Claims Filing Manual

Transcription

1 laims Filing Manual May 2013

2 ontents laim Filing... 5 Procedures for laim Submission... 5 laim Mailing Instructions equests for Adjustments Administrative or Medical Necessity Appeals... 5 laim Filing Deadlines... 6 Deadline Exceptions... 6 efunds for laims Overpayments or Errors... 6 laim Form Field equirements MS 1500 laim Form equired Fields Paper MS 1500 Instructions and Examples of Supplemental Information in Item Paper MS 1500 National Drug odes (ND) Electronic (EDI) MS 1500 Instructions and Examples of Supplemental Information in Item EDI MS 1500 Other Instructions EDI MS 1500 National Drug odes (ND) orrected MS 1500 claims via EDI equired Fields (UB-04 laim Forms) ND on UB Submission of POA Indicators for Primary and Secondary Diagnoses General POA equirements POA Indicators are as follows, blanks are not acceptable: POA oding eporting POA on the UB-04 laim Form eporting POA in Electronic 837I Format All Patient efined Diagnosis elated Groups (AP-DG) Birth Weight ommon auses of laim Processing Delays, ejections or Denials Electronic Data Interchange (EDI) for Medical and Hospital laims Submitting secondary claims electronically Electronic laims Submission (EDI) Hardware/Software equirements ontracting with Emdeon and Other Electronic Vendors ontacting the EDI Technical Support Group Specific Data ecord equirements Electronic laim Flow Description Invalid Electronic laim ecord ejections/denials Plan Specific Electronic Edit equirements Example of a Professional Electronic laim Example of an Institutional Electronic laim Exclusions Exlcuded laim ategories Excluded Provider ategories Select Health laims Filing Manual

3 ommon ejections Invalid Electronic laim ecords ommon ejections from Emdeon Invalid Electronic laim ecords ommon ejections from the Plan (EDI Edits within the laim System) Electronic emittance Advice Electronic Billing Inquiries How to Minimize etrospective hart eview Why are retrospective chart reviews necessary? Tips for Accurate Diagnosis oding EOB Denial odes Appendix - Supplemental Information Ambulance laims Procedure ode Destination Modifiers Authorization equirements For Ambulance Services Ambulance Services Not overed Ambulatory Surgery laims Anesthesia laims ertified egistered Nurse Anesthetists (NA) Modifiers Behavioral Health laims Identifying Mental Health laims Provider Types Authorization equirements o-pays Labs Outpatient Behavioral Health in the E Inpatient Behavioral Health DGs H/FQH Behavioral Health claims Behavioral Health services covered by Medicaid fee-for-service hiropractic laims Authorizations laim Submission laims inquiries Eligibility and benefits inquiry Provider elations Durable Medical Equipment (DME) laims Billing equirements eimbursement Types Authorization equirements Modifiers Enteral Therapy Nebulizers Early, Periodic, Screening and Diagnostic Testing (EPSDT) laims Billing Guidelines Immunizations Additional Billing Notes Home Health ontents 3

4 Authorizations requirements o-pays Same day visits Billable Procedure odes: Home Infusions and Injectable Drugs laims Authorization requirements Family Planning codes Maternity laims Authorization equirements Ultrasounds P Injections Nurse Midwives oordination of Benefits and o-pays Multiple Surgical eduction Payment Policy Nursing Home laims Authorization equirements laim submission guidelines Physical, Occupational and Speech Therapy laims enal Dialysis laims Authorization requirements Exhibits MS 1500 Form HNS Fax Inquiry Form Institute for Health and ecovery Integrated (IH) Screening Tool (SBIT) Prenatal isk Assessment Form UB-04 Form Universal 17-P Authorization Form Select Health laims Filing Manual

5 laim Filing Procedures for laim Submission Select Health of South arolina, Inc. s First hoice 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. laims for billable 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 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 participating 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. ejected 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. ejected claims are not registered in the claim processing system and can be resubmitted as a new claim. laims 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 laims in this booklet. laim Mailing Instructions Submit claims to Select Health of South arolina, Inc. at the following address: Select Health of South arolina Attn: laim Processing Department P. O. Box 7120 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 Provider Support Line at to arrange transmission. Note: Select Health Plan EDI Payer ID# Any additional questions may be directed to Provider laim Services at or to Select Health of South arolina s Network Operations department at equests for Adjustments equests for adjustments may be submitted by phone to: Provider laim Services at (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 arolina Attn: laim Processing Department P. O. Box 7120 London, KY Administrative or Medical Necessity Appeals Administrative or medical necessity appeals must be submitted in writing to: Select Health of South arolina Attn: Appeals Department P. O. Box harleston, S laim Filing Procedures for laim Submission 5

