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Contents

„

Claim Filing . . . . 5

Procedures for Claim Submission . . . .5

Claim Mailing Instructions . . . .5

Requests for Adjustments . . . . 5

Administrative or Medical Necessity Appeals . . . . 5

Claim Filing Deadlines . . . .6

Deadline Exceptions . . . . 6

Refunds for Claims Overpayments or Errors . . . .6

„

Claim Form Field Requirements . . . . 6

CMS 1500 Claim Form Required Fields . . . .7

Paper CMS 1500 Instructions and Examples of Supplemental Information in Item 24 . . . . 10

Paper CMS 1500 National Drug Codes (NDC) . . . . 10

Electronic (EDI) CMS 1500 Instructions and Examples of Supplemental Information in Item 24 . . . . 10

EDI CMS 1500 Other Instructions . . . . 11

EDI CMS 1500 National Drug Codes (NDC) . . . . 11

Corrected CMS 1500 claims via EDI . . . . 11

Required Fields (UB-04 Claim Forms) . . . . 12

NDC on UB-04 . . . . 16

Submission of POA Indicators for Primary and Secondary Diagnoses . . . . 17

General POA Requirements . . . . 17

POA Indicators are as follows, blanks are not acceptable: . . . . 17

POA Coding . . . . 17

Reporting POA on the UB-04 Claim Form . . . . 17

Reporting POA in Electronic 837I Format . . . . 17

All Patient Refined Diagnosis Related Groups (APR-DRG) . . . . 18

Birth Weight . . . . 19

Common Causes of Claim Processing Delays, Rejections or Denials . . . . 19

„

Electronic Data Interchange (EDI) for Medical and Hospital Claims . . . . 22

Submitting secondary claims electronically . . . . 22

Electronic Claims Submission (EDI) . . . . 23

Hardware/Software Requirements . . . . 23

Contracting with Emdeon and Other Electronic Vendors . . . . 23

Contacting the EDI Technical Support Group . . . . 23

Specific Data Record Requirements . . . . 23

Electronic Claim Flow Description . . . . 24

Invalid Electronic Claim Record Rejections/Denials . . . . 24

Plan Specific Electronic Edit Requirements . . . . 24

Example of a Professional Electronic Claim . . . . 25

Example of an Institutional Electronic Claim . . . . 28

Exclusions . . . . 31

Exlcuded Claim Categories . . . . 31

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Contents | 3

Common Rejections . . . . 31

Invalid Electronic Claim Records – Common Rejections from Emdeon . . . . 31

Invalid Electronic Claim Records – Common Rejections from the Plan (EDI Edits within the Claim System) . . . . 31

835 Electronic Remittance Advice . . . . 32

Electronic Billing Inquiries . . . . 32

How to Minimize Retrospective Chart Review . . . . 33

Why are retrospective chart reviews necessary? . . . . 33

Tips for Accurate Diagnosis Coding . . . . 33

EOB Denial Codes . . . . 35

„

Appendix - Supplemental Information . . . . 36

Ambulance Claims . . . . 37

Procedure Code Destination Modifiers . . . . 37

Authorization Requirements For Ambulance Services . . . . 37

Ambulance Services Not Covered . . . . 37

Ambulatory Surgery Claims . . . . 38

Anesthesia Claims . . . . 38

Certified Registered Nurse Anesthetists (CRNA) . . . . 38

Modifiers . . . . 38

Behavioral Health Claims . . . . 38

Identifying Mental Health Claims . . . . 38

Provider Types . . . . 39

Authorization Requirements . . . . 39

Co-pays . . . . 39

Labs . . . . 39

Outpatient Behavioral Health in the ER . . . . 39

Inpatient Behavioral Health DRGs . . . . 39

RHC/FQHC Behavioral Health claims . . . . 39

Behavioral Health services covered by Medicaid fee-for-service . . . . 39

Chiropractic Claims . . . . 40

Authorizations . . . . 40

Claim Submission . . . . 40

Claims inquiries . . . . 40

Eligibility and benefits inquiry . . . . 40

Provider Relations . . . . 40

Durable Medical Equipment (DME) Claims . . . . 40

Billing Requirements . . . . 40 Reimbursement Types . . . . 40 Authorization Requirements . . . . 41 Modifiers . . . . 41 Enteral Therapy . . . . 41 Nebulizers . . . . 41

Early, Periodic, Screening and Diagnostic Testing (EPSDT) Claims . . . . 41

Billing Guidelines . . . . 41

Immunizations . . . . 41

Additional Billing Notes . . . . 41

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Authorizations requirements . . . . 42

Co-pays . . . . 42

Same day visits . . . . 42

Billable Procedure Codes: . . . . 42

Home Infusions and Injectable Drugs Claims . . . . 43

Authorization requirements . . . . 43

Family Planning codes . . . . 43

Maternity Claims . . . . 43

Authorization Requirements . . . . 43

Ultrasounds . . . . 43

17-P Injections . . . . 43

Nurse Midwives . . . 43

Coordination of Benefits and Co-pays . . . . 43

Multiple Surgical Reduction Payment Policy . . . . 44

Nursing Home Claims . . . . 45

Authorization Requirements . . . . 45

Claim submission guidelines . . . . 45

Physical, Occupational and Speech Therapy Claims . . . . 45

Renal Dialysis Claims . . . . 45

Authorization requirements . . . . 45

„

Exhibits . . . . 46

CMS 1500 Form . . . . 47

HNS Fax Inquiry Form . . . . 48

Institute for Health and Recovery Integrated (IHR) Screening Tool (SBIRT) . . . . 49

Prenatal Risk Assessment Form . . . . 50

UB-04 Form . . . . 51

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Claim Filing | Procedures for Claim Submission | 5

„

Claim Filing

Procedures for Claim Submission

Select Health of South Carolina, Inc.’s First Choice health

plan, hereafter referred to as the plan, is required by state and federal regulations to capture specific data

regarding services rendered to its members. The provider

must adhere to all billing requirements to ensure timely

processing of claims. In most cases, Select Health follows

the Medicaid billing requirements.

Claims for billable services provided to plan members must

be submitted by the provider who performed the services. Claims filed with the plan are subject to the following

procedures:

• Verification that all required fields are completed on the

CMS 1500 or UB-04 forms.

• Verification that all diagnosis and procedure codes are

valid for the date of service.

• Verification of member eligibility for services under

the plan during the time period in which services were

provided.

• Verification that the services were provided by a partic

-ipating provider or that the “out of plan” provider has received authorization to provide services to the eligible.

• Verification that an authorization has been given for

services that require prior authorization by the plan.

