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All Section 1011 payment requests must be submitted via
Electronic Data Interchange (EDI); hard copy requests are not accepted.
TrailBlazer returns hard copy payment requests and requires providers to
resubmit them electronically via EDI. Quarterly payments are issued to
providers including adjusting payment amounts to account for a pro-rata
reduction as necessary.
Providers must gather the information requested on the PPD form
(CMS-10130A) or other equivalent form prepared by the provider to
determine if a patient is eligible for services under the Section 1011
program.
A completed signature document must be maintained in the provider’s file and
not submitted unless requested. The document would then be considered part
of the necessary paperwork for any records request. Link directly to the PPD
form and to detailed instructions for completing the form below:
The Section 1011 online payment request processing system, the Fiscal
Intermediary Standard System (FISS)–UARS, is available as follows:
Monday – Friday
7 a.m. – 8 p.m. CT
Saturdays and Sundays
7 a.m. – 2 p.m. CT
The requirements for the PV ID, the password which grants access to DDE and UARS,
have changed for providers who allow their passwords to expire. Effective June
10, 2007, when a password is allowed to expire, new criteria are applied for log
in. A screen prompts the provider to change the expired password and the new
password must meet the following requirements.
- Have at least 8 characters.
- Contain specified special characters. (Non-alphanumeric such as punctuation
symbols. For example = - ! @ # $ % ^ & *)
- Use a mix of upper and lower case letters.
To keep the PV ID password active and prevent it from expiring, observe the time
frames below:
- Log in within the first 30 days of receipt of initial PV ID assignment.
- Log in at least every 60 days following your initial log in.
- Log in at least two weeks prior to payment request due dates (Payment
Request and On-call Payment).
Other important PV ID information:
- PV ID is required for each user within an organization.
- PV ID is faxed to you once one has been issued.
- Once a PV ID has expired, to obtain a new PV ID, resubmit Page 8 of the
Electronic Date Interchange (EDI) Enrollment Packet.
- A new PV ID cannot be issued on the same day it is requested.
Based on the Emergency Medical Treatment and Labor Act (EMTALA) regulations,
certain revenue centers are not considered emergency services and are excluded
from Section 1011 program payment. Additionally, certain diagnosis codes, when
used as the primary diagnosis, are excluded from Section 1011 program payment.
View the Revenue Center Exclusion List for a list of excluded codes.
For inquiry, log into DDE and select “01” (MAP 1701). On the inquiry screen,
select “12” (MAP 1702) and enter the Health Insurance Claim (HIC)
number/patient identifier to check the status of an individual payment
request or “56” (Claim Count Summary) for a summary of all payment requests
filed under a particular Provider Identification Number (PIN).
As stated in the Final Policy, Section 1011 is the payer of last resort.
Providers are required to first seek payment from all other payment sources.
For additional information, review
Payment Received From Other Sources. Further, TrailBlazer
does not coordinate benefits or provide payment information to the other
sources of payment.
Page 35 of the Section 1011 Final Policy states that providers are required
to notify TrailBlazer of any payment made by a third party or patient subsequent
to any Section 1011 reimbursement. An overpayment may occur if a provider
receives payments in excess of the approved payment amount.
To notify TrailBlazer of a potential overpayment, submit a letter on corporate
letterhead addressed to the Director of Reimbursement and Reporting stating
that an overpayment has been identified; or you may send an e-mail to
section.1011@trailblazerhealth.com.
Include the following information in your notification.
- Subject/Statement: Overpayment.
- Health Insurance Claim Number (HIC)/Patient Identifier.
- Document Control Number (DCN).
- Provider name.
- Provider Identiication Number (PIN)
- Date(s) of service.
- Amount of payment.
- Reason for overpayment.
- Provider contact title, telephone number and e-mail address.
TrailBlazer withholds the dollar amount of the overpayment from the provider’s
next quarterly Section 1011 payment. If the provider does not have a
sufficient balance to repay the overpayment in full, TrailBlazer notifies
the provider that they have 30 days to repay the overpayment without accrual
of interest.
