INSTITUTIONAL. billing module

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UB-92

Billing Module

Basic Rules... 2

Before You Begin ... 2

Reimbursement and Co-payment... 2

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Basic Rules

Instructions for completing the UB-92 claim form are included on the following pages. There are some basic rules you must know before you complete the claim form.

• Always use the UB-92.

• Use one claim form for each client.

• Be sure the information on the form is legible.

Before You Begin

Before you begin to fill out the claim form you should answer the following questions:

• Is the client eligible for EqualityCare on the date of service?

• Do you have a copy of the client's proof of eligibility?

• Does EqualityCare cover the service?

• Have the service limitations been exceeded?

• Did you obtain prior authorization, if applicable?

• Have you checked to make sure the client does not have other insurance?

If your response to all of the above questions is favorable, you can begin to fill out the claim form using the instructions in this module.

A separate notation is made when inpatient-billing instructions differ from outpatient billing instructions. Use the instructions applicable to the type of claim you are completing. The number appearing with each instruction corresponds to the form locators on the UB-92.

Reimbursement and Co-Payment

Reimbursement

EqualityCare reimbursement for covered services is based on a variety of payment methodologies depending on the service provided:

• EqualityCare fee schedule

• By report pricing • Billed charges • Invoice charges • Negotiated rates • Level of care • Per diem

A schedule of EqualityCare fees by procedure is available online at http://wyequalitycare.acs-inc.com or upon written request to:

ACS, Inc. P.O. Box 667

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COPAYMENT SCHEDULE

$2.00

Rural Health Clinic encounters

Federally Qualified Health Center encounters

$6.00

Outpatient hospital visits (non-emergency)

Revenue Codes: 450-459 and 510-519

EXCEPTIONS

Co-payment requirements do not apply to:

-Recipients under age 21 -Nursing Facility Residents -LTC Waiver recipients (Pharmacy only) -Pregnant Women -Family planning services -Emergency services -Hospice services -Medicare Crossovers -Assisted Living Facility

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EXHIBIT 1

Sample UB-92 Claim Form

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Field Item Description Req Action 1 Provider Name, Address

and Telephone Number

X Enter the name of the provider submitting the bill, complete mailing address and telephone number.

2 Unlabeled Field Not required.

3 Patient Control Number X (Optional) Enter your account number for the client. Any alpha/numeric character will be

accepted and referenced on the Remittance Advice. No special characters are allowed, e.g., *@-#, etc. 4 Type of Bill X Enter the three-digit code indicating the specific

type of bill. The code sequence is as follows: First Digit 1 Hospital 2 Skilled Nursing 3 Home Health 7 Clinic (ESRD,FQHC,RHC or CORF) 8 Special Facility (Hospice, CAH) Second Digit 1 Inpatient 2 ESRD 3 Outpatient 4 Other 5 Intermediate Care Level 1 6 Intermediate Care Level 2 7 Subacute Inpatient 8 Swingbed Medicare/ EqualityCare Third Digit 0 Non-payment/zero claim 1 Admit through discharge

claim

2 Interim - 1st claim

3 Interim - continuing claim 4 Interim - last claim (thru

date is discharge date)

5 Federal Tax Number Not Required. 6 Statement Covers Period

From/Through Dates

X Enter the inpatient dates from date of admission through date of discharge or outpatient date of service. For services rendered on a single day, enter that date (MMDDYY) in both the "FROM" and "THROUGH" fields.

7 Covered Days I (Required for inpatient billing) Enter the number of days covered. Count date of admission but not date of discharge.

8 Non-Covered Days X (Required for inpatient billing when applicable) Enter the days of care not covered by EqualityCare. 9 Co-Insurance Days X (When applicable) Enter the number of

co-insurance days paid by Medicare. 10 Lifetime Reserve Days Not required.

11 Unlabeled Field Not required.

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Field Item Description Req Action

13 Patient's Address X Enter the full mailing address of client. 14 Birth Date X Enter month, day and year of client's birthdate.

(MMDDYY)

15 Sex X (Optional) Enter appropriate code.

M=Male, F=Female, or U=Unknown 16 MS (Patient Marital Status) Not required.

17 Admission Date X Enter the date the client was admitted as an inpatient or the date of outpatient care. (MMDDYY)

18 Admission Hr X Enter the code corresponding to the hour of admission as shown in the table:

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Field Item Description Req Action Enter appropriate code

19 Admission Type X Inpatient: 1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn Outpatient: No entry required Home Health:

Codes same as Inpatient

20 SRC-Source of Admission X Enter the Source of Admission Code.

21 Discharge Hour X (When applicable) Enter the hour the client was discharged.

22 Patient Status X Enter the two-digit code indicating the status of the patient as noted below:

Code 01 02 03 04 05 06 07 20 30 Description

Discharged – home or self care Discharged – other hospital Discharged – SNF

Discharged – ICF

Discharged – other type of institution Discharged – home health organization Left against medical advice

Expired

Still a patient – used for interim billing

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Field Item Description Req Action 24,25,26,

27,28 29,30

Condition Codes X (Required) Enter codes used to identify conditions relating to this claim that may affect payer

processing as noted below: Code 01 02 03 04 06 08 17 38 39 77 80 81 82 Description

Military Service related

Condition is employment related Patient is covered by insurance not reflected here

HMO Enrollee

ESRD patient in first year of entitlement covered by employer group health insurance

Patient would not provide information concerning other insurance coverage Patient is over 100 years old

Semiprivate room not available Private room medically necessary Provider accepts assignment

Patient is eligible for Medicare Part A only Patient is eligible for Medicare Part B only Patient is eligible for both Medicare Parts

A and B

If any information is coded here, complete the appropriate form locator(s) 50, 58-62, or 63-66.