• Verification of whether there is Medicare coverage or

any other third party resources, and if so, verification the plan is the “payer of last resort” on all claims submitted to the plan.

When required data elements are missing or are invalid, claims will be rejected by the plan for correction and

resubmission.

Rejected claims are defined as claims with invalid or missing required data elements, such as the provider tax identification number or

member ID number, that are returned to the provider or

EDI* source without registration in the claim processing system. This applies to claims submitted on paper or electronically.

Rejected claims are not registered in the claim processing system and can be resubmitted as a new claim.

Claims originally rejected for missing or invalid data elements must be corrected and resubmitted within 180 calendar days

from the date of service.

Denied claims are registered in the claim processing system

but do not meet requirements for payment under plan guidelines. They should be resubmitted as a corrected claim. This applies to claims submitted on paper or electronically.

Denied claims must be resubmitted as corrected claims within 180 calendar days from the date of service.

* For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital Claims in this booklet.

Claim Mailing Instructions

Submit claims to Select Health of South Carolina, Inc. at the following address:

Select Health of South Carolina Attn: Claim Processing Department P. O. Box 7120

London, KY 40742

The plan encourages all providers to submit claims

elec-tronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon Provider

Support Line at 1.800.845.6592 to arrange transmission.

Note: Select Health Plan EDI Payer ID# 23285 Any additional questions may be directed to Provider

Claim Services at 1.800.575.0418 or to Select Health

of South Carolina’s Network Operations department at 1.800.741.6605.

Requests for Adjustments

Requests for adjustments may be submitted by phone to: Provider Claim Services at 1.800.575.0418

(Select the prompts for the correct plan and then select the prompt for claim issues.)

If you prefer to write, please be sure to stamp each claim submitted “corrected” or “resubmission” and address the letter to:

Select Health of South Carolina Attn: Claim Processing Department P. O. Box 7120

London, KY 40742

Administrative or Medical Necessity Appeals

Administrative or medical necessity appeals must be submitted in writing to:

Select Health of South Carolina Attn: Appeals Department P. O. Box 40849

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Health care professionals submitting appeals on the behalf of a member must file the appeal within 90 calendar days of denial or action notification.

Refer to the Health Care Professionals and Providers

Manual online in the Provider section of the Select Health

website at www.selecthealthofsc.com for complete

instructions on submitting appeals.

Claim Filing Deadlines

Original invoices must be submitted to the plan within 180 calendar days from the date services were rendered or

compensable items were provided.

Resubmission of previously denied claims with corrections and requests for adjustments must be submitted within 365 days from the date services were rendered or

compensable items were provided.

Deadline Exceptions

Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the primary

insurer’s EOB.

Refunds for Claims Overpayments or Errors

The plan and South Carolina Department of Health and

Human Services (SCDHHS) encourage providers to conduct regular self-audits to ensure accurate payment.

Medicaid program funds that were improperly paid or overpaid must be returned. If the provider’s practice determines it has received overpayments or improper payments, the provider is required to make immediate

arrangements to return the funds to Select Health or follow the SCDHHS protocol for returning improper

payments or overpayment.

Contact Select Health Provider Claim Services at

1.800.575.0418 to arrange the repayment. There are two

ways to return overpayments:

1. Complete the overpayment worksheet located on the

Select Health website, www.selecthealthofsc.com, in

the Provider section under Provider Forms and have the plan deduct the overpayment/improper payment amount from future claims payments. Send the

completed form to:

Select Health of South Carolina Attn: Claims Processing Department P O Box 7120

London, KY 40742

2. Complete the overpayment worksheet and submit

along with a refund check for the overpayment/ improper payment amount directly to:

Select Health of South Carolina Cost Containment & TPL Department P O Box 7320

London, KY 40742

„

Claim Form Field Requirements

The following charts describe the required fields that must

be completed for the standard Centers for Medicare and

Medicaid Services (CMS) CMS 1500 or UB-04 claim forms.

A sample of each form can be found in the exhibits.

• If the field is required without exception, an “R”

(required) is noted in the “Required” or “Conditional”

box.

• If completing the field is dependent upon certain

circumstances, the requirement is listed as “C” (condi

-tional), and the relevant conditions are explained in the “Instructions and Comments” box.

The CMS 1500 claim form must be completed for all professional medical services, and the UB-04 claim form

must be completed for all facility claims. All claims must be submitted within the required filing deadline of one year

from the date of service.

Although the following examples of claim filing require

-ments refer to paper claim forms, claim data require-ments apply to all claim submissions, regardless of the method of submission (electronic or paper).

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Claim Form Field Requirements | CMS 1500 Claim Form Required Fields | 7

CMS 1500 Claim Form Required Fields

CMS 1500 Claim Form Required Fields

Field # Field Description Instructions and Comments Conditional*Required or

1 INSURANCE PROGRAM IDENTIFICATION Check only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. R

1a INSURED’S ID NUMBER Health plan’s member identification number or Medicaid identification number. R

2 PATIENT’S NAME First Name, Middle Initial)(Last Name, Enter the patient’s name as it appears on the member’s health plan I.D. card. R

3 PATIENT’S BIRTH DATE/SEX MMDDYY/M or F. R

4 INSURED’S First Name, Middle Initial)NAME (Last Name, Enter the patient’s name as it appears on the member’s health plan I.D. card. R

5 PATIENT’S ADDRESS Street, City, State, Zip Code) (Number, Telephone (include Area Code)

Enter the patient’s complete address and telephone number. Do not punctuate

the address or phone number. R

6 PATIENT RELATIONSHIP TO INSURED Always indicate self. R

7 INSURED’S ADDRESS Street, City, State, Zip Code) (Number,

Telephone (include Area Code) C

8 PATIENT STATUS Enter the patient’s marital status. Indicate if the patient is employed or is a student. C

9 OTHER INSURED’S NAME Name, First Name, Middle Initial)(Last Refers to someone other than the patient. Completion of fields 9a through 9d is required if patient is covered by another insurance plan. Enter the complete

name of the insured. C

9a OTHER INSURED’S POLICY OR GROUP NUMBER REQUIRED if #9 is completed. C

9b OTHER INSURED’S BIRTH DATE/SEX REQUIRED if #9 is completed. MMDDYY/M or F by check box. C

9c EMPLOYER’S NAME OR SCHOOL NAME This field is related to the insured in field #9. C

9d INSURANCE PLAN NAME OR PROGRAM NAME REQUIRED if #9 is completed. C

10a, b, c IS PATIENT’S CONDITION RELATED TO: Indicate yes or no for each category. Is condition related to employment, auto accident or other accident? R

