AmeriHealth Connect. Claim Filing Instructions

Transcription

1 AmeriHealth onnect laim Filing Instructions

2

3 NOTES

4 AmeriHealth onnect Table of ontents Section Title Page # laim Filing 1 Procedures for laim Submission 1 laim Mailing Instructions 2 laim Filing Deadlines 2 Exceptions 2 efunds for laims Overpayment 2 laim Form Field equirements 5 equired Fields (MS 1500 laim Form) 5 Professional laims EDI Mapping 14 equired Fields (UB-04 laim Form) 20 Institutional laims EDI Mapping 31 Instructions & Examples of Supplemental Information 39 eporting Supplemental Info on laims 39 eporting ND on Professional laims 40 eporting ND on Institutional laims 41 eporting POA on Institutional laims 43 ommon auses of laim Processing Delays, ejections, or Denials 47 Electronic Data Interchange (EDI) 50 Procedures for Electronic Submission 51 Hardware and Software equirements 51 ontracting with Emdeon and Other Electronic Vendors 51 ontacting the EDI Technical Support Group 51 Specific Data ecord equirements 52 Electronic laim Flow Description 52 Invalid Electronic laim ecord ejections/denials 54 Plan Specific Electronic Edit equirements 54 Exclusions 54 ommon ejections 55 esubmitted Professional orrected laims 55 Electronic Billing Inquiries 57 Tips for Accurate Diagnosis oding 58

5 Table of ontents Section Title Page # Appendix Supplemental Information 60 Ambulance 61 Anesthesia 62 Audiology 62 hemotherapy 62 hiropractic are 62 Dialysis 62 DME 62 Family Planning 63 Home Health are 66 Infusion Therapy 66 Injectable Drugs 66 Maternity 66 Multiple Surgery eduction Payment Policy 66 Physical Occupational and Speech Therapy 67 Termination of Pregnancy 67

6 laim Filing Procedures for laim Submission AmeriHealth onnect, hereafter referred to as the Plan, is required by State and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims. When required data elements are missing or are invalid, claims will be rejected by the Plan for correction and re-submission. laims for billable and capitated services provided to Plan members must be submitted by the provider who performed the services. laims filed with the Plan are subject to the following procedures: Verification that all required fields are completed on the MS 1500 or UB-04 forms. Verification that all Diagnosis and Procedure odes are valid for the date of service. Verification for electronic claims against 837 edits at Emdeon Verification of the referral for Specialist or non-primary are Physician claims. 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 participating provider or that the out of plan provider has received authorization to provide services to the eligible member. Verification that the provider participated with the Medical Assistance Program at the time of service. IMPOTANT: ejected claims are defined as claims with invalid or required missing data elements, such as the provider tax identification number, member ID number, that are returned to the provider or EDI* source without registration in the claim processing system. ejected claims are not registered in the claim processing system and can be resubmitted as a new claim. 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. Denied claims must be resubmitted as corrected claims within 365 calendar days from the date of service. Note: These requirements apply to claims submitted on paper or electronically. * For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital laims in this booklet. 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 that the Plan is the payer of last resort on all claims submitted to the Plan. laim Mailing Instructions * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 1 Provider Services

7 Submit claims to AmeriHealth onnect at the following address: AmeriHealth onnect laim Processing Department P.O. Box 7851 London, KY The Plan encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon s Provider Support Line at to arrange transmission. Any additional questions may be directed to the EDI Technical Support Hotline at or by at edi@amerihealthcaritaspa.com laim 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. e-submission of previously denied claims with corrections and requests for adjustments must be submitted within 365 calendar days from the date services were rendered or compensable items were provided. Exceptions laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer s EOB. Important: laims originally rejected for missing or invalid data elements must be corrected and re-submitted within 180 calendar days from the date of service. ejected claims are not registered as received in the claim processing system. (efer to the definitions of rejected and denied claims on page 1.) efunds for laims Overpayments or Errors AmeriHealth onnect and the Pennsylvania Department of Public Welfare 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 that it has received overpayments or improper payments, the provider is required to make (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: laims Processing Department AmeriHealth onnect P.O. Box 7851 London, KY Outpatient medical appeals must be submitted in writing to: Provider Appeals Department AmeriHealth onnect PO Box 7853 London, KY Inpatient medical appeals must be submitted in writing to: Provider Appeals Department AmeriHealth onnect PO Box 7852 London, KY Written Disputes should be mailed to: Informal Practitioner Dispute AmeriHealth onnect P.O. Box 7851 London, KY efer to the Provider Manual or look online at the Provider enter of the AmeriHealth onnect website at wwww.amerihealthconnectpa.com for complete instructions on submitting appeals. Note: AmeriHealth onnect EDI Payer ID# Important: equests for adjustments may be submitted by telephone to: Provider laim Services * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 2 Provider Services

