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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.

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    Medicare Crossover for Other Blue Plan Members (CMS-1500)

    Completing a claim correctly when a member has primary coverage with Medicare and secondary coverage (Medicare Supplement) from another Blue Plan will decrease your chance of receiving claim denials. The following instructions apply to items on the CMS-1500 form or its electronic counterpart that require specific Medicare Supplement information:

    Item 9

    • Enter the last name, first name and middle initial of the member if it is different from that shown in Item 2. Otherwise, you may enter the word “SAME”. If no Medigap benefits are assigned, leave blank.

    Item 9a

    • Enter the Medicare Supplement member’s policy and/or group number preceded by MEDIGAP, MG, or MGAP.

    • Item 9d must be completed if you enter a policy and/or group number in 9a.


    Item 9b

    • Enter the birth date (MM/DD/YYYY) and gender of the member.

    Item 9c

    • Leave this field blank if the Blue Plan secondary payer’s name is entered in 9d.

    • Enter the correct Blue Plan name as the secondary carrier in 9c. For example, if the member has a Medicare Supplement with Blue Cross and Blue Shield (BCBS) of Michigan, then BCBS of Michigan should be indicated as the secondary carrier, not Blue Cross and Blue Shield of Florida (BCBSF). Use an abbreviated street address, two letter postal code, and zip code copied from the member’s Medicare Supplement ID card. For example: 1234 Anywhere St, MD 12345.

    Item 9d

    • Enter the correct Blue Plan name as the secondary carrier.

    Note: All information must be complete and accurate in items 9, 9a, 9b, 9c and 9d of the CMS-1500 form in order for the Medicare carrier to be able to forward claim information. If prior arrangements have been made with the private insurer, the carrier will forward the Medicare information electronically. Otherwise, the carrier will forward a hard copy of the claim to the private insurer.

    Item 11d

    • If you submit a claim with a Medicare Remittance Notice attached, always mark “YES” in 11d.

    • If you mark “NO” in 11d, the claim will pass through the system but attachments will not be reviewed.

    • If your billing system is hard-coded to mark “NO” automatically in 11d, please manually override your system to mark “YES” when submitting a claim with the Medicare Remittance Notice attached.


    Item 13

    • The signature in this item authorizes payment of mandated Medigap benefits to a participating physician or supplier if required Medicare Supplement information is included in items 9 through 9d.

    • The member or member’s representative must sign this item or the signature must be on file as a separate Medigap authorization.

    • The Medigap assignment on file in the participating physician or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.

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    3. The medical services are not covered or authorized for the provider and/or recipient.

    ?? There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.

    ?? A valid 2-digit place of service code is required. Please refer to the Place of Service List on page 9 in this manual.

    ?? Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.

    ?? Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.

    ?? Verify that the billed services are covered for the recipient’s coverage type. Covered services vary by program type. For example, some recipients have coverage only for family planning services. If you bill the Program for procedures that are not for family planning, these are considered non-covered services and the Program will not pay you. Refer to regulations for each program type to determine the covered services for that program.

    ?? Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.


    4. The claim is a duplicate, has previously been paid or should be paid by another party.

    ?? MMIS-II edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.

    ?? If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.

    ?? If a recipient is enrolled in an MCO, you must bill that organization for services rendered. Verify that the recipient’s 11-digit MA number is entered correctly on the claim form.

    Finally, some errors occur simply because the data entry operators have incorrectly keyed or were unable to read data on the claim. In order to avoid errors when a claim is scanned, please ensure that this information is either typed or printed clearly. When a
    claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying or scanning error, resubmit the claim.

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    Medicare Crossover for Other Blue Plan Members (UB-04)

    Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:

    Form Locator 50 – Payer

    • Enter “Medicare” as the primary payer on line A.

    • Enter the appropriate Blue Plan name as the secondary payer on line B.

    o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.

    o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.


    Form Locator 53 – ASG BEN

    • A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.

    • This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.

    • The member or representative’s signature must be on file as a separate Medigap authorization.

    • The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.