10d RESERVED FOR LOCAL USE Not Required

11 INSURED’S POLICY GROUP OR FECA NUMBER Required when other insurance is available. Complete if more than one other medical insurance is available or if “yes” to 10a, b, c. C 11a INSURED’S BIRTH DATE/SEX Same as #3. Required if 11 is completed. C

11b EMPLOYER’S NAME OR SCHOOL NAME Required if employment is indicated in field #10. C

11c INSURANCE PLAN NAME OR PROGRAM NAME Enter name of health plan. Required if #11 is completed. C

11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Yes or no by check box. If yes, complete #9a-d. R

12 PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE Enter “Signature on File,” “SOF” or legal signature. R

13 INSURED’S OR AUTHORIZED PERSON’S SIGNATURE Enter “Signature on File,” “SOF” or legal signature. Not Required

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CMS 1500 Claim Form Required Fields

Field # Field Description Instructions and Comments Conditional*Required or

14 DATE OF CURRENT: ILLNESS symptom) OR INJURY (Accident)(First

OR PREGNANCY (LMP) MMDDYY. C

15 IF PATIENT HAS SAME OR SIMILAR ILLNESS, GIVE FIRST

DATE MMDDYY. C

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MMDDYY. C

17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required if a provider other than the member’s primary care physician referred, ordered or supervised the services or supplies on the claim. C

17a OTHER I.D. NUMBER OF REFERRING PHYSICIAN

Enter the health plan provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of #17a. Required if #17 is completed.

NUCC defines the following qualifiers used in 5010A1:

0B State License Number 1G Provider UPIN

G2 Plan Assigned Provider ID

LU Location Number (this qualifier is used for supervising provider only)

C

17b NATIONAL PROVIDER IDENTIFIER (NPI) Enter the NPI number of the referring provider, ordering provider or other source. Required if #17 is completed. C

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Required when place of service is inpatient. MMDDYY. C

19 RESERVED FOR LOCAL USE Not Required

20 OUTSIDE LAB CHARGES Not Required

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate items 1,2,3, OR 4 to item 24E by line)

Diagnosis codes must be valid ICD codes for the date of service. “E” codes are NOT acceptable as a primary diagnosis.

NOTE: Claims with invalid diagnosis codes will be denied for payment. R

22 MEDICAID RESUBMISSION CODE ORIGINAL REF. NO.

Medicaid resubmission code: For electronic claims

• Use “6” for adjustment of prior claim.

• Use “7” for replacement of a prior claim in loop 2300

Original REF No: • REF01 = F8

• REF02 = 13 digit original claim number, no dashes or spaces For paper claims:

• For resubmissions or adjustments, enter “ADJ” in the Resubmission Code section.

• Enter the claim ID# of the original claim in the Original Ref No. section.

C

23 PRIOR AUTHORIZATION NUMBER Enter the authorization number. Refer to the Provider Manual or call Provider Services to determine if services rendered require an authorization. C

24a DATE(S) OF SERVICE

If filing drug related codes, in the shaded area enter the NDC qualifier followed by the NDC number. NDC qualifier: N4.

For all claims, in the unshaded area, enter the “from” and “to” date in the MMDDYY format. If the service was performed on one day there is no need to complete the “to” date.

R

24b PLACE OF SERVICE Enter the CMS standard place of service code. R

24c EMG This field was originally titled “type of service” and is no longer used. This is now an emergency indicator field. Enter Y for yes or leave blank for no in the

bottom unshaded area of the field. R

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Claim Form Field Requirements | CMS 1500 Claim Form Required Fields | 9

CMS 1500 Claim Form Required Fields

Field # Field Description Instructions and Comments Conditional*Required or

24d PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS MODIFIER For all claims in the unshaded area, enter procedure codes (5-7 digits) and modifiers (2 digits) must be valid for date of service. Note: Modifiers affecting

reimbursement must be placed in the 1st modifier position.

R

24e DIAGNOSIS CODE Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). Diagnosis codes must be valid ICD codes for the

date of service. R

24f CHARGES Enter charges. Enter zero ($0.00) or actual charged amount. A value must be entered including capitated services. R

24g DAYS OR UNITS Enter quantity. Value must be greater than zero. (Field allows up to 3 digits.) R

24h EPSDT FAMILY PLAN Not Required

24i ID QUALIFIER

If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is reported in the qualifier field in 24i.

If the other ID number is the health plan ID number, enter G2. If the other

ID number is another unique identifier, refer to the NUCC guidelines for the appropriate qualifier.

R

24j RENDERING PROVIDER ID • The individual rendering the service is reported in 24j. Enter the health plan ID number in the shaded area of the field. Remember to use qualifier G2.

• Enter the NPI number in the unshaded area of the field.

Recommended R 25 FEDERAL TAX ID NUMBER SSN/EIN Physician or supplier’s federal tax ID (employer identification or Social Security) number. R

26 PATIENT’S ACCOUNT NO. The provider’s billing account number. R

27 ACCEPT ASSIGNMENT? Always indicate section pertaining to Medicaid payments.YES. Refer to the back of the CMS 1500 (08-05) form for the R

28 TOTAL CHARGE Enter the total billed amount for all services. R

29 AMOUNT PAID received from the primary payer prior to invoicing the plan. Medicaid programs REQUIRED when another carrier is the primary payer. Enter the payment

are always the payers of last resort. C

30 BALANCE DUE REQUIRED when #29 is completed. C

31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES

OR CREDENTIALS/DATE

May use “signature on file” if the provider’s billing designee has a written attestation signed by the provider that allows the billing designee to file claims

on the provider’s behalf. R

32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE

RENDERED (If other than home)

REQUIRED unless #33 is the same information. Enter the physical location, with

a 9-digit zip code, include the hyphen. (P.O. Box #’s are not acceptable.) 32a – Enter the NPI number (unless rendering provider is not required to have an NPI).

32b – Enter the ID qualifier and the Medicaid ID number or taxonomy code. Qualifiers: Use 1D with Medicaid ID or ZZ with taxonomy code (no spaces).

R

33 PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE AND PHONE NUMBER

Enter the complete name and address of the provider requesting to be paid for services. Enter a street address; a P.O. Box is no longer allowed in this field. Do not use punctuation or use other symbols in the address, and enter a 9-digit zip code, including the hyphen.

33a – Enter the NPI number (unless rendering provider is not required to have an NPI).

33b – Enter the ID qualifier and the Medicaid ID number or taxonomy code. Qualifiers: Use 1D with Medicaid ID or ZZ with taxonomy code (no spaces).