8 M 1500 laim Form Field equirements immediate arrangements to return the funds to AmeriHealth onnect or follow the DPW protocol for returning improper payments or overpayment. A. ontact AmeriHealth onnect Provider laim Services at to arrange the repayment. There are two ways to return overpayments to AmeriHealth onnect: 1. Have AmeriHealth onnect deduct the overpayment/improper payment amount from future claims payments. 2. Submit a check for the overpayment/improper payment amount directly to: laims Processing Department AmeriHealth onnect PO Box 7851 London, KY Note: Please include the member s name and ID, date of service, and laim ID B. Providers may follow the Pennsylvania Medical Assistance (MA) Provider Selfaudit Protocol to return improper payments or overpayments. Access the DPW voluntary protocol process via the following link: DPW Provider Self Audit Protocol * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 3 Provider Services

9 M 1500 laim Form Field equirements laim Form Field equirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 4 Provider Services

10 M 1500 laim Form Field equirements The following charts describe the required fields that must be completed for the standard enters for Medicare and Medicaid Services (MS) MS 1500 or UB-04 claim forms. If the field is required without exception, an (equired) is noted in the equired or onditional box. If completing the field is dependent upon certain circumstances, the requirement is listed as (onditional) and the relevant conditions are explained in the Instructions and omments box. The MS 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 180 days from the date of service. Although the following examples of claim filing requirements refer to paper claim forms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic or paper). equired Fields (MS 1500 laim Form) MS 1500 laim Form Field # Field Description 1 Insurance Program Identification Instructions and omments heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. equired or onditional* 1a Insured I.D. Number Health Plan s member identification number. If submitting a claim for a newborn that does not have an identification number, enter the mother s ID number. For electronic submissions, ID must be less than 13 alphanumeric characters. In-network providers: please omit the three alpha characters preceding the member s ID number on the claim. Out of area providers: please enter the three alpha characters preceding the member s ID number on the claim. 2 Patient s Name (Last, First, Middle Initial) 3 Patient s Birth Date / Sex Enter the patient s name as it appears on the member s Health Plan I.D. card. If submitting a claim for a newborn that does not have an identification number, enter Baby Girl or Baby Boy and last name. efer to page 22 for additional newborn billing information, including Multiple Births. MMDDYY / M or F If submitting a claim for a newborn, enter newborn and DOB/Sex 4 Insured s Name (Last, First, Middle Initial) 5 Patient s Address (Number, Street, ity, State, Zip) Telephone Enter the patient s name as it appears on the member s Health Plan I.D. card, or Enter the newborn s name when the patient is a newborn. Enter the patient s complete address and telephone number. (Do not punctuate the address or phone number.) * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 5 Provider Services

11 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description (include area code) 6 Patient elationship To Insured 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) 8 eserved for NU use 9 Other Insured's Name (Last, First, Middle Initial) 9a Other Insured's Policy Or Group # 9b eserved for NU use 9c eserved for NU use 9d Insurance Plan Name Or Program Name 10a,b,c Is Patient's ondition elated To: Always indicate self. Instructions and omments efers to someone other than the patient. ompletion of fields 9a through 9d is equired if patient is covered by another insurance plan. Enter the complete name of the insured. Note: "OB claims that require attached EOBs must be submitted on paper. equired if # 9 is completed. equired if # 9 is completed. Indicate Yes or No for each category. Is condition related to: a) Employment b) Auto Accident c) Other Accident equired or onditional* Not equired Not equired Not equired 10d laim odes (Designated by NU) To comply with DPW s EPSDT reporting requirements, continue to use this field to report EPSDT referral codes, as follows; YD Dental (equired for Age 3 and above) YO Other YV Vision YH Hearing YB Behavioral YM - Medical * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 6 Provider Services