    Form Locator 54 – Prior Payments

    • Enter the amount you have received toward payment of this bill from Medicare on line A.


    Form Locator 58 – Insured’s Name

    • Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.

    Form Locator 59 – P. Rel

    • Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).


    Form Locator 60 – Insured’s Unique ID

    • Enter the patient’s Medicare HIC number as shown on the ID card on line A.

    • Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
    Form Locator 61 – Group Name

    • Enter the name of the group or plan through which the insurance is provided to the member.

    Form Locator 62 – Insurance Group No.

    • Enter the group number as identified on the ID card.

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    If you have been paid, but paid incorrectly for a claim or received payment from a third party after Medical Assistance has made payment, you must complete and submit an Adjustment Request Form (DHMH 4518A) to correct the payment. See page 21 for a reproduction of DHMH 4518A.

    If an incorrect payment was due to a keying error made by Medical Assistance, or you billed the incorrect number of units, you must complete an Adjustment Request Form following the directions on the back of the form. When completing the Adjustment Form, do not bill only for remaining unpaid amounts or units, bill for entire amount(s).


    Example: You submitted and received payment for three units, but you should have billed for five units. Do not bill for the remaining two units; bill for the full five units.

    Total Refunds – If you receive an incorrect payment, return the check issued by the Medical Assistance Program only when every claim payment listed on the remittance advice is incorrect, i.e., none of the recipients listed are your patients. When this occurs,
    return with a copy of the remittance advice and the check with a complete Adjustment Request Form to the address on the bottom of the form.

    Partial Refunds – If you receive a remittance advice, which lists some correct payments and some incorrect payments do not return the Medical Assistance Program check. Deposit the check and file an Adjustment Request Form for each individual claim paid
    incorrectly.

    NOTE: For overpayments or refunds, the provider may issue and submit one check to cover more than one Adjustment Request Form.

    Before mailing Adjustment Request Forms, be sure to attach any supporting documentation such as remittance advices and CMS-1500 claim forms. Adjustment Request Forms should be mailed to:
             
                                                               Medical Assistance Adjustment Unit
                                                                        P.O. Box 13045
                                                                   Baltimore, MD 21203

    If you have any questions or concerns, please contact the Adjustment Unit at 410-767-5346.



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    Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program 


     Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing (such charges are known as “balance billing”). QMB is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability


    The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain circumstances.) Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers --not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions

    Please ensure that you and your staffs are aware of the federal balance billing law and policies regarding QMB individuals. Contact the Medicaid Agency in the States in which you practice to learn about ways to identify QMB patients in your State and procedures applicable to Medicaid reimbursement for their Medicare cost-sharing. If you are a Medicare Advantage provider, you may also contact the MA plan for more information. Finally, all Medicare providers should ensure that their billing software and administrative staff exempt QMB individuals from Medicare costsharing billing and related collection efforts.

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    1. When can a provider bill a recipient?
    You can bill the recipient only under the following circumstances:

    • If the service provided is not covered by Medical Assistance and you have notified the recipient prior to providing the care that the service is not covered; or

    • If the EVS reported a message that the recipient is not eligible for Medical Assistance on the date you provided services.

    2. Can a provider bill Maryland Medicaid recipients for missed appointment?
    No. Federal policy prohibits providers from billing Medicaid recipients for any missed appointments. To obtain a copy of the transmittal (MCO #52) that explains this policy, visit www.state.md.us/mma/providerinfo.

    3. Where can a provider call to check the status of claims?
    Provider Relations is available Monday-Friday to assist providers with questions regarding the status of claims. To reach a representative, call 410-767-5503 or 1-800-445-1159 between 8:00 am – 5:00 pm.

    4. Where can a provider obtain a copy of a Remittance Advice (RA)?

    Copies of RAs are available for up to two years by accessing the Program’s website at www.emdhealthchoice.org. eMedicaid registration must be completed by an Administrator. To request an eMedicaid brochure, please call the Provider
    Training and Liaison Unit at 410-767-6024. To obtain copies of RAs older than two years, you may call a representative at (410) 767-5503 between the hours of 8:00 a.m. – 5:00 p.m.