R

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Paper CMS 1500 Instructions and Examples of

Supplemental Information in Item 24

The following are types of supplemental information that

can be entered in the shaded lines of item number 24:

• Anesthesia duration in hours and/or minutes with start

and end times

• Narrative description of unspecified codes

• National Drug Codes (NDC) for drugs (see next section

for more information)

• Vendor Product Number – Health Industry Business

Communications Council (HIBCC)

• Product Number Health Care Uniform Code Council –

Global Trade Item Number (GTIN), formerly Universal Product Code (UPC) for products

• Product Code (UPC) for products formerly Universal

• Contract rate

The following qualifiers are to be used when reporting

these services.

7 Anesthesia information

ZZ Narrative description of unspecified code (all

miscellaneous fields require this section be reported)

N4 National Drug Codes

VP Vendor Product Number Health Industry Business

Communications Council (HIBCC)

OZ Product Number Health Care Uniform Code Council

– Global Trade Item Number (GTIN)

CTR Contract rate

All unspecified procedure or HCPCS codes

require a narrative description be reported in the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry of 61 characters from the beginning of 24A to the end of 24G.

To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the number/code/ information. Do not enter hyphens or spaces within the number/code.

More than one supplemental item can be reported in the

shaded lines of item number 24. Enter the first qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information.

Paper CMS 1500 National Drug Codes (NDC)

• NDC should be entered in the shaded sections of item

24A through 24G.

• To enter NDC information, begin at 24A by entering the

qualifier N4 and then the 11 digit NDC information.

• Do not enter a space between the qualifier and the

11-digit NDC number.

• Enter the 11-digit NDC number in the 5-4-2 format (no

hyphens).

• Do not use 99999999999 for a compound medication.

Bill each drug as a separate line item with its appro-priate NDC.

• Enter the drug name and strength.

• Enter the NDC quantity unit qualifier:

• F2 – International Unit

• GR – Gram • ML – Milliliter • UN – Unit

• Enter the NDC quantity.

• Do not use a space between the NDC quantity unit

qualifier and the NDC quantity.

• Note: The NDC quantity is frequently different than

the HCPC code quantity.

Example of entering the identifier N4 and the NDC number

on the CMS 1500 claim form:

Electronic (EDI) CMS 1500 Instructions and Examples

of Supplemental Information in Item 24

Details pertaining to EPSDT, anesthesia minutes and

corrected claims may be sent in Notes (NTE) or Remarks (NSF format).

Details sent in NTE that will be included in claim processing:

• Please include L1, L2, etc. to show line numbers related

to the details. Please include these letters after those specified below:

• EPSDT claims need to begin with the letters

“EPSDT” followed by the specific code.

• Anesthesia minutes need to begin with the letters

“ANES” followed by the specific times.

• Corrected claims need to begin with the letters

From MM DD YY To MM DD YY 1 DATE(S) OF SERVICE PLACE OF SERVICE

PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances)

CPT/HCPCS MODIFIER DIAGNOSIS 24. A. B. C. D. EMG N400074202302 KETORLAC 15MG/ML SYRING N4 qualifier 11-digit NDC number

Drug name and strength

NDC unit qualifier NDC quantity

ML2 J1885 10 15 12 11 15 12 11

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Claim Form Field Requirements | CMS 1500 Claim Form Required Fields | 11

RPC followed by the details of the original claim (as per contract instructions).

• DME claims requiring specific instructions should

begin with DME followed by specific details.

EDI CMS 1500 Other Instructions

EDI – Field 33b (Professional)

• Field 33b – Other ID# - Professional: 2310B loop, REF01=G2, REF02+ Plan’s Provider Network Number.

• This field holds less than 13 Digits - Alphanumeric.

• Field is required.

• Note: Do not send the provider on the 2400 loop. This loop is not used in determining the provider ID on the claims.

EDI – Field 45 and 51 (Institutional)

• Field 45 – Service Date must not be earlier than the claim statement date.

• Service Line Loop 2400, DTP*472.

• Claim statement date Loop 2300, DTP*434.

• Field 51 – Health Plan ID – the number used by the

health plan to identify itself.

• Select Health Plan EDI Payer ID# is 23285.

EDI – Reporting DME

• DME claims requiring specific instructions should

begin with DME followed by specific details.

• Example: NTE*ADD*DME AEROSOL MASK, USED

W/DME NEBULIZER.

EDI CMS 1500 National Drug Codes (NDC)

The NDC is used to report prescribed drugs and biologics

when required by government regulation or as deemed by the provider to enhance claim reporting/adjudication processes. Continue to report NDC in the LIN segment of Loop ID-2410. This segment is used to specify billing/ reporting for drugs provided that may be part of the service(s) described in SV1.

• When LIN02 equals N4, LIN03 contains the NDC

number. This number should be sent with no hyphens

and should be 11 digits. Submit one occurrence of the

LIN segment per claim line. Claims requiring multiple NDC’s sent at claim line level should be submitted using

CMS 1500 or UB-04 paper claim.

• When submitting NDC in the LIN segment, the CTP

segment is requested. This segment is to be submitted with the unit of measure and the quantity.

• When submitting this segment, CTP03 (pricing), CTP04

(quantity) and CTP05 (unit of measure) are required.

EDI claims with NDC information should be sent using the 2410 loop line segment. Please consult your EDI vendor if not submitting in X12 format for details on where to submit the NDC number to meet this specification.

Corrected CMS 1500 claims via EDI

• Use “6” for adjustment of prior claims or “7” for

replacement of a prior claim utilizing bill type in loop 2300, CLM05-03 (837P).

• Include the original claim number in segment REF01=F8

and REF02=the 13 digit original claim number; no dashes or spaces.

Do include the plan’s claim number to submit your

claim with the 6 or 7.

Do use this indicator for claims that were previously

processed (approved or denied).

Do not use this indicator for claims that contained

errors and were not processed (rejected upfront).

Do not submit corrected claims electronically and via

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Required Fields (UB-04 Claim Forms)

UB-04 Claim Form Required Fields

Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X

Outpatient, Bill Types 13X, 23X, 33X, 83X

Field # Field Description Instructions and Comments Conditional*Required or Conditional*Required or

1 UNLABELED FIELDProvider name, address and telephone number

Line a: complete provider name

Line b: complete address or post office number Line c: city, state and zip code

Line d: area code and telephone number

R R

2 UNLABELED FIELDPay-To name, address and secondary ID fields

Enter the Remit address. Billing provider’s designated pay-to

address. R R

3a PATIENT CONTROL NO. Provider’s patient account/control number. R R

3b MEDICAL RECORD NO. Enter the patient’s medial or health record number. Not required Not required

4 TYPE OF BILL

Enter the appropriate three- or four-digit code.