12 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* For all other claims enter new ondition odes as appropriate. Available 2-digit ondition odes include nine codes for abortion services and four codes for worker s compensation. Please refer to NU for the complete list of codes. Examples include: 11 Insured's Policy Group Or FEA # 11a Insured's Birth 11b AD Abortion Performed due to a Life Endangering Physical ondition aused by, Arising from or Exacerbated by the Pregnancy Itself W3 Level 1 Appeal equired when other insurance is available. omplete if more than one Other Medical insurance is available, or if yes to 10a, b, c. Same as # 3. equired if 11 is completed. Date / Sex Other laim ID Enter the following qualifier and accompanying identifier to report the claim number assigned by the payer for worker s compensation or property and casualty: Y4 Property asualty laim Number 11c Insurance Plan Name Or Program Name 11d Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature 14 Date Of urrent Illness Injury, Pregnancy (LMP) Enter qualifier to the left of the vertical, dotted line; identifier to the right of the vertical, dotted line. Enter name of Health Plan. equired if 11 is completed. Y or N by check box. If yes, complete # 9 a-d. MMDDYY or MMDDYYYY Enter applicable 3-digit qualifier to right of vertical dotted line. Qualifiers include: 431 Onset of urrent Symptoms or Illness 484 Last Menstrual Period (LMP) Not required Use the LMP for pregnancy. Example: * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 7 Provider Services

13 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 15 Other Date MMDDYY or MMDDYYYY Enter applicable 3-digit qualifier between the left-hand set of vertical dotted lines. Qualifiers include: 454 Initial Treatment 304 Latest Visit or onsultation 453 Acute Manifestation of a hronic ondition 439 Accident 455 Last X-ay 471 Prescription 090 eport Start (Assumed are Date) 091 eport End (elinquished are Date) 444 First Visit or onsultation Example: 16 Dates Patient Unable To Work In urrent Occupation 17 Name Of eferring Physician Or Other Source equired if a provider other than the member s primary care physician rendered invoiced services. Enter applicable 2-digit qualifier to left of vertical dotted line. If multiple providers are involved, enter one provider using the following priority order: 1. eferring Provider 2. Ordering Provider 3. Supervising Provider Qualifiers include: DN eferring Provider DK Ordering Provider DQ Supervising Provider Example: 17a Other I.D. Number Of eferring 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. If the Other ID number is the Health Plan ID number, enter G2. If the Other ID * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 8 Provider Services

14 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. equired or onditional* The NU defines the following qualifiers used in 5010A1: 0B State License Number 1G Provider UPIN Number G2 Provider ommercial Number LU Location Number (This qualifier is used for Supervising Provider only.) equired if # 17 is completed. 17b National Provider Identifier (NPI) 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU) 20 Outside Lab harges 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) Enter the NPI number of the referring provider, ordering provider or other source. equired if #17 is completed. equired when place of service is in-patient. MMDDYY (indicate from and to date) Enter additional claim information with identifying qualifiers as appropriate. For multiple items, enter three blank spaces before entering the next qualifier and data combination. The NU defines the following qualifiers: 0B State License Number 1G Provider UPIN Number G2 Provider ommercial Number LU Location Number (This qualifier is used for Supervising Provider only) N5 Provider Plan Network Identification Number SY Social Security Number X5 State Industrial Accident Provider Number ZZ Provider Taxonomy Enter the applicable ID indicator to identify which version of ID codes is being reported: 9 - ID-9-M 0 - ID-10-M Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Not equired Not equired Enter the codes to identify the patient s diagnosis and/or condition. List no more than 12 ID diagnosis codes. elate lines A L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 9 Provider Services