6 Health care professionals submitting appeals on the behalf of a member must file the appeal within 90 calendar days of denial or action notification. efer to the Health are Professionals and Providers Manual online in the Provider section of the Select Health website at for complete instructions on submitting appeals. 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. esubmission 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 laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the primary insurer s EOB. efunds for laims Overpayments or Errors The plan and South arolina Department of Health and Human Services (SDHHS) 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 SDHHS protocol for returning improper payments or overpayment. 2. omplete the overpayment worksheet and submit along with a refund check for the overpayment/ improper payment amount directly to: Select Health of South arolina ost ontainment & TPL Department P O Box 7320 London, KY 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. A sample of each form can be found in the exhibits. If the field is required without exception, an (required) is noted in the equired or onditional box. If completing the field is dependent upon certain circumstances, the requirement is listed as (conditional), 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 one year 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). ontact Select Health Provider laim Services at to arrange the repayment. There are two ways to return overpayments: 1. omplete the overpayment worksheet located on the Select Health website, 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 arolina Attn: laims Processing Department P O Box 7120 London, KY Select Health laims Filing Manual

7 MS 1500 laim Form equired Fields MS 1500 laim Form equired Fields Field # Field Description Instructions and omments 1 INSUANE POGAM IDENTIFIATION 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 INSUED S ID NUMBE Health plan s member identification number or Medicaid identification number. 2 PATIENT S NAME (Last Name, First Name, Middle Initial) Enter the patient s name as it appears on the member s health plan I.D. card. 3 PATIENT S BITH DATE/SEX MMDDYY/M or F INSUED S NAME (Last Name, First Name, Middle Initial) PATIENT S ADDESS (Number, Street, ity, State, Zip ode) Telephone (include Area ode) PATIENT ELATIONSHIP TO INSUED INSUED S ADDESS (Number, Street, ity, State, Zip ode) Telephone (include Area ode) 8 PATIENT STATUS 9 9a 9b 9c 9d 10a, b, c OTHE INSUED S NAME (Last Name, First Name, Middle Initial) OTHE INSUED S POLIY O GOUP NUMBE OTHE INSUED S BITH DATE/ SEX EMPLOYE S NAME O SHOOL NAME INSUANE PLAN NAME O POGAM NAME IS PATIENT S ONDITION ELATED TO: Enter the patient s name as it appears on the member s health plan I.D. card. Enter the patient s complete address and telephone number. Do not punctuate the address or phone number. Always indicate self. Enter the patient s marital status. Indicate if the patient is employed or is a student. efers to someone other than the patient. ompletion of fields 9a through 9d is required if patient is covered by another insurance plan. Enter the complete name of the insured. EQUIED if #9 is completed. EQUIED if #9 is completed. MMDDYY/M or F by check box. This field is related to the insured in field #9. EQUIED if #9 is completed. Indicate yes or no for each category. Is condition related to employment, auto accident or other accident? 10d ESEVED FO LOAL USE Not equired 11 INSUED S POLIY GOUP O FEA NUMBE equired when other insurance is available. omplete if more than one other medical insurance is available or if yes to 10a, b, c. 11a INSUED S BITH DATE/SEX Same as #3. equired if 11 is completed. 11b 11c 11d EMPLOYE S NAME O SHOOL NAME INSUANE PLAN NAME O POGAM NAME IS THEE ANOTHE HEALTH BENEFIT PLAN? PATIENT S O AUTHOIZED PESON S SIGNATUE INSUED S O AUTHOIZED PESON S SIGNATUE equired if employment is indicated in field #10. Enter name of health plan. equired if #11 is completed. Yes or no by check box. If yes, complete #9a-d. Enter Signature on File, SOF or legal signature. Enter Signature on File, SOF or legal signature. 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. laim Form Field equirements MS 1500 laim Form equired Fields 7