• 1st position indicates lead zero (do not include the lead zero on electronic claims).

• 2nd position indicates type of facility.

• 3rd position indicates type of care.

• 4th position indicates billing sequence.

R R

5 FED. TAX NO. Enter the number assigned by the federal government for tax reporting purposes. R R

6 STATEMENT COVERS PERIOD FROM/THROUGH Enter dates for the full range of services being invoiced.(Format: MMDDYY) R R

7 UNLABELD FIELD No entry required. Not required Not required

8a PATIENT IDENTIFIER Report only if number is different from the patient’s Medicaid ID in Field 60. C C

8b PATIENT NAME

Patient’s last name, first name and middle initial as it appears on

the health plan ID card. Use a comma or space to separate the

last and first names.

Titles: (Mr., Mrs., etc.) should not be reported in this field.

Prefix: No space should be left after the prefix of a name (e.g. McKendrick).

Hyphenated names: Both names should be capitalized and

separated by a hyphen (no space).

Suffix: A space should separate a last name and suffix.

Newborn claims: If the baby has not been named, insert “girl”

or “boy” in front of the mother’s last name. Verify that the appropriate last name is recorded for the mother and baby.

R R

9a-e PATIENT ADDRESS

The mailing address of the patient:

Street address

City

State ZIP code

Country code (report if other than USA)

R R

10 PATIENT DATE OF BIRTH The patient’s birth date in “MMDDYYYY” format. R R

11 PATIENT’S SEX

The sex of the patient recorded at admission, outpatient service

of start of care. M – male F – female U – unknown R R ADMISSION 12-15

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Claim Form Field Requirements | Required Fields (UB-04 Claim Forms) | 13

UB-04 Claim Form Required Fields

Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X

Outpatient, Bill Types 13X, 23X, 33X, 83X

Field # Field Description Instructions and Comments Conditional*Required or Conditional*Required or 12 ADMISSION/START OF CARE

DATE The start date for this episode of care. For inpatient this is the actual admission date of the patient. (Format: MMDDYY) R R

13 ADMISSION HOUR Code referring to the hour during which the patient was admitted for inpatient or outpatient care. R R

14 ADMISSION TYPE Code indicating the priority of this admission/visit. R Not required

15 SOURCE OF REFERRAL FOR ADMISSION OR VISIT (SRC)

Code indicating the source of the referral for this admission or

visit. R Not required

16 DISCHARGE HOUR (DHR) Code indicating the discharge hour of the patient from inpatient care. R R

17 DISCHARGE STATUS (STAT) A code indicating the disposition or discharge status of the patient at the end service for the period covered on this bill, as

reported in Field 6. R R

18-28 CONDITION CODES A code used to identify conditions or events relating to this bill that may affect processing. If more than one code applies, list in

numerical order. C C

29 ACCIDENT STATE When services reported on the claim are related to an auto accident, the two-digit state abbreviation where the accident

occurred must be entered. C C

30 UNLABELED FIELD 31-34 OCCURRENCE CODES AND DATES 31-34 a-b

Enter the code and associated date defining significant event relating to this bill. If only one code and date are used, they

must be entered in Field 31a, b. If more than one code and date

are used, they must be entered in Fields 31a, b through 34 a, b in alphanumeric sequence using the “MMDDYY” format.

C C

35-36 OCCURRENCE SPAN CODES AND DATES 35-36a-b Code and the related dates that identify an event that relates to the payment of the claim. C C 37a-b UNLABELED FIELD REQUIRED number of the original claim. for resubmissions or adjustments. Enter the claim C C

38 UNLABELED FIELD Responsible party name and address. C C

39-41 VALUE CODES 39-41 a-d

Code structure to relate amounts or values to identify data elements necessary to process this claim by the payer.

If more than one value code applies, list in alphanumeric order.

Reporting birth weight - If reporting abnormal birth weight through use of Value Codes, populate fields 39, 40, 41 a, b, c, d – Value

Codes and Amounts. Use Value Code 54 and report the birth weight in grams.

C C

42 REV.CD. Revenue Code – Codes that identify specific accommodations, services and items furnished to the patient in your facility. R R

43 DESCRIPTION Revenue code narrative description of the related revenue categories. Abbreviations may be used. R R

44 HCPCS/RATES/HIPPS CODE Enter the applicable rate, CPT, HCPCS or HIPPS code and modifier based on the bill type of inpatient or outpatient. R R

45 SERV. DATE Report line item dates of service for each revenue code or CPT, HCPCS/HIPPS code. R R

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UB-04 Claim Form Required Fields

Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X

Outpatient, Bill Types 13X, 23X, 33X, 83X

Field # Field Description Instructions and Comments Conditional*Required or Conditional*Required or

46 SERV. UNITS

Report units of service to include items such as number of

accommodation days, miles, pints of blood, renal dialysis days,

etc.

Observations - Report OBS as one unit per 24 hour period up to

72 hours.

R R

47 TOTAL CHARGES Report grand total of submitted charges. R R

48 NON-COVERED CHARGES To reflect the non-covered charges for the destination payer as it pertains to the related revenue code. Required when Medicare

is primary. C C

49 UNLABELED FIELD Not Required Not Required

50 PAYER NAME Enter the name for each payer being invoiced. When the patient has other coverage, list the payers as indicated below. Line A

refers to the primary payer, B is secondary and C is tertiary. R R

51 HEALTH PLAN ID The number used by the health plan to identify itself. Select Health’s payer ID is 23285. R R

52 REL. INFO

Release of information certification indicator. This field is required on paper and electronic invoices. Line A refers to the primary payer, B to the secondary and C to the tertiary. It is expected the provider has all necessary release information on file. It is expected all released invoices contain “Y.”

R R

53 ASG. BEN. Valid entries are “Y” (yes) and “N” (no). R R

54 PRIOR PAYMENTS The A, B, C indicators refer to the information in Field 50. C C

55 EST. AMOUNT DUE Enter the estimated amount due (the difference between “total charges” and any deductions such as other coverage). C C

56 NATIONAL PROVIDER IDENTIFIER – BILLING PROVIDER

The unique identification number assigned to the provider

submitting the bill. NPI is the National Provider Identifier. R R

57a-c OTHER (BILLING) PROVIDER IDENTIFIER A unique identification number assigned to the provider submitting the bill by the health plan. Report the facility ID

number assigned by the health plan. C C

58 INSURED’S NAME Information refers to the payers listed in Field 50. In most cases, this will be the patient name. When other coverage is available,

the insured is indicated here. R R

59 P. REL Enter the patient’s relationship to insured. For Medicaid programs, the patient is the insured. (Code 01: Patient is insured). R R

60 INSURED’S UNIQUE IDENTIFIER

Enter the patient’s health plan ID exactly as it appears on the patient’s ID card on the same lettered line (a, b or c) that corresponds to the line on which the Select Health payer information was shown in Fields 50-51. When other insurance is

present, enter that plan ID on line A.