15 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments description in this field. Note: laims with invalid diagnosis codes will be denied for payment. equired or onditional* 22 esubmission ode and/or Original ef. No 23 Prior Authorization Number For resubmissions or adjustments, enter the appropriate bill frequency code (7 or 8 see below) left justified in the Submission ode section, and the laim ID# of the original claim in the Original ef. No. section of this field. Additionally, stamp resubmitted or corrected on the claim 7 eplacement of Prior laim 8 Void/cancel of Prior laim Enter the referral or authorization number. efer to the Provider Manual to determine if services rendered require an authorization or referral. 24A 24B Date(s) Of Service Place Of Service From date: MMDDYY. If the service was performed on one day leave To blank or re-enter From Date. See below for Important Note (instructions) for completing the shaded portion of field 24. Enter the MS standard place of service code. 00 for place of service is not acceptable. 24 EMG This is an emergency indicator field. Enter Y for Yes or leave blank for No in the bottom (unshaded area of the field). 24D Procedures, Procedure codes (5 digits) and modifiers (2 digits) must be valid Services Or for date of service. Supplies Note: Modifiers affecting reimbursement must be placed in the 1 st PT/HPS modifier position Modifier *See additional information below for EDI requirements 24E Diagnosis Pointer Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). Diagnosis codes must be valid ID-9 codes for the date of service, and must be entered in field 21. Do not enter diagnosis codes in 24E. 24F harges Enter charges. A value must be entered. Enter zero ($0.00) or actual charged amount. (this includes capitated services.) 24G Days Or Units Enter quantity. Value entered must be greater than or equal to zero. Blank is not acceptable. (Field allows up to 3 digits) 24H EPSDT Family Plan 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 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional Not required 10 Provider Services

16 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. equired or onditional* 0B 1G G2 LU State License Number Provider UPIN Number Provider ommercial Number Location Number If the rendering provider does have an NPI see field 24J below.. If the Other ID number is the Health Plan ID number, enter G2. 24J endering Provider ID The individual rendering the service is reported in 24J. Enter the Provider Health Plan legacy ID number in the shaded area of the field. Use Qualifier G2 for the Provider Health Plan legacy ID. See 24I for the correct qualifier for non NPI values. ecommended 25 Federal Tax I.D. Number SSN/EIN 26 Patient's Account No. 27 Accept Assignment Enter the NPI number in the unshaded area of the field. Physician or Supplier's Federal Tax ID numbers. The provider's billing account number. Always indicate Yes. efer to the back of the MS 1500 (08-05) form for the section pertaining to Medicaid Payments. 28 Total harge Enter charges. A value must be entered. Enter zero (0.00) or actual charges (this includes capitated services. Blank is not acceptable. 29 Amount Paid equired when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing the Plan. Medicaid programs are always the payers of last resort. 30 eserved for NU Use Not equired 31 Signature Of Physician Or Supplier Including Actual signature is required. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 11 Provider Services

17 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Degrees Or redentials / Date 32 Name and Address of Facility Where Services Were endered (If other than Home or Instructions and omments equired unless #33 is the same Enter the physical location. (P.O. Box # s are not acceptable here) Office) 32a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 32b. Other ID# Enter the Health Plan ID # (strongly recommended) equired or onditional* Enter the G2 qualifier followed by the Health Plan ID # The NU defines the following qualifiers: 0B State License Number G2 Provider ommercial Number LU Location Number 33 Billing Provider Info & Ph # equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. equired Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable 33a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number 33b. Other ID# Enter the Health Plan ID # (strongly recommended) Enter the G2 qualifier followed by the Health Plan ID # The NU defines the following qualifiers: 0B State License Number G2 Provider ommercial Number ZZ Provider Taxonomy equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 12 Provider Services

18 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description qualifier and number. Instructions and omments equired or onditional* * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 13 Provider Services

19 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 1 Insurance Program Identification 2000B, SB09 = I ommercial Insurance 1a Insured ID Number <Plan Name> Member s identification number 2 Patient s Name (Last, First, Middle Initial) 2010BA/NM1 Use 2330A for OB Data 2010BA/NM1 New Born (2010A/NM1) 2010A/NM1 2010A/NM1 3 Patient s Birth Date/Sex 2010BA/DMG 2010A/DMG - Newborn 4 Insured s Name (Last, First, Middle Initial) 2010BA/NM1 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (Include Area ode) 2010A/N3/N4 6 Patient elationship To Insured 2000/PAT01 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) Us 2330A for OB data 8 eserved for NU use Blank N 9 Other Insured's Name (Last, First, Middle Initial) 2330A/NM1 9a Other Insured's Policy Or Group # 2320/SB N 9b eserved for NU use Not in IG N 9c eserved for NU use Not in IG N 9d Insurance Plan Name Or Program Name 2330 NM1 10d laim odes (Designated by NU) Not in IG * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 14 Provider Services