More information on the withholding of overpayments is located on pages 67-68
of the Final Policy.
All professional fees must be billed under the physician’s Section 1011 PIN
as an outpatient payment request, using Type of Bill (TOB) 131. Specific
revenue codes apply only to physician services for billing purposes. Below
are important points regarding billing, revenue codes, and PINs:
- For billing codes, see Revenue Codes for Physicians.
- The following revenue codes are excluded from Section 1011: 0960, 0961, 0962, 0964 and 0969.
- When the payment request is entered with the hospital's PIN (TOB 131 or
111), the facility will receive the edit response 7PFEE, which states:
“Revenue codes 096X, 097X and 098X are identified as professional fees
and must be billed under the physician’s number. Payment requests with
professional fees are not allowed for hospitals.”
Section 1011 pays physicians to administer general anesthesia or direct another
trained professional while they administer the anesthesia. The payment request
is submitted under the physician’s PIN. Below is information on the required
codes, modifiers, and times:
For detailed information, examine
General Anesthesia Payment Request Requirements.
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Revenue code 0963 must be submitted for the anesthesia charge.
-
Anesthesia CPT® codes 00100 – 01999. The submission of a Not Otherwise
Classified (NOC) code must include a description of the service in the
Remarks field.
-
Anesthesia modifiers:
- AA – Anesthesiologist personally performed the service.
- QY – Medical direction of one Certified Registered
Nurse Anesthetist (CRNA) or Anesthesiologist Assistant (AA).
- QK – Medical direction of two, three, or four concurrent anesthesia procedures.
- AD – Supervision, of more than four concurrent procedures.
-
Time must indicate the duration of the procedure (in minutes) in the
TOT COV and COV UNIT fields. (Example:
123 minutes would be entered as 123.)
-
Note: Anesthesia time starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services in the
operating room or an equivalent area and ends when the anesthesia
practitioner is no longer furnishing anesthesia services to the patient,
that is, when the patient may be placed safely under postoperative care.
For TOB 131, providers should bill separate payment requests to correct reason code
12205 when the dates of service span two consecutive years for outpatient payment
requests.
Example: A patient is admitted to the emergency room on December 31, 2006.
The emergency room physician treats and observes the patient until the
afternoon of January 1, 2007, at which time the patient is stabilized.
Consider the following to determine the number of payment requests required:
- Two separate payment requests must be submitted for services provided on December 31,
2006 and January 1, 2007, which is a single visit spanning two consecutive years.
- If stabilization had not occurred until January 2, 2007, one bill for 2006 would be
required for the service provided on December 31 and a second bill would be needed
for the dates of service January 1-2, 2007.
If a single payment request is submitted, reason code 12205 applies. It states,
“The year in the statement covers from field is not the same as the year in
the statement covers through field. Please verify the statement covers period.
Where the from and through years are different, submit a separate claim for
each.”
Hospitals have the option of enrolling and receiving payment in one of two ways:
- Hospital receives payments for both the hospital and physician services, or
- Hospital receives payment for the hospital and a portion of on-call payments
made by the hospital.
The Final Policy notes that hospitals must file the hospital on-call
information collection instrument within 180 days of the end of the federal
fiscal quarter to claim payment. The Request for Section 1011 Hospital On-Call
Payments to Physicians form (CMS-10130B) can be found at the following link:
www.cms.hhs.gov/CMSforms/downloads/cms10130b.pdf.
This form must be completed, signed, and dated by an officer or administrator
of the hospital and mailed to the following address:
TrailBlazer Health Enterprises, LLC
Section 1011 - Reimbursement and Reporting
P.O. Box 660529
Dallas, Texas 75266-0529
For questions concerning the payment request process, feel free to contact
Section 1011 Customer Service at (866) 860-1011. Representatives are available
Monday through Friday from 8:00 a.m. – 5:00 p.m. CT. The TTY toll-free
telephone number for the speech and hearing impaired is (888) 492-4849.
Providers occasionally discover after submitting a request that they have
made errors entering the data. When these errors are identified, report them
in writing via fax to (469) 372-6143 or by using the e-mail address
section.1011@trailblazerhealth.com. Since action cannot be taken on verbal
requests, send the following information specific to the error and its
correction:
Subject Line: Request for correction of payment request.