R R

61 GROUP NAME Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line

A refers to the primary payer, B to secondary and C to tertiary. C C

62 INSURANCE GROUP NO. Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage.

Line A refers to the primary payer, B to secondary and C to tertiary. C C

63 TREATMENT AUTHORIZATION CODES Enter the health plan referral or authorization number. Line A refers to the primary payer, B to secondary and C to tertiary. R R

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Claim Form Field Requirements | Required Fields (UB-04 Claim Forms) | 15

UB-04 Claim Form Required Fields

Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X

Outpatient, Bill Types 13X, 23X, 33X, 83X

Field # Field Description Instructions and Comments Conditional*Required or Conditional*Required or

64 DCN

Document Control Number - New field. The control number (claim number) assigned to the original bill by the health plan as part of their internal control. Previously, 64 contained the Employment Status Code (ESC). The ESC field has been

eliminated. Note: Resubmitted claims must contain the original

claim ID.

C C

65 EMPLOYER NAME

The name of the employer that provides health care coverage for the insured individual identified in Field 58. Required when the employer if the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer, B to secondary and C to tertiary.

C C

66 DIAGNOSIS AND PROCEDURE CODE QUALIFIER The qualifier that denotes the version of International Classification of Diseases (ICD) reported. Qualifier codes: ICD:

9 –Ninth revision, 0 – Tenth revision. Not required Not required

67 PRINCIPAL DIAGNOSIS CODE and PRESENT ON ADMISSION INDICATOR (POA)

Enter the complete ICD diagnosis code; the condition

established after study to be chiefly responsible for causing the admission of the patient for care. Include the 4th and 5th digits

if applicable. Each diagnosis code must be valid for the date of service.

Present on Admission is defined as present at the time the order

for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department,

are considered as present on admission. The POA Indicator

is applied to the principal diagnosis as well as all secondary

diagnoses that are reported.

R R

67a-q Other Diagnosis Codes

The ICD diagnoses codes corresponding to all conditions that coexist at the time of admission, develop subsequently or affect the treatment received and/or the length of stay. Exclude

diagnoses that relate to an earlier episode, which have no

bearing on the current hospital stay.

C C

68 UNLABELD FIELD

69 ADMITTING DIAGNOSIS CODE Enter the complete ICD diagnosis code, include the 4th and 5th digits if applicable, which describe the patient’s diagnosis at

admission. R R

70 PATIENT’S REASON FOR VISIT

Enter the complete ICD diagnosis code describing the patient’s reason for visit at the time of outpatient registration. Include

the 4th and 5th digits if applicable.

Required for all unscheduled outpatient visits. Up to three ICD codes may be entered in Fields a, b, c.

C C

71 PROSPECTIVE PAYMENT SYSTEM (PPS) CODE

The PPS codes assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. Required when the health plan/provider contract requires this information. Up to four digits.

C C

72a-c EXTERNAL CAUSE OF INJURY (ECI) CODE

The ICD diagnosis codes pertaining to external cause of

injuries, poisoning or adverse effect. External cause of injury “E” diagnosis codes should not be billed as primary and/or admitting diagnosis.

C C

73 UNLABELD FIELD

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UB-04 Claim Form Required Fields

Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X

Outpatient, Bill Types 13X, 23X, 33X, 83X

Field # Field Description Instructions and Comments Conditional*Required or Conditional*Required or

74 PRINCIPAL PROCEDURE CODE AND DATE

The ICD code that identifies the principal procedure performed at the claim level during the period covered by this bill and the

corresponding date.

Inpatient facility – ICD is required when a surgical procedure is

performed.

Outpatient facility or Ambulatory Surgical Center – PT, HCPCS

or ICD is required when a surgical procedure is performed.

C

R

C

R

74a-e OTHER PROCEDURE CODES AND DATES

The ICD codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on

which the procedures were performed.

Inpatient facility – ICD is required when a surgical procedure is

performed.

Outpatient facility or Ambulatory Surgical Center – CPT, HCPCS

or ICD is required when a surgical procedure is performed.

C C C C 75 UNLABELD FIELD 76

ATTENDING PROVIDER NAME AND IDENTIFIERS

NPI#/QUALIFIER/OTHER ID#

Enter the NPI of the physician who has primary responsibility for the patient’s medical care or treatment in the upper line and their name in the lower line, last name first. If the attending physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the attending physician.

R R

77

OPERATING PHYSICIAN NAME AND IDENTIFIERS

NPI#/QUALIFIER/OTHER ID#

Enter the NPI of the physician who performed surgery on the patient in the upper line and their name in the lower line, last name first. If the operating physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the attending physician. Required when a surgical procedure code

is listed.

R R

78-79 OTHER PROVIDER (INDIVIDUAL) NAMES AND IDENTIFIERS NPI#/QUALIFIER/OTHER ID#

Enter the NPI# of any physician, other than the attending physician, who has responsibility for the patient’s medical care or treatment in the upper line and his/her name in the lower line, last name first. If the other physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#.

C C

80 REMARKS FIELD Area to capture additional information necessary to adjudicate the claim. C C

81CC

a-d TAXONOMY CODE

If an NPI number is entered in Field 56 and the provider‘s NPI

number is mapped to a taxonomy code, enter qualifying code B3 for Taxonomy code and enter the 10-digit Taxonomy code for

the rendering provider.

C C

*Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided.

NDC on UB-04

• NDC should be entered in Form Locator 43 in the Revenue Description Field.

• Report the N4 qualifier in the first two positions, left-justified.

• Do not enter spaces.

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Claim Form Field Requirements | Submission of POA Indicators for Primary and Secondary Diagnoses | 17

• Do not use 99999999999 for a compound

medication. Bill each drug as a separate line item

with its appropriate NDC.

• Immediately following the last digit of the NDC (no

delimiter), enter the Unit of Measurement Qualifier.

• F2 – International Unit

• GR – Gram • ML – Milliliter • UN – Unit

• Immediately following the Unit of Measure Qualifier,

enter the unit quantity with a floating decimal for fractional units limited to three digits (to the right of the decimal).