8 MS 1500 laim Form equired Fields Field # Field Description Instructions and omments a 17b 18 equired or onditional* DATE OF UENT: ILLNESS (First symptom) O INJUY (Accident) O PEGNANY (LMP) MMDDYY. IF PATIENT HAS SAME O SIMILA ILLNESS, GIVE FIST MMDDYY. DATE DATES PATIENT UNABLE TO WOK IN UENT OUPATION MMDDYY. NAME OF EFEING PHYSIIAN O OTHE SOUE OTHE I.D. NUMBE OF EFEING PHYSIIAN NATIONAL POVIDE IDENTIFIE (NPI) HOSPITALIZATION DATES ELATED TO UENT SEVIES equired if a provider other than the member s primary care physician referred, ordered or supervised the services or supplies on the claim. 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. equired if #17 is completed. NU 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) Enter the NPI number of the referring provider, ordering provider or other source. equired if #17 is completed. equired when place of service is inpatient. MMDDYY. 19 ESEVED FO LOAL USE Not equired 20 OUTSIDE LAB HAGES Not equired DIAGNOSIS O NATUE OF ILLNESS O INJUY. (elate items 1,2,3, O 4 to item 24E by line) MEDIAID ESUBMISSION ODE OIGINAL EF. NO. 23 PIO AUTHOIZATION NUMBE 24a DATE(S) OF SEVIE Diagnosis codes must be valid ID codes for the date of service. E codes are NOT acceptable as a primary diagnosis. NOTE: laims with invalid diagnosis codes will be denied for payment. 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 EF No: EF01 = F8 EF02 = 13 digit original claim number, no dashes or spaces For paper claims: For resubmissions or adjustments, enter ADJ in the esubmission ode section. Enter the claim ID# of the original claim in the Original ef No. section. Enter the authorization number. efer to the Provider Manual or call Provider Services to determine if services rendered require an authorization. If filing drug related codes, in the shaded area enter the ND qualifier followed by the ND number. ND 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. 24b PLAE OF SEVIE Enter the MS standard place of service code. 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. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 8 Select Health laims Filing Manual

9 MS 1500 laim Form equired Fields Field # Field Description Instructions and omments 24d 24e 24f POEDUES, SEVIES O SUPPLIES PT/HPS MODIFIE DIAGNOSIS ODE HAGES 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 1 st modifier position. 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 codes for the date of service. Enter charges. Enter zero ($0.00) or actual charged amount. A value must be entered including capitated services. equired or onditional* 24g DAYS O UNITS Enter quantity. Value must be greater than zero. (Field allows up to 3 digits.) 24h EPSDT FAMILY PLAN Not equired 24i 24j 25 ID QUALIFIE ENDEING POVIDE ID FEDEAL TAX ID NUMBE SSN/ EIN 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 NU guidelines for the appropriate qualifier. The individual rendering the service is reported in 24j. Enter the health plan ID number in the shaded area of the field. emember to use qualifier G2. Enter the NPI number in the unshaded area of the field. Physician or supplier s federal tax ID (employer identification or Social Security) number. ecommended 26 PATIENT S AOUNT NO. The provider s billing account number. 27 AEPT ASSIGNMENT? Always indicate YES. efer to the back of the MS 1500 (08-05) form for the section pertaining to Medicaid payments. 28 TOTAL HAGE Enter the total billed amount for all services. 29 AMOUNT PAID EQUIED 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 BALANE DUE EQUIED when #29 is completed SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS/DATE NAME AND ADDESS OF FAILITY WHEE SEVIES WEE ENDEED (If other than home) PHYSIIAN S, SUPPLIE S BILLING NAME, ADDESS, ZIP ODE AND PHONE NUMBE 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. EQUIED 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). 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). *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. laim Form Field equirements MS 1500 laim Form equired Fields 9

10 Paper MS 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 odes (ND) for drugs (see next section for more information) Vendor Product Number Health Industry Business ommunications ouncil (HIB) Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN), formerly Universal Product ode (UP) for products Product ode (UP) for products formerly Universal ontract 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 odes VP Vendor Product Number Health Industry Business ommunications ouncil (HIB) OZ Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN) T ontract rate All unspecified procedure or HPS 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 MS 1500 National Drug odes (ND) ND should be entered in the shaded sections of item 24A through 24G. To enter ND information, begin at 24A by entering the qualifier N4 and then the 11 digit ND information. Do not enter a space between the qualifier and the 11-digit ND number. Enter the 11-digit ND number in the format (no hyphens). Do not use for a compound medication. Bill each drug as a separate line item with its appropriate ND. Enter the drug name and strength. Enter the ND quantity unit qualifier: F2 International Unit G Gram ML Milliliter UN Unit Enter the ND quantity. Do not use a space between the ND quantity unit qualifier and the ND quantity. Note: The ND quantity is frequently different than the HP code quantity. Example of entering the identifier N4 and the ND number on the MS 1500 claim form: 1 N4 qualifier 24. A. DATE(S) OF SEVIE B.. D. POEDUES, SEVIES, O SUPPLIES From To PLAE OF (Explain Unusual ircumstances) MM DD YY MM DD YY SEVIE EMG PT/HPS MODIFIE N KETOLA 15MG/ML SYING J digit ND number Drug name and strength ND quantity ML2 ND unit qualifier Electronic (EDI) MS 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 emarks (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. orrected claims need to begin with the letters DIAGNOSIS 10 Select Health laims Filing Manual