- Name, title and telephone number of billing contact person.
- Health Insurance Claim Number (HIC)/Patient Identifier Number.
- Document Control Number (DCN).
- Provider Identification Number (PIN).
- From and to date(s) of service.
- Identify the error submitted with instructions on how the error is to be corrected.
Effective September 20, 2007, Section 1011 no longer inactivates payment
requests. Instead, requests are rejected in the Undocumented Alien
Reimbursement System (UARS) with one of the following reason codes:
- 38200 – Duplicate payment requests submitted in error.
- 70021 – Payment requests, other than duplicates, submitted in error, e.g., patient ineligible, service not EMTALA related, or incorrect Patient Identifier Number (HIC) used.
In the past, to correct a payment request submitted in error, TrailBlazer
inactivated the request by changing the status from suspended (S) to inactive
(I) which deleted the payment request and any associated audit trail or
remarks from the system.
When a provider discovers they have submitted a payment request in error, it
is important to alert Section 1011 of the error. Immediately fax the
information requested below to (469) 372-6143:
Subject Line/Statement: Request for rejection of payment request.
- Date of the fax.
- Name of facility/provider.
- Name, title and telephone number of the billing contact person.
- Reason(s) for rejection.
- If request involves a duplicate, include information listed below pertaining to both payment requests.
- Health Insurance Claim Number (HIC)/Patient Identifier Number.
- Document Control Number (DCN).
- Provider Identification Number (PIN).
- Patient Control Number.
- Medical Record Number.
- From and to date(s) of service.
- Amount of payment request.
Section 1011 payment requests are often delayed by inconsistencies between
patients’ listed gender and the information provided about their age,
diagnosis and CPT/HCPC codes. Diagnoses and procedures that apply only to
males are frequently assigned to female patients and vice versa. Also
causing problems are diagnoses and procedures that don’t correlate with
patients’ ages. Payment requests containing these mismatches are delayed
and risk rejection.
Recycled HIC numbers in the DDE form appear to be the culprit. Providers
should take care to ensure that each patient is identified by a unique,
12-digit HIC. While providers are encouraged to use their PIN number for
the first six numbers in the HIC, if the following six numbers remain
unchanged from patient to patient, previously keyed patient demographic
information can show up in subsequently entered payment requests. This can
cause the processing system to reject these subsequent requests as invalid.
Page 53 of the Section 1011 Final Policy states:
“All payment requests would be aggregated (by CMS during claims processing)
at the state level. Each provider within a state would receive payment equal
to the lesser of its costs, the Medicare reimbursement rate or, if provider
payments exceed the state allotment, a proportional payment of the Medicare
reimbursement rate.”
Review the Section 1011 Payment Calculation Example, which can also be
found under Payment Request Resources on this page. Additional information
regarding Section 1011 payment rules can be found in Section XIII of the Final
Policy.
Click here to review Section 1011 State Allocations by fiscal year.
Section 1011 makes electronic payments directly to providers according to
established payment request cycles. Payments are issued on scheduled
payment dates without regard to when Section 1011 originally received payment
requests. If, during the payment cycle, a state exceeds its quarterly
allotment, all payment requests are reduced by an equal percentage, a
calculation called a pro-rata reduction.
Providers use electronic remittance advice (ERA) to get information about
their Section 1011 payments. Once set up to receive ERAs, providers are
notified of their ERA Receiver ID, which is required to log on to GPNet,
the electronic data interchange (EDI) gateway to TrailBlazer. A detailed
explanation of ERA and a
guide to using GPNet to retrieve ERAs is available on
the Resources page under
Section 1011 Job Aids.
TrailBlazer offers free PC Print Software that allows providers to print ERAs
from a personal computer. This software and a user’s guide are located on
the Resources page under Miscellaneous Forms.
TrailBlazer is committed to ensuring the provider community has all the
information necessary to assist with accurate payment request submission. The
following resources have been developed to aid with payment request submissions.
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