    5. How can a provider request a check tracer?
    You may call Provider Relations (410) 767-5342 between the hours of 8:00 am to 4:30 pm.

    6. How can a provider request training for paper billing?
    The Provider Training and Liaison Unit provides quarterly trainings to Maryland Medicaid providers. To register for the training, call 410-767-6024 or go to www.dhmh.state.md.us and click on Provider Training to view the schedule and
    registration form.- 19 -

    7. Can you check EVS for future dates?
    No, however you can check EVS for past eligibility up to one year.

    8. How long does a provider have to file a claim?
    A provider has nine months from the date of service to submit a claim for payment. For other time statutes, see page two.

    9. Claims should be mailed to what address?
                   Claims Processing
                   P.O. Box 1935
                   Baltimore, MD 21203

    10. How long should I wait before I check claim status?
    Under normal conditions, if you have sent a paper claim, wait six weeks before calling Provider Relations.

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    Proactive steps to identify QMB individuals you serve and to communicate with State  Medicaid Agencies (and Medicare Advantage plans if applicable), can promote compliance  with QMB balance billing prohibitions.

    1. Determine effective means to identify QMB individuals among your patients. Find out what cards are issued to QMB individuals so you can in turn ask all your patients if they have them. Learn if you can query state systems to verify QMB enrollment among your patients. If you are a Medicare Advantage provider contact the plan to determine how to identify the plan’s QMB enrollees.

    2. Discern what billing processes apply to seek reimbursement for Medicare cost-sharing from the States in which you operate. Different processes may apply to original Medicare and MA services provided to QMB beneficiaries. For original Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordination & Recovery Center (BCRC) to automatically receive Medicareadjudicated claims.

    • If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare Remittance Advice. • Understand the processes you need to follow to request reimbursement for Medicare cost-sharing amounts if they are owed by your State. You may need to complete a State Provider Registration Process and be entered into the State payment system to bill the State.

    3. Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts.

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    MVP Health Care has developed this guide to help orient you to the key data fields that are changing on the new CMS-1500 Paper Claim Form that will be accepted by MVP Health Care starting 10/1/06 and mandatory beginning 4/1/07. The following example illustrates the changes between the HCFA-1500 claim form and the MVP Health Care data requirements on the new CMS-1500 paper claim form.

    MVP Health Care Data Field Changes on CMS-1500 Paper Claim Form

    CMS- 1500 Box                                  Submission Requirement

    Box 24a-h Shaded Lines                  Use the shaded lines above the service lines for:  Anesthesia start/stop times  Other service line information ( e.g. descriptions for unspecified codes )


    Box 24i*                                 Use the shaded space above “NPI” to report qualifier ZZ when reporting Rendering Taxonomy in the shaded space in the top half  of Box 24j



    Box 24j*                                  Use the shaded space above the NPI to report Rendering Taxonomy


    Box 33a                                    NPI                            
    Box 33b                                   Taxonomy code (preceded by ZZ qualifier)

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    Critical Care Services and Other Procedures Provided on the Same Day by the Same Physician as Critical Care Codes 99291 – 99292

    The following services when performed on the day a physician bills for critical care are included in the critical care service and should not be reported separately:

    • The interpretation of cardiac output measurements (CPT 93561, 93562);

    • Chest x-rays, professional component (CPT 71010, 71015, 71020);

    • Blood draw for specimen (CPT 36415);

    • Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090);

    • Gastric intubation (CPT 43752, 91105);

    • Pulse oximetry (CPT 94760, 94761, 94762);

    • Temporary transcutaneous pacing (CPT 92953);

    • Ventilator management (CPT 94002 – 94004, 94660, 94662); and

    • Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600).

    No other procedure codes are bundled into the critical care services. Therefore, other medically necessary procedure codes may be billed separately.

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    All paper claims are required to be submitted using the new CMS-1500 (02/12) form.
    The National Uniform Claim Committee (NUCC) recently revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12). The Centers for Medicare & Medicaid Services (CMS) adopted form CMS-1500 (02/12), which replaced the older CMS-1500 claim form (08/05), effective with claims received on and after April 1, 2014.