11 P 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 MS 1500 Other Instructions EDI Field 33b (Professional) Field 33b Other ID# - Professional: 2310B loop, EF01=G2, EF02+ 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. laim 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 EDI eporting DME DME claims requiring specific instructions should begin with DME followed by specific details. Example: NTE*ADD*DME AEOSOL MASK, USED W/DME NEBULIZE. EDI claims with ND 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 ND number to meet this specification. orrected MS 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, LM05-03 (837P). Include the original claim number in segment EF01=F8 and EF02=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 paper at the same time. EDI MS 1500 National Drug odes (ND) The ND 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. ontinue to report ND in the LIN segment of Loop ID 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 ND number. This number should be sent with no hyphens and should be 11 digits. Submit one occurrence of the LIN segment per claim line. laims requiring multiple ND s sent at claim line level should be submitted using MS 1500 or UB-04 paper claim. When submitting ND in the LIN segment, the TP segment is requested. This segment is to be submitted with the unit of measure and the quantity. When submitting this segment, TP03 (pricing), TP04 (quantity) and TP05 (unit of measure) are required. laim Form Field equirements MS 1500 laim Form equired Fields 11

12 equired Fields (UB-04 laim Forms) UB-04 laim Form equired Fields Field # Field Description Instructions and omments 1 2 UNLABELED FIELD Provider name, address and telephone number UNLABELED FIELD Pay-To name, address and secondary ID fields 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 Enter the emit address. Billing provider s designated pay-to address. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* 3a PATIENT ONTOL NO. Provider s patient account/control number. 3b MEDIAL EOD NO. Enter the patient s medial or health record number. Not required Not required 4 TYPE OF BILL 5 FED. TAX NO. 6 STATEMENT OVES PEIOD FOM/THOUGH Enter the appropriate three- or four-digit code. 1 st position indicates lead zero (do not include the lead zero on electronic claims). 2 nd position indicates type of facility. 3 rd position indicates type of care. 4 th position indicates billing sequence. Enter the number assigned by the federal government for tax reporting purposes. Enter dates for the full range of services being invoiced. (Format: MMDDYY) 7 UNLABELD FIELD No entry required. Not required Not required 8a 8b 9a-e PATIENT IDENTIFIE PATIENT NAME PATIENT ADDESS eport only if number is different from the patient s Medicaid ID in Field 60. 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. The mailing address of the patient: Street address ity State ZIP code ountry code (report if other than USA) 10 PATIENT DATE OF BITH The patient s birth date in MMDDYYYY format. 11 PATIENT S SEX ADMISSION The sex of the patient recorded at admission, outpatient service of start of care. M male F female U unknown *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 12 Select Health laims Filing Manual

13 UB-04 laim Form equired Fields Field # Field Description Instructions and omments 12 ADMISSION/STAT OF AE DATE Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* The start date for this episode of care. For inpatient this is the actual admission date of the patient. (Format: MMDDYY) 13 ADMISSION HOU ode referring to the hour during which the patient was admitted for inpatient or outpatient care. 14 ADMISSION TYPE ode indicating the priority of this admission/visit. Not required 15 SOUE OF EFEAL FO ADMISSION O VISIT (S) 16 DISHAGE HOU (DH) 17 DISHAGE STATUS (STAT) ONDITION ODES 29 AIDENT STATE 30 UNLABELED FIELD a-b OUENE ODES AND DATES a-b OUENE SPAN ODES AND DATES 35-36a-b UNLABELED FIELD ode indicating the source of the referral for this admission or visit. ode indicating the discharge hour of the patient from inpatient care. 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. 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. When services reported on the claim are related to an auto accident, the two-digit state abbreviation where the accident occurred must be entered. 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. ode and the related dates that identify an event that relates to the payment of the claim. EQUIED for resubmissions or adjustments. Enter the claim number of the original claim. Not required 38 UNLABELED FIELD esponsible party name and address VALUE ODES a-d 42 EV.D. 43 DESIPTION 44 HPS/ATES/HIPPS ODE 45 SEV. DATE ode 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. eporting birth weight - If reporting abnormal birth weight through use of Value odes, populate fields 39, 40, 41 a, b, c, d Value odes and Amounts. Use Value ode 54 and report the birth weight in grams. evenue ode odes that identify specific accommodations, services and items furnished to the patient in your facility. evenue code narrative description of the related revenue categories. Abbreviations may be used. Enter the applicable rate, PT, HPS or HIPPS code and modifier based on the bill type of inpatient or outpatient. eport line item dates of service for each revenue code or PT, 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. laim Form Field equirements equired Fields (UB-04 laim Forms) 13