20 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 11 Insured's Policy Group Or FEA # 2300/PWK 2000B/SB 11a Insured's Birth Date / Sex 2010BA/DMG A/DMG02 11b Other laim ID Not in IG 11c 11d Insurance Plan Name Or Program Name Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature 14 Date Of urrent Illness Injury, Pregnancy (LMP) 2000B/SB B/SB LM /OI LM /OI /DTP03 N 15 Other Date 16 Dates Patient Unable To Work In urrent Occupation 17 Name Of eferring Physician Or Other Source 17a 17b Other ID Number Of eferring Physician (Plan Provider ID#) National Provider Identifier (NPI) (Enter the referring provider s NPI) 2300/DTP A/NM1 2310A/EF A/NM109. N 19 Additional laim Information (Designated by NU) 2300/NTE01 20 Outside Lab 2400/PS102 N N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 15 Provider Services

21 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) 2300, HIXX 22 esubmission ode and/or Original ef. No Used for Original laim # 2300/EF/Qualifier F8 2300/EF/ Qualifier 9F N equired when LM05-3 (laim Frequency ode) indicates this claim is a replacement or void to a previously adjudicated claim. 23 Prior Authorization Number 24A eferral Number Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J 2300/EF/Qualifier G1 2300/EF/ Qualifier 9F 2400/DTP 24B Place Of Service 2400/SV EMG 2400/SV109 N 24D Procedures, Services Or Supplies PT/HPS Modifier 2400/SV1 24E Diagnosis Pointer 2400/SV1 24F harges 2300/LM 24G Days Or Units 2400/SV1 24H EPSDT Family Plan 2400/SV1 24I ID Qualifier 2310B/EF01 24J endering Provider ID 2310B/NM B/EF02 25 Federal Tax ID Number SSN/EIN 2010AA/EF of Billing Provider 26 Patient's Account No. 2300/ML01 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 16 Provider Services

22 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 27 Accept Assignment Not in IG N 28 Total harge Loop 2300/LM 29 Amount Paid OB data should be submitted as it was received from other payer 2300/AMT 2430/AMT 30 Balance Due 2430/AMT N 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date 32 Name And Address Of Facility Where Services Were endered (If Other Than Home Or Office). NOTE: Ambulance information should be sent as per 837 IG Not in IG D/2310E 2300/ & 1 N 32a. NPI number of Supervising Provider name 32b. Other ID# (AmeriHealth onnect issued Provider Identification Number) Strongly recommended 2310D 2310B/EF01=G2 33 Billing Provider Info & Ph # Submission of Taxonomy is strongly recommended P.O. Box in the Billing Address will cause the claim to be rejected at the clearinghouse. P.O. Box may only be submitted with the Pay to Provider 2010AA/NM1 2010AA/N3 2010AA/N4 2010AA/PE 2000A/PV * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 17 Provider Services

23 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 33a. NPI number 2010AA equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 33b. Other ID# Health Plan issued Provider Identification #) Strongly recommended If Billing is also the endering Provider: 2010BB/EF Enter the Health Plan Provider ID # (strongly encouraged.) Enter the G2 qualifier followed by the Health Plan ID #. 2000A/PV equired when the endering Provider is an Atypical Provider and does not have an NPI number. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 18 Provider Services

24 UB-04 laim Field equirements equired Fields (UB-04 laim Forms) UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 1 Unlabeled Field NUB Billing Provider Name, Address and Telephone Number 2 Unlabeled Field NUB Pay-to Name and Address Service Location, no PO Boxes Left justified Line a: Enter the complete provider name. Line b: Enter the complete address Line c: ity, State, and zip code Line d: Enter the area code, telephone number. Enter emit Address Enter the Facility POMISe Provider I.D. (PPID) number. Left justified Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 3a Patient ontrol No. Provider's patient account/control number 3b Medical/Health ecord The number assigned to the Number patient s medical/health record by the provider 4 Type Of Bill Enter the appropriate three or four -digit code. 1 st position is a leading zero Do not include the leading zero on electronic claims. 2nd position indicates type of facility. 3rd position indicates type of care. 4th position indicates billing sequence. 5 Fed. Tax No. Enter the number assigned by the federal government for tax reporting purposes. 6 Statement overs Period From/Through Enter dates for the full ranges of services being invoiced. MMDDYY * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 19 Provider Services