    • Medicare began accepting claims on the revised form, (02/12), on January 6, 2014;
    • As of April 1, 2014, Medicare only accepts paper claims on the revised CMS-1500 claim form, (02/12); and
    When completing the claim form, ensure to use all capital typeface.
    The revised form has a number of changes. The two most prevalent changes are new indicators to differentiate between ICD-9 and ICD-10 codes and new qualifiers to identify the role of the provider entered in item 17.
    • The NUCC created a presentation that reviews the changes in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

    Item 17 qualifiers
    The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
    • DN -- referring provider
    • DK -- ordering provider
    • DQ -- supervising provider
    Providers should enter the qualifier to the left of the dotted vertical line on item 17.
    • Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).

    Item 21 and 24E diagnosis changes
    The revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.

    Item 21
    • For version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set), up to 12 diagnosis codes.
    • Enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines A- L to lines of service in 24E by the letter of the line. Use the highest level of specificity.
    • Do not provide narrative description in this field.
    • Do not insert a period in the ICD-9-CM or ICD-10-CM code.
    • The "ICD Indicator" identifies the ICD code set being reported. Enter the applicable ICD indicator as a single digit between the vertical, dotted lines.
    • Indicator code set
    • 0 -- ICD-10-CM diagnosis
    • 9 -- ICD-9-CM diagnosis
    Reminder: Providers cannot submit ICD-9 codes for claims with dates of service on and after October 1, 2015.


    Item 24E
    • For version 02/12, the reference will be a letter from A-L.
    • When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L".
    Additional changes
    The following additional changes are also included in the revised form:

    Item 8
    • Form version 02/12: Leave blank.

    Item 9b
    • Form version 02/12: Leave blank.

    Item 11b
    • Form version 02/12: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Provide this information to the right of the vertical dotted line.

    Item 14
    • Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14.
    ASCA reminder

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     Global Surgery

    Critical care services shall not be paid on the same calendar date the physician also reports a procedure code with a global surgical period unless the critical care is billed with CPT modifier -25 to indicate that the critical care is a significant, separately identifiable evaluation and management service that is above and beyond the usual pre and post operative care associated with the procedure that is performed.

    Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into the critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services, e.g., endotracheal intubation, shall be excluded from the determination of the time spent providing critical care.

    This policy applies to any procedure with a 0, 10 or 90 day global period including cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing CPR shall be excluded from the determination of the time spent providing critical care. In this instance it must be the physician who performs the resuscitation who bills for this service. Members of a code team must not each bill Medicare Part B for this service.

    When postoperative critical care services (for procedures with a global surgical period) are provided by a physician other than the surgeon, no modifier is required unless all surgical postoperative care has been officially transferred from the surgeon to the physician performing the critical care services. In this situation, CPT modifiers "-54" (surgical care only) and "-55"(postoperative management only) must be used by the surgeon and intensivist who are submitting claims. Medical record documentation by the surgeon and the physician who assumes a transfer (e.g., intensivist) is required to support claims for services when CPT modifiers -54 and -55 are used indicating the transfer of care from the surgeon to the intensivist. Critical care services must meet all the conditions previously described in this manual section.

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    • Drug Billing

    o Providers are required to bill GHP with the applicable NDC and CPT/HCPCs codes for drugs.

    ** Reporting NDC on a CMS-1500 claim form

    • Enter the NDC in the shaded sections of item 24A through 24G

    o To enter the NDC information, enter the qualifier and then the 11 digit NDC information. Please enter the information without hyphenation.

    o Providers are to bill each drug for a compound medication as a separate line item with the appropriate NDC.

    • Enter the drug name and strength

    • Enter the NDC quantity unit qualifier

    • Enter the NDC quantity


    ** Reporting NDC on a UB-04 claims form

    • Enter the NDC in the revenue description field (form locator 43)

    o To enter the NDC information, enter the qualifier in the first two positions, left-justified, followed immediately by the 11 character NDC without hyphenation.

