solutions (PES) software free of charge from the DHS website located at:
 
 
If you download and use PES you are not required to certify.
 
Alternatively, providers may submit claims via the PROMISe™ Provider Portal located at:
 
 
20. Claims are rejecting due to “other insurance” even when that insurance is no
longer valid for an individual. How can this be corrected?
 
Response: If you are receiving rejections because EVS states that the recipient has a third party resource (e.g., Blue Cross, Aetna, etc,) and the recipient is no longer covered by the third party resource, the recipient must contact their County Assistance Office to have the third party resource removed from their file. In the meantime, providers must bill the primary insurance for denial and use Attachment Type Code 11 on the CMS-1500 claim form. If submitting electronically, use the reason code from the EOB or 835 in the appropriate TPL loops. Please note that providers must keep copies of EOBs/EOMBs on file for a period of at least four years per Chapter 1101.51(e).
 
21. How should immunizations for EPSDT screens be reported on the CMS-1500
claim form?
 
Response: Please refer to the EPSDT Billing Guide and the EPSDT Periodicity Schedule and Coding Matrix (both documents are PDF downloads).
 
22. Are diagnosis codes required when billing for all claim types?
 
Response: Effective January 1, 2012, ALL providers including Waiver providers must report a diagnosis code when submitting the following claim types:
  • Professional – up to 12 diagnosis codes
  • Institutional – 1 primary diagnosis code, 24 additional diagnosis codes
  • Dental – up to four diagnosis codes may be submitted; however a diagnosis code is NOT required on dental claims. 
23. Can claim adjustments be submitted electronically?
 
Response: Yes, claim adjustments may be submitted electronically via the 837 claim transaction and on the PROMISe™ Provider Portal.
 
24. Can ASCs and SPUs submit more than one claim line per invoice?
 
Response: No. As per Chapter 1126 of the Pennsylvania Code, Ambulatory Surgical Centers and Short Procedure Units are only permitted to bill for a facility fee (according to the PSR Notice). The facility fee is an all inclusive fee that includes but is not limited to:
  • Nursing, technician and related services;
  • Use of the facility;
  • Drugs, biological, surgical dressings, supplies, splints, casts and appliances and equipment directly related to the provision of surgical procedures;
  • Administrative, recordkeeping and housekeeping items and services;
  • Materials for anesthesia;
  • The ASC or SPU shall submit invoices to DHS in accordance with the instructions in the Provider Handbook.
25. The billing guides on the DHS website only refer to submitting the CMS-1500 paper claim form. Where do you go for assistance when billing electronically.
 
Response: The PROMISe™ Companion Guides will assist you in submitting electronic 837 claim transactions using certified third-party software. There is a PROMISe™ Companion Guide for each transaction set available at:
 
 
If you submit claims using the Provider Electronic Solutions (PES) software, the user manual located here will assist you with your claim submissions.
 
If you submit claims via the PROMISe™ Provider Portal, the user manual located here will assist you with your claim submissions.

26. How can I get training? I took the e-Learning course and still do not understand. 
 
Response: You may request training by contacting the Provider Service Center at 1-800-537-8862. Please inform the PSR Representative that you are calling to request PROMISe™ training. Training is free of charge to all providers.