• Any unused spaces for the quantity are left blank.

Note that the decision to make all data elements left-justified was made to accommodate the largest quantity possible. The description field on the UB-04 is 24 characters in length. An example of the methodology is

illustrated below:

N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 4 5 . 5 6 7

Submission of POA Indicators for Primary

and Secondary Diagnoses

General POA Requirements

• POA Indicator reporting is mandatory for all claims

involving inpatient admissions to general acute care hospitals or other facilities.

• POA is defined as present at the time the order for

inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are

considered POA.

• A POA Indicator must be assigned to principal and

secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an “other diagnosis.”

• Issues related to inconsistent, missing, conflicting

or unclear documentation must be resolved by the

provider.

• If a condition would not be coded and reported based

on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, the POA Indicator

would not be reported.

POA Indicators are as follows, blanks are not

acceptable:

• “Y” = Yes = present at the time of inpatient admission.

• “N” = No = not present at the time of inpatient

admission.

• “U” = Unknown = documentation is insufficient to

determine if condition was present at time of inpatient

admission.

• “W” = Clinically Undetermined = provider is unable to

clinically determine whether condition was present at time of inpatient admission or not.

• “1” = Exempt from POA reporting.

POA Coding

• Use the UB-04 Data Specifications Manual and the ICD

Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each “principal” diagnosis and “other” ICD diagnosis codes reported on the UB-04 and ASC X12N 837 Institutional (837I).

• Hospitals reporting with the 5010 format will no longer

report a POA Indicator of “1” for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting.

Reporting POA on the UB-04 Claim Form

• Fields 67 A – Q: valid primary and secondary diag

-nosis codes (up to five digits) are to be placed in the unshaded portion of 67 A – Q, followed by the applicable POA Indicator (one character) in the shaded portion of 67 A – Q.

Sample UB-04 populated with primary and secondary

diagnosis codes and POA indicators:

DX

A

B

C

D

I

J

K

L

M

a

b

c

66

67

69 ADMIT 70 PATIENT DX REASON DX 71 CODEPPS 2449 Y25001 N29620 UV1581 W FL 67 Primary Diagnosis Code FL 67 A-Q Secondary Diagnosis Codes FL 67 POA FL 67 A-Q POA

Reporting POA in Electronic 837I Format

The provider is to submit their POA data via the K3

segment on all 837I claims, (004010X096A1).

• Although this segment can repeat, the plan requires the

provider to submit POA data on a single K3 segment.

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validated.

• K301 must contain POA as the first three characters or

the POA data will not be picked up. K3*POA~

• K3 segment must only contain details pertaining to the

Principal and Other Diagnosis found in the HI segment

with qualifiers BK for Principal and BF for Other Diagnosis prior to the ending Z (or X).

• The POA Indicator for the BN – External Cause of Injury

on the K3 segment with POA is entered following

the ending Z (or X). This is required by Emdeon for

Medicare claims as well.

• No POA Indicator is to be sent for the BJ/ZZ – Admitting

Diagnosis Data. Following the letters POA in the K3 segment is to be only those identified on the Medicare Bulletin. 1, Y, N, U, W are valid, with ending characters of X or Z and E-Code indicator.

POA Indicator Example:

POA Indicators for an electronic claim with one principal

and five secondary diagnoses should be coded as:

K3*POAYNUW1YZ.POA

Y The principal diagnosis is always the first indicator after “POA.” In this example, the principal diagnosis was present on

admission.

N The first secondary diagnosis was not present on admission, designated by “N.” U It was unknown if the second secondary diagnosis was present on admission, designated by “U.”

W It is clinically undetermined if the third secondary diagnosis was present on admission, designated by “W.”

1

The fourth secondary diagnosis was exempt from reporting for POA, designated by “1.”

NOTE: Hospitals reporting with the 5010 format on and after Jan. 1, 2011, will no longer report a POA indicator of “1” for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting.

Y The fifth secondary diagnosis was present on admission, designated by “Y.”

Z The last secondary diagnosis indicator is followed by the letter “Z” to indicate the end.

The next table outlines the payment implications for each of the different POA Indicators.

CMS POA Indicator Options and Definitions

Code Reason for Code

Y

Diagnosis was present at time of inpatient admission. CMS will pay the complicating condition/major complicating condition (CC/MCC) DRG for those selected Hospital Acquired Conditions (HACs) that are coded as “Y” for the POA Indicator.

N Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “N” for the POA Indicator.

U

Documentation insufficient to determine if the condition was present at the time of inpatient admission.

CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “U” for the POA.

W

Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

CMS will pay the CC/MCC DRG for those selected HACs that are coded as “W” for the POA Indicator.

1

Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A.

CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “1” for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list.

Key Points:

• IPPS hospitals will no longer report the POA Indicator of 1.

• ICD-CM diagnosis codes that are exempt from the POA

reporting requirement should be left ‘blank’ instead of populating a 1.

• In addition, the K3 segment, which was required for

reporting POA in the 4010A1 version of the 837I, is no

longer used to report POA.

• For 5010 the POA indicators will instead follow the diagnosis code in the appropriate 2300 HI segment.

All Patient Refined Diagnosis Related Groups

(APR-DRG)

Effective with dates of service Jan. 1, 2012, Select Health moved to the “All Patient Refined Diagnosis Related

Groups” (APR-DRGs) method of paying for hospital inpa

-tient services.

The goals of the APR-DRGs payment are to employ a methodology that is sustainable and more appropriate to

Medicaid using a modern DRG algorithm, which enables

reduced payment for hospital-acquired conditions and simplifies the current payment method.

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Claim Form Field Requirements | Common Causes of Claim Processing Delays, Rejections or Denials | 19

APR-DRGs version 28 replaced the current 3M grouper

version 24.

APR-DRGs is a classification system that classifies patients

according to:

• Reason for admission.

• Severity of illness (SOI).

APR-DRGs grouping process:

• SOI is used for payment calculation.

• Dependent on patient diagnosis and procedures.

• Severity levels define the degree of illness a patient is

experiencing.

• Payment is adjusted to appropriately reimburse hospi

-tals at a higher level for treating sicker patients. This payment method will apply to general acute care hospitals (including distinct-part units of general hospitals

both inside South Carolina and out of state.

Payment methods for inpatient services provided by free-standing long-term psychiatric facilities and residential treatment facilities are unaffected.