    • Enter the NDC quantity unit qualifier

    • Enter the NDC quantity

    ** Reporting NDC through EDI

    • The NDC is to be billed in loop 2410 LIN3

    o Reimbursement for specialty pharmaceuticals (i.e. hematology/oncology drugs), will follow Medicaid reimbursement guidelines.



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    Box 12. Have the patient or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the patient or other authorized person on file authorizing the release of any medical or other information necessary to process this claim.


    Box 13. Have the subscriber or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the Member or other authorized person on file authorizing assignment of payment to you.


    Box 14. Enter the date of injury or medical Emergency. For conditions of pregnancy enter the LMP. If other conditions of illness, enter the date of onset of first symptoms.

    Box 24  The 6 service lines in section 24 have been divided horizontally to accommodate submission of both the NPI number and BCBSNC identifier during the NPI transition, and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. Use of the supplemental information fields should be limited to the reporting of NDC codes. If reporting NDC codes, report the NDC qualifier “N4” in supplemental field 24a followed by the NDC code and unit information (UN = unit; GR = Gram; ML = Milliliter; F2 = International Unit).





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    Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment


    When a patient remains an inpatient of a SNF, TEFRA hospital or unit, swing-bed, or hospice beyond the end of a calendar month, providers must submit a bill for each calendar month. (See §50.2.1 for frequency of billing for inpatient services.) Claims for the beneficiary are to be submitted in service date sequence. The shared system must edit to prevent acceptance of a continuing stay claim or course of treatment claim until the prior bill has been processed. If the prior bill is not in history, the incoming bill will be returned to the provider with the appropriate error message.

    When an out-of-sequence claim for a continuous stay or outpatient course of treatment is received, FIs will search the claims history for the prior bill. They do not suspend the out-of-sequence bill for manual review, but perform a history search for an adjudicated claim. For bills other than hospice bills, if the prior bill is not in the finalized claims history, they return to the provider the incoming bill with an error message requesting the prior bill be submitted first, if not already submitted. The returned bill may only be resubmitted after the provider receives notice of the adjudication of the prior bill. A typical error message would be as follows:

    Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.

    For a partial hospitalization program claim to determine out-of-sequence claim submission for the outpatient course of treatment, providers must utilize the correct frequency digit in the type of bill as follows:

    If the “from” and “through” (FL6) dates on the claim being submitted include the dates for all services of the course of treatment, then the frequency digit in the type of bill will be a “1” [Admit through Discharge Claim] (i.e., 131, 761, or 851). The final Patient Discharge Status code (FL 17) will be entered.

    If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the start of the course of treatment (first of a series of bills) and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “2” [Interim – First Claim] (i.e., 132, 762, or 852). The Patient Discharge Status code (FL 17) will be a “30”.

    If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the neither at the start or at the completion of the course of treatment and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “3” [Interim – Continuing Claim] (i.e., 133, 763, or 853). The Patient Discharge Status code (FL 17) will be a “30”
    .
    If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the completion of the course of treatment (last of a series of bills) and no additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “4” [Interim – Last Claim] (i.e., 134, 764, or 854). The final Patient Discharge Status code (FL 17) will be entered.

     Providers may submit Interim Bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the type of bill and sequentially.

    For a hospice claim that is out of sequence, the FI searches their claims history. If the FI finds the prior claim has been received but has not been finalized (for instance, it has been suspended for additional development), they do not cause the out of sequence claim to be returned to the provider. Instead, they hold the out of sequence claim until the prior claim has been finalized and then process the out of sequence claim. If the prior hospice claim has not been received, the out of sequence hospice claim is returned to the provider with an error message as described above. FIs shall perform editing to ensure hospice claims are processed in sequence after any necessary medical review of the claims has been completed.

    Since hospice claims received out of sequence do not pass all required edits, they do not meet the definition of “clean” claims defined in §80.2 below. As a result, they are not subject to the mandated claims processing timeliness standard and are not subject to interest payments. FIs will enter condition code 64 on the out of sequence claims they are holding when awaiting the processing of the prior claims to indicate that they are not “clean” claims.