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Field Item Description Req Action 32,33,34

35

Occurrence Codes and Dates

X (Required when applicable) Enter the appropriate occurrence code(s) and the date of occurrence for reporting information on the type of accident, crime victim, benefits, other insurance, or date of

termination or third party coverage. Code 01 02 03 04 05 06 11 23 24 25 Description Auto accident

Auto accident/no fault insurance Accident/tort liability

Accident/employment related Other accident

Crime victim Date of onset

Benefits exhausted (Medicare) Date insurance denied

Date benefits terminated by primary payor If there is any information coded in these form locator(s) then give full details in the appropriate fields 50, 58-62, 63-69.

36 Occurrence Span Code and Dates

X Enter the occurrence span codes and the corresponding dates.

37 ICN Not required.

38 Responsible Party Name and Address

Not required.

39,40,41 Value Codes and Amounts X Enter the value codes and amounts when related to other insurance.

42 R Code (Revenue Code) X Enter the appropriate four-digit revenue code necessary to identify the specific accommodation or ancillary services.

43 Revenue Description Enter a narrative description of the related revenue categories included on this bill.

44 HCPCS / Rates X Outpatient only: place the appropriate HCPCS code for all laboratory and radiology related services when billing.

NOTE: HCPCS Laboratory procedure codes and

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Field Item Description Req Action

45 Services Date X (Required for outpatient services) Enter the dates of service for each Revenue code.

46 S. Units (Units of Services) X Enter a quantitative measure of service rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints of blood, or renal dialysis treatments, etc. Partial units are NOT allowed.

47 Total Charges X List the total charges for each revenue code line item. This includes any non-covered charges. Total the column at the bottom.

Outpatient: When billing outpatient laboratory and radiology procedures, list the charge for each procedure.

48 Non-Covered X (Required when applicable) Enter detailed breakdown of non-covered charges on applicable codes. Total the column. List non-covered Medicare amount from Medicare EOMB in this field.

49 Unlabeled Charge Columns Not required.

50 Payer (Identification) X EqualityCare is payer of last resort. All other forms of third party resources should be listed first. Use the A-C spaces to list all insurance resources available. If other insurance is listed, give complete details in fields 58-62. List any prior payments in field 54 and attach documentation of payment or denial.

51 Provider No. X Enter the nine-digit EqualityCare Provider Number. 52 Rel (Release of

information certification indicator)

Not required.

53 Asg Ben (Assignment of benefits certification indicator)

Not required.

54 Prior Payments X (Required when applicable) If there is an entry in 50, enter the amount received toward payment of this bill prior to the billing date by the indicated payer.

55 Estimated Amount Due Not required.

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Field Item Description Req Action

Enter the expected patient contribution as determined by DFS.

58 Insured's Name X (Required when applicable) Refer to field 50. If any other insurance information is listed, enter the policyholder name.

59 P. Rel (Patient's

Relationship to Insured)

X (Required when applicable) Enter the patient's relationship corresponding to the other policyholder as listed in field 58.

60 Cert./ SSN/HIC/ID No. (Patient's EqualityCare Client ID Number)

X If EqualityCare is the only payer, list the client's ten-digit EqualityCare Client ID Number on the first line. If other insurance is listed, list agreement number or HIC number that corresponds to the type of coverage identified on each line of field 58.

61 Insured's Group Name X (Required when applicable) Enter the name of the group or plan through which the insurance is provided if the client is covered by insurance other than EqualityCare.

62 Insurance Group Number X (Required when applicable) Enter the group

identification number assigned by the carrier or fund administrator to identify the group under which the client is covered.

63 (PA) Treatment Authorization

X (Required when applicable) If the procedure/services require prior authorization, enter the number from the PA or PCN form here. Refer to PA form sample and instructions in Chapter Seven of the General Manual. 64 ESC (Employment Status

Code)

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Field Item Description Req Action

65 Employer Name X (Required when applicable) Enter the name of the employer that might or does provide health care coverage for the individual identified in field 58. 66 Employer Location X (Required when applicable) Enter the specific

location of the employer of the individual. 67 Principal Diagnosis Code X Enter the ICD-9-CM code (exactly as in book)

describing the principal diagnosis. Use the most specific 3, 4 or 5-digit code for the diagnosis (use all 5 digits if applicable). Enter the codes for diagnosis other than the principal diagnosis in fields 68-75.

68-78 Other Diagnosis Codes X (Required when applicable) Enter the ICD-9-CM diagnosis codes corresponding to additional

conditions that co-exist at the time of admission (or time of service), or develop subsequently, that had an effect on the treatment received during the length of stay or time of service.

79 Procedure Coding Method Used

Not required. 80 Principal Procedure Code

and Date

X (Required when applicable) Enter the ICD-9-CM procedure code only for the primary procedure with date of service following.

81 Other Procedure Codes and Dates

X (Required when applicable) Enter the ICD-9-CM codes identifying the procedures, other than the principal procedure, performed during the billing period covered by this bill and the dates on which the procedures (identified by the codes) were performed.

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Field Item Description Req Action

83 Other Physician ID X (Required when applicable) Enter the UPIN number of the physician performing the principal procedure. If a UPIN number is not available, enter the physician's nine-digit EqualityCare Provider number and name.

84 Remarks Not required.

85 Provider Representative Signature

X A personal signature, a facsimile signature, typed signature, computer generated name, initials or an authorized signature must appear in this field. Providers are responsible for all claims billed using their EqualityCare provider number whether the provider, the provider’s employee, sub-contractor, vendor, or business agent submits the claim.

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