25 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 7 Unlabeled Not Used. Leave Blank. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 8a Patient Identifier Patient Health Plan ID is conditional if number is different from field 60 8b Patient Name Patient name is required. Last name, first name, and middle initial. Enter the patient name 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. Newborns and Multiple Births: If submitting a claim for a newborn that does not have an identification number, enter Baby Girl or Baby Boy and last name. efer to page 42 for additional newborn billing information, including Multiple Births. 9a-e Patient Address The mailing address of the patient 9a. Street Address 9b. ity 9c. State 9d. ZIP ode 9e. ountry ode (report if other than USA) 10 Patient Birth Date The date of birth of the patient ight-justified; MMDDYYYY * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 20 Provider Services

26 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 11 Patient Sex The sex of the patient recorded at admission, outpatient service, or start of care. 12 Admission Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 12 Admission Date The start date for this episode of care. For inpatient services, this is the date of admission. ightjustified 13 Admission Hour The code referring to the hour during which the patient was admitted for inpatient or outpatient care. Left Justified 14 Admission Type A code indicating the priority of this admission/visit. 15 Source of eferral for Admission or Visit A code indicating the source of the referral for this admission or visit. 16 Discharge Hour ode indicating the discharge hour of the patient from inpatient care. 17 Patient Discharge Status 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 ondition odes The following is unique to Medicare eligible Nursing Facilities. ondition codes should be billed when Medicare Part A does not cover Nursing Facility Services Applicable ondition odes: X2 Medicare EOMB on File X4 Medicare Denial on File When submitting claims for services not covered by Medicare and the resident is eligible for Medicare Part A, the following instructions should be followed: ondition codes: Enter condition code X2 or X4 when one of the following criteria is applicable to the nursing facility service for which you are billing: o There was no 3-day prior hospital stay o The resident was not transferred within 30 days of a hospital discharge o The resident s 100 benefit days are exhausted o There was no 60 day break in daily skilled care o Medical Necessity equirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 21 Provider Services

27 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* are not met o Daily skilled care requirements are not met All other fields must be completed as per the appropriate billing guide Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 29 Accident State The accident state field contains the two-digit state abbreviation where the accident occurred. equired when applicable. 30 Unlabeled Field Leave Blank Occurrence odes and Dates 31a,b 34a,b 35a,b 36a,b Occurrence Span odes And Dates Enter the appropriate occurrence code and date. equired when applicable. A code and the related dates that identify an event that relates to the payment of the claim. equired when applicable. 37a,b EPSDT eferral ode equired when applicable. Enter the applicable 2-character EPSDT eferral ode for referrals made or needed as a result of the screen. YD Dental *(equired for Age 3 and Above) YV Vision YH Hearing YB Behavioral YM medical YO Other * * 38 esponsible Party Name and Address The name and address of the party responsible for the bill. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 22 Provider Services

28 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 39a,b,c,d 41a,b,c,d Value odes and Amounts A code structure to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization. Value odes and amounts. If more than one value code applies, list in alphanumeric order. equired when applicable. Note: If value code is populated then value amount must also be populated and vice versa. 42 ev. d. odes that identify specific accommodation, ancillary service or unique billing calculations or arrangements. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 43 evenue Description The standard abbreviated description of the related revenue code categories included on this bill. See NUB instructions for Field 42 for description of each revenue code category. 44 HPS/Accommodation ates/hipps ate odes 1. The Healthcare ommon Procedure oding system (HPS) applicable to ancillary service and outpatient bills. 2. The accommodation rate for inpatient bills. 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems. Enter the applicable rate, HPS or HIPPS code and modifier based on the Bill Type of Inpatient or Outpatient. 45 Serv. Date eport line item dates of service for each revenue code or HPS/HIPPS code. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 23 Provider Services