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    FLs 39, 40, and 41. Value Codes and Amounts.
    a. Each code must be accompanied by an amount.
    b. All codes are two alphanumeric digits.
    c. Amounts may be up to ten numeric positions. (00000000.00)
    d. If code 06 is entered, there must be an entry for code 37.
    e. If codes 08 and/or 10 are entered, there must be an entry in FL 10.
    f. If codes 09 and/or 11 are entered, there must be an entry in FL 9.
    g. If codes 12, 13, 14, 15, 41, 43, or 47 are entered as zeros, occurrence codes 01, 02, 03, 04, or 24 must be present.
    h. Entries for codes 37, 38, and 39 cannot exceed three numeric positions.
    i. If the blood usage data is present, code 37 must be numeric and greater than zero.


    FL 42. Revenue Codes.
    a. Four numeric positions.
    b. Must be listed in ascending numeric sequence except for the final entry, which must be “0001” for hardcopy claims only.
    c. There must be a revenue code adjacent to each entry in FL 47.
    d. For bill types 32X and 33X the following revenue codes require a 5-position HCPCS code:
    0274, 029X, 042X, 043X, 044X, 055X, 056X, 057X, 0601, 0602, 0603, and 0604.
    e. For bill type 34X, the following revenue codes require a 5-position HCPCS code:
    0271-0274, 42X, 43X, 44X, and 0601-0604.
    f. For bill type 21X, 32X, 33X, or 11X (IRF facilities) the following revenue codes require a 5-position HIPPS code:
    0022 (SNF only), 0023 (HH only), 0024 (IRFs only).

    0 0

    General Billing

    • Report inpatient services with appropriate revenue and HCPCS codes
    • Report the number of observation hours in Field Locator 46

    Observation Following ER
    Bill observation services that are a result of an emergency department visit on the same UB-04 form.

    Observation Following SDC
    Bill observation services that are a result of an outpatient surgical procedure (SDC) on the same UB-04 form.

    Inpatient Following Observation

    • Bill observation services that convert to an inpatient admission on the same UB-04 form as the inpatient admission.

    • Enter the inpatient admission date in Form Locator 6 (statement covers period) as the beginning (from) date of the UB-04 form. Do not include the observation date within the statement covers period date range; this will cause the claim to deny as billed incorrectly because the number of admission days will not equal the number of days indicated by the statement covers period.

    • Enter the date on which the patient was admitted for inpatient services or other start of care in Field Locator 12.

    • Enter the time at which the patient was admitted for inpatient services or other start of care in Field Locator 13; hours are entered in two-digit military time (e.g., use 14 for 2:00 p.m.).

    Per Diem Facilities
    Bill observation services that convert to an inpatient admission after midnight of the observation day with the date of the observation service in Field Locator 45 and the number of hours in Field Locator 46.

    Observation with Ancillary Services

    Bill outpatient ancillary services received during an observation stay using appropriate revenue codes and HCPCS codes on the same UB-04 form as the observation services.

    Observation with Radiological Procedures
    Bill observation services used in conjunction with radiological procedures (i.e., CAT scan, MRI, ultrasound) on the same UB-04 form as the radiological procedure.


    Observation with Diagnostic Procedures 

    Bill observation services used in conjunction with diagnostic procedures on the same UB-04 form as the diagnostic services.

    OI Denial Review Request
    • Submit OI denial reviews as a Corrected Claim Appeal along with a completed Provider Claim Appeal Form.
    • Submit as an outpatient claim and include only the observation room charges. All other outpatient charges that are submitted on the claim with the observation date of service will be denied.

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    Establishing Date of Filing - Postmark Date - Carriers


    Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, legal holiday, or other day all or part of which is a non-work-day for Federal employees because of Federal statute or executive order, the claim will be considered timely if it is filed on the next workday.