Birth Weight

With the implementation of the APR-DRGs payment methodology, Select Health must ensure we are reporting

the appropriate encounter data for abnormal birth

weights; therefore, we are requesting providers bill as

follows:

• Please use ICD CM code ranges V21.30-V21.35 or 764 –

765.1 as appropriate and/or

• Birth weight can be reported through use of Value Code

54 followed by the actual birth weight in grams

• Birth weight must be numeric.

• Birth weight must be a whole number without decimal points.

• Birth weight cannot be greater than four numeric

characters (9999).

Birth Weight Billing Examples

UB-04 Paper claim

If reporting abnormal birth weight through the use of the applicable ICD code, populate field 67.

If reporting abnormal birth weight through use of value codes, populate fields 39, 40, 41 a, b, c, d – value codes

and Amounts. Use value code 54 – newborn birth weight in grams.

Electronic Billing

If billing electronically in addition to reporting the diag

-nosis code, please report abnormal birth weight in loop

2300, segment HI, with the qualifier BE and value code

54 in HI01-2 and the newborn’s weight in grams in the

monetary amount field - HI01-5.

Common Causes of Claim Processing Delays,

Rejections or Denials

Authorizations or Referral Number Invalid or Missing A

valid authorization number must be included on the claim form for all services requiring prior authorization.

Attending Physician ID Missing or Invalid Inpatient claims

must include the name of the physician who has primary responsibility for the patient’s care or treatment and the medical license number in the appropriate field (76) on the

UB-04 claim form. Medical license number formats are:

2 alpha, 6 numeric, 1 alpha (AANNNNNNA) or 2 alpha, 6 numeric characters (AANNNNNN).

Billed Charges Missing or Incomplete A billed charge

amount must be included for each service/procedure/ supply on the claim form.

Diagnosis Code Missing 4th or 5th Digit Precise

coding sequences must be used to accurately complete

processing. Review the ICD-CM manual for the fourth- and

fifth-digit extensions. The Ö4th or Ö5th symbol in the manual determines when additional digits are required. Diagnosis, Procedure or Modifier Codes Invalid or Missing

Coding From the most current coding manuals (ICD-CM,

CPT or HCPCS) or appropriate unique coding is required to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed.

DRG Codes Missing or Invalid Hospitals contracted for

payment based on DRG codes should include this informa

-tion on the claim form.

EOBs (Explanation of Benefits) from Primary Insurers

DX A B C D I J K L M a b c 66 67 69 ADMIT 70 PATIENT DX REASON DX 71 PPSCODE 764.08 a b c d

VALUE CODES VALUE CODES VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT

39 40 41

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Missing or Incomplete A copy of the EOB from all third-party insurers must be submitted with the original claim form. Include pages with run dates, coding explanations

and messages.

EPSDT Information Missing or Incomplete EPSDT

informa-tion should be billed in accordance with the South Carolina

Medicaid Physician Provider Manual. Immunization admin

-istration, topical fluoride varnish, laboratory tests, blood level assessments, age limited screenings and elective tests are covered separately utilizing the appropriate CPT code and billed according to the periodicity schedule. EPSDT services may be submitted electronically or on paper. The administration CPT codes 90471 – 90474 are covered for the administration of vaccines provided through the VFC program for beneficiaries age 19 and older. For the administration of vaccines by injection, the following CPT

codes must be used:

90471 – Immunization administration – This code will

only cover the first vaccine administered.

90472 – Each additional vaccine – List separately in

addition to code for primary procedure.

Note: Use code 90472 in conjunction with code 90471.

This code can only be billed twice per visit, regardless of how many additional vaccines are administered at the time

of the visit.

For the administration of the FluMIST® or PRV by intranasal

or oral, the following CPT codes must be used:

90473 – Immunization administrations by intranasal

or oral, one vaccine. This code will only cover the first

vaccine administered per visit.

90474 – Each additional intranasal or oral vaccine.

For members under 19 years of age, you must use the new administration codes:

90460 – Immunization administration through 18 years

of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component (one unit per date of service).

90461 – Each additional vaccine/toxoid component

(two units per date of service).

CPT advises to bill these codes based on the number of

components. At this time, SCDHHS will continue to use these codes per admin istration of each vaccine/toxoid and

not per compo nent for the VFC program.

The administration of VFC vaccines is limited to a

maximum of three units per date of service regard less of

the number of additional vaccines adminis tered.

Include all primary and secondary diagnosis codes on the claim.

Missing or invalid data elements or incomplete claim forms will cause claim-processing delays, inaccurate payments, rejections or denials.

Regardless of whether reimbursement is expected, the billed amount of the service must be documented on the claim. Missing charges will result in rejections or denials.

All billed codes must be complete and valid for the time period in which the service is rendered. Incomplete, discontinued or invalid code will result in claim rejections or denials.

State-level HCPCS coding takes precedence over national level codes unless otherwise specified in individual provider contracts.

The services billed on the claim form should exactly match the services and charges detailed on the accompanying EOB. If the EOB charges appear different due to global coding requirements of the primary insurer, submit claim with the appropriate coding, which matches the total charges on the EOB.

Secondary claims can also be submitted electronically.

Refer to the section entitled “Submitting Secondary Claims Electronically.”

EPSDT Coding Tips

• Modifiers 01 and 02 are not required for EPSDT claim

submission to First Choice.

• Primary care physicians can bill for topical fluoride

varnish treatments, CPT code D1206 as part of the EPSDT exam.

• Claims for VFC vaccine administration must include:

• The appropriate vaccination product (toxoid) CPT

code.

• The appropriate vaccination administration code

for this code combination, only the adminis tration

code will be reimbursable.

• When billing First Choice, Federally Qualified Health

Centers (FQHCs) and Rural Health Centers (RHCs) must also submit CPT codes for the vaccination products.

• When billing for vaccines not covered under the VFC

program or for beneficiaries over the age of 19, the provider may bill for the vaccine and the administration code 96372.

References

Related documents

Please enclose originals of all receipts, medical prescriptions, medical or hospital invoices or any other documents proving the costs sustained (in the event of partial refund

• If this is a new claim, complete ALL PARTS of the Claim Form. If treatment was received in the United States you do not need to complete PART C. If treatment was received outside

I authorise any licensed doctor, practitioner of the healing art, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group

I authorise any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group

48 NAME, ADDRESS, CITY, STATE, ZIP CODE – Enter the billing provider service location Name, Address, City, State, and nine-digit ZIP Code. 49 NPI – Enter the billing or

All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, Primary Care Physician [PCP]

For more instructions and information about claims submission, providers and their staff are encouraged to refer to the paper claim instructions on how to complete this form

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date.. Details of diagnosis of the illness / Details of injury including nature and extent of