29 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 46 Serv. Units eport units of service. A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints of blood, renal dialysis treatments, etc. 47 Total harges Total charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total harges includes both covered and non-covered charges. eport grand total of submitted charges. Value entered must be greater than zero ($0.00). Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 48 Non-overed harges To reflect the non-covered charges for the destination payer as it pertains to the related revenue code. equired when Medicare is Primary. 49 Unlabeled Field Not required Not required 50 Payer 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, secondary; and, tertiary. 51 Health Plan Identification Number The number used by the health plan to identify itself. AmeriHealth onnect s Payer ID is # el. Info elease of Information ertification Indicator. This field is required on Paper and Electronic Invoices. Line A refers to the primary payer; B, secondary; and, tertiary. It is expected that the provider have all necessary release information on file. It is expected that all released invoices contain "Y" 53 Asg. Ben. Valid entries are "Y" (yes) and "N" (no). * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 24 Provider Services

30 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 54 Prior Payments The A, B, indicators refer to the information in Field Est. Amount Due Enter the estimated amount due (the difference between Total harges and any deductions 56 National Provider Identifier Billing Provider such as other coverage). The unique identification number assigned to the provider submitting the bill; NPI is the national provider identifier. equired if the health care provider is a overed Entity as defined in HIPAA egulations. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 57 A,B, Other (Billing) Provider Identifier A unique identification number assigned to the provider submitting the bill by the health plan. 57 A, B, cont d 23, 2007omplete if NPI is not mandated in Field 56. The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider Identifier. Use this field to report other provider identifiers as assigned by the health plan listed in Field 50 A,B,. 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. 59 P. el Enter the patient s relationship to insured. For Medicaid programs the patient is the insured. ode 01: Patient is Insured) 60 Insured s Unique Identifier Enter the patient's Health Plan ID exactly as it appears on the patient's ID card on line B or. When other insurance is present, enter the plan ID on line A. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 25 Provider Services

31 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 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, secondary; and, tertiary. 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, secondary; and, tertiary. 63 Treatment Authorization odes Enter the Health Plan referral or authorization number. Line A refers to the primary payer; B, secondary; and, tertiary. Field 63A is required. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 64 DN Document ontrol Number. New field. The control number assigned to the original bill by the health plan or the health plan s fiscal agent as part of their internal control. Previously, field 64 contained the Employment Status ode. The ES field has been eliminated. Note: esubmitted claims must contain the original claim ID 65 Employer Name The name of the employer that provides health care coverage for the insured individual identified in field 58. equired when the employer of the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer; B, secondary; 66 Diagnosis and Procedure ode Qualifier (ID Version Indicator) and, tertiary. The qualifier that denotes the version of International lassification of Diseases (ID) reported. Not equired Not equired * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 26 Provider Services

32 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 67 Prin. Diag. d. and Present on Admission (POA) Indicator The ID-9-M codes describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for occasioning the admission of the patient for care). Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 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. (See page 37 for detailed Paper and EDI Instructions) 67 A - Q Other Diagnosis odes The ID-9-M diagnoses codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that 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. 68 Unlabeled Field 69 Admitting Diagnosis ode The ID diagnosis code describing the patient s diagnosis at the time of admission. equired for inpatient admissions. 70 Patient s eason for Visit The ID-9-M diagnosis codes describing the patient s reason for visit at the time of outpatient registration. equired for all unscheduled outpatient visits. Up to three ID-9-M codes may be entered in fields a,b,c. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 27 Provider Services

33 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 71 Prospective Payment System (PPS) ode 72a-c External ause of Injury (EI) ode 73 Unlabeled Field 74 Principal Procedure code and Date 74a-e Other Procedure odes and Dates The PPS code assigned to the claim to identify the DG based on the grouper software called for under contract with the primary payer. equired when the Health Plan/ Provider contract requires this Up to 4 digits. The ID diagnosis codes pertaining to external cause of injuries, poisoning, or adverse effect. External ause of Injury E diagnosis codes should not be billed as primary and/or admitting diagnosis. equired if applicable. The ID code that identifies the principal procedure performed at the claim level during the period covered by this bill and the corresponding date. Inpatient facility ID 9 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID 9 is required when a surgical procedure is performed. The ID codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Inpatient facility ID 9 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID 9 is required when a surgical procedure is performed. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 28 Provider Services

34 UB-04 laim Field equirements UB-04 laim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 75 Unlabeled 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. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 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. equired when a surgical procedure code is listed 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 their 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# 80 emarks Field Area to capture additional information necessary to adjudicate the claim. 81,a-d ode-ode Field To report additional codes related to Form Locator (overflow) or to report externally maintained codes approved by the NUB for inclusion in the institutional data set. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 29 Provider Services