    Where the claim is submitted to the carrier by mail, if it is material and to the advantage of the provider, the claim can be considered filed on the day the envelope was postmarked in the United States. Thus, where an undated claim is received by the carrier in the mail early in the month after the filing date, the envelope should, if practical, be retained. If, in such a case, an envelope with a legible postmark is not available, a 7-day tolerance will usually apply. For example, a claim for services provided in May 2000 received by a carrier on or before January 10, 2002, may be presumed by the carrier, in the absence of evidence to the contrary, to have been mailed on or before January 2, 2002, (which is the date the time limit expires because it is the first Federal workday after Saturday, December 31). This rule will be applicable where the claim was mailed within the contiguous 48 States and the District of Columbia and received by a carrier within such States. In other cases, the reasonable tolerance may be longer and will depend on the usual mailing time under the particular circumstances.

     Frequency of Billing for Providers

    Different types of providers are paid based on different payment policies depending upon the circumstance of the provider. These payment policies are described in detail in the chapters related to the provider type. The following billing requirements are to strike a balance between program administration efficiency and maintaining cash flow for providers.

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    UB-04 Billing

    Code Description Comments

    036X Operating Room Rev Code CPT/HCPCS required
    045X Emergency Room Rev Code Use to bill all surgical procedures performed in the emergency room.
    049X Ambulatory Surgery Rev Code CPT/HCPCS required
    0762 Observation Room Rev Code
    082x–085x, 088x Dialysis Rev Codes


    Outpatient Services
    • Outpatient services will be reimbursed on a fee for service basis, unless otherwise specified.
    • Outpatient services billed on a paper UB04 or electronic 837I, version 5010 - will only be reimbursed when submitted with both a revenue code and a valid CPT/HCPCS code. Claim lines submitted without a valid CPT/HCPCS code will not be separately reimbursed.
    - Exception: CPT/HCPCS is not required for Observation Rev Codes 0760, 0762, or Dialysis Rev Codes 0821–0889.


    Emergency Room Services
    Emergency room (ER) care is reimbursed at a contracted rate, including:
    • Facility services directly related to the services provided as part of the emergency room care.
    • Procedure/s performed in the emergency room setting.

    Harvard Pilgrim reimburses the following services separately from the contracted rate:
    • Ancillary services such as laboratory, pathology, radiology, etc that support the services provided.
    • Procedure/s performed outside of the ER setting (i.e., operating room, ambulatory surgery, clinic, treatment room).



    Observation Stay
    Observation stay is reimbursed at a contracted case rate and includes all facility services provided as part of the observation stay including but not limited to pharmacy, supplies, and ancillary services, such as laboratory, pathology, radiology, etc. (Refer to Observation Stay for more information.)


    Emergency room services preceding observation stay
      When emergency room precedes an observation stay, the entire emergency episode is included in the observation reimbursement for inclusive payment according to the contracted observation rate.

    Outpatient surgery/significant procedures related to observation stay
    • Observation services billed in conjunction with outpatient surgery or other significant procedures are considered part of the procedure and no separate observation reimbursement will be made.


    Outpatient Surgery/Significant Procedures
    Outpatient surgery/significant procedures are reimbursed at a contracted rate, including:
    • Facility services that are directly related to the procedure performed including but not limited to anesthesia, operating room, recovery room, observations, implantable device, most pharmacy and supplies.
    • Harvard Pilgrim reimburses the following services separately from the contracted rate:
    - Ancillary services such as laboratory, pathology, radiology.

    0 0



    Primary care practitioner is defined as:

    1. A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or

    2. A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.

    Primary care services are defined as HCPCS Codes:

    1. 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;

    2. 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and

    3. 99341 through 99350 for new and established patient home E/M visits.


    Practitioner Identification

    Primary care practitioners will be identified using the National Provider Identifier (NPI) number of the rendering practitioner on claims. If the claim is submitted by a practitioner’s group practice, the rendering practitioner’s NPI must be included on the line-item for the primary care service and reflect an eligible HCPCS as identified. In order to be eligible for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians’ services. Regardless of the specialty area in which they may be practicing, the specific nonphysician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.

    The claims data used for the primary care percentage calculations depend on the potential primary care practitioner’s date of enrollment in Medicare. We will use Medicare claims data 2 years prior to the PCIP payment year to determine PCIP eligibility for those potential primary care practitioners who were enrolled in Medicare in that year. For example, for CY 2011, we will use Medicare claims data from CY 2009 for practitioners who were already enrolled in Medicare in CY 2009. We will use claims data from the year immediately preceding the PCIP payment year in order to determine PCIP eligibility for potential primary care practitioners who newly enroll in Medicare in the year immediately preceding the PCIP payment year. For example, for CY 2011, we will use the available Medicare claims data from CY 2010 only for potential primary care practitioners who newly enrolled in Medicare in CY 2010.

    Eligible practitioners for PCIP payments in a given calendar year who were enrolled in Medicare 2 years earlier will be listed by eligible NPI in the Primary Care Incentive Payment Program Eligibility File, available after January 31 of the PCIP payment year on their Medicare contractor’s website. Eligible practitioners for PCIP payments in a given calendar year who were newly enrolled in Medicare in the year immediate preceding the PCIP payment year will be identified in the PCIP Payment for New Providers Enrolled in Medicare File, available after October 1 of the PCIP payment year. Practitioners should contact their contractor with any questions regarding their eligibility for the PCIP.

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    UB 04 FL 4. Type of Bill

    a. Must not be spaces.
    b. Must be a valid code for billing. Valid codes are:

    First Digit - Type of Facility:
    1 - Hospital
    NOTE: Hospital-based multi-unit complexes may also have use for the following first digits when billing non-hospital services:
    2 - Skilled Nursing
    3 - Home Health
    4 - Religious Non-Medical (Hospital)
    7 - Clinic or Renal Dialysis Facility (requires special information in second digit below)
    8 - Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)


    Second Digit - Classification (if first digit is 1-5):
    1 - Inpatient (Part A)
    2 - Hospital-Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)
    3 - Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)
    4 - Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “nonpatients”)
    8 - Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)

    Second Digit - Classification (first digit is 7):
    1 - Rural Health Clinic (RHC)
    2 - Hospital-Based or Independent Renal Dialysis Facility
    4 - Other Rehabilitation Facility (ORF)
    5 - Comprehensive Outpatient Rehabilitation Facility (CORF)
    6 - Community Mental Health Center (CMHC)
    7 - Free-Standing Provider-Based Federally Qualified Health Center (FQHC)

    Second Digit - Classification (first digit is 8):
    1 - Hospice (Nonhospital-based)
    2 - Hospice (Hospital-based)
    5 - Critical Access Hospital (CAH)


    Third Digit - Frequency:
    A - Admission/Election Notice
    B - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Termination/Revocation Notice
    C - Hospice Change of Provider
    D - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Void/Cancel
    E - Hospice Change of Ownership
    F - Beneficiary Initiated Adjustment Claim (For A/B MAC (A) use only)
    G - CWF Initiated Adjustment Claim (For A/B MAC (A) use only)
    H - CMS initiated Adjustment Claim (For A/B MAC (A) use only)
    I - A/B MAC (A) Adjustment Claim (Other than QIO or Provider) (For A/B MAC (A) use only)
    J - Initiated Adjustment Claim-Other (For A/B MAC (A) use only)
    K - OIG Initiated Adjustment Claim (For A/B MAC (A) use only)
    M - MSP Initiated Adjustment Claim (For A/B MAC (A) use only)
    P - QIO Adjustment Claim (For A/B MAC (A) use only)
    Q – Claim Submitted for Reconsideration Outside of Timely Limits (For A/B MAC (A) use only)
    0 - Nonpayment/zero claims
    1 - Admit Through Discharge Claim
    2 - Interim - First Claim
    3 - Interim – Continuing Claims (Not valid for PPS bills. Exception: SNF PPS bills)
    4 - Interim – Last Claim (Not valid for PPS bills. Exception: SNF PPS bills)
    5 - Late charge
    7 - Correction
    8 - Void/Cancel
    9 - Final Claim for a Home Health PPS Episode

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