14 UB-04 laim Form equired Fields Field # Field Description Instructions and omments 46 SEV. UNITS eport units of service to include items such as number of accommodation days, miles, pints of blood, renal dialysis days, etc. Observations - eport OBS as one unit per 24 hour period up to 72 hours. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* 47 TOTAL HAGES eport grand total of submitted charges. 48 NON-OVEED HAGES 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 equired Not equired 50 PAYE NAME 51 HEALTH PLAN ID 52 EL. INFO 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 is tertiary. The number used by the health plan to identify itself. Select Health s payer ID is elease 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 to the tertiary. It is expected the provider has all necessary release information on file. It is expected all released invoices contain Y. 53 ASG. BEN. Valid entries are Y (yes) and N (no). 54 PIO PAYMENTS The A, B, indicators refer to the information in Field EST. AMOUNT DUE 56 57a-c NATIONAL POVIDE IDENTIFIE BILLING POVIDE OTHE (BILLING) POVIDE IDENTIFIE 58 INSUED S NAME 59 P. EL 60 INSUED S UNIQUE IDENTIFIE 61 GOUP NAME 62 INSUANE GOUP NO. 63 TEATMENT AUTHOIZATION ODES Enter the estimated amount due (the difference between total charges and any deductions such as other coverage). The unique identification number assigned to the provider submitting the bill. NPI is the National Provider Identifier. A unique identification number assigned to the provider submitting the bill by the health plan. eport the facility ID number assigned by the health plan. 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. Enter the patient s relationship to insured. For Medicaid programs, the patient is the insured. (ode 01: Patient is insured). 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 When other insurance is present, enter that plan ID on line A. 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 to tertiary. 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 to tertiary. Enter the health plan referral or authorization number. Line A refers to the primary payer, B to secondary and to tertiary. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 14 Select Health laims Filing Manual

15 UB-04 laim Form equired Fields Field # Field Description Instructions and omments 64 DN 65 EMPLOYE NAME a-q DIAGNOSIS AND POEDUE ODE QUALIFIE PINIPAL DIAGNOSIS ODE and PESENT ON ADMISSION INDIATO (POA) Other Diagnosis odes 68 UNLABELD FIELD 69 ADMITTING DIAGNOSIS ODE 70 PATIENT S EASON FO VISIT 71 72a-c POSPETIVE PAYMENT SYSTEM (PPS) ODE EXTENAL AUSE OF INJUY (EI) ODE 73 UNLABELD FIELD Document ontrol 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 ode (ES). The ES field has been eliminated. Note: esubmitted claims must contain the original claim ID. The name of the employer that provides health care coverage for the insured individual identified in Field 58. equired 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 to tertiary. The qualifier that denotes the version of International lassification of Diseases (ID) reported. Qualifier codes: ID: 9 Ninth revision, 0 Tenth revision. Enter the complete ID 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. onditions 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. The ID 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. Enter the complete ID diagnosis code, include the 4th and 5th digits if applicable, which describe the patient s diagnosis at admission. Enter the complete ID diagnosis code describing the patient s reason for visit at the time of outpatient registration. Include the 4th and 5th digits if applicable. equired for all unscheduled outpatient visits. Up to three ID codes may be entered in Fields a, b, c. The PPS codes 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 information. Up to four digits. The ID 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. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* Not required equired or onditional* Not 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. laim Form Field equirements equired Fields (UB-04 laim Forms) 15

16 UB-04 laim Form equired Fields Field # Field Description Instructions and omments 74 74a-e PINIPAL POEDUE ODE AND DATE OTHE POEDUE ODES AND DATES 75 UNLABELD FIELD ATTENDING POVIDE NAME AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# OPEATING PHYSIIAN NAME AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# OTHE POVIDE (INDIVIDUAL) NAMES AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# 80 EMAKS FIELD 81 a-d TAXONOMY ODE 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 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID 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 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID is required when a surgical procedure is performed. 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. 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. 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#. Area to capture additional information necessary to adjudicate the claim. 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. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* 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. ND on UB-04 ND should be entered in Form Locator 43 in the evenue Description Field. eport the N4 qualifier in the first two positions, left-justified. Do not enter spaces. Enter the 11-character ND number in the format (no hyphens). 16 Select Health laims Filing Manual

17 Do not use for a compound medication. Bill each drug as a separate line item with its appropriate ND. Immediately following the last digit of the ND (no delimiter), enter the Unit of Measurement Qualifier. F2 International Unit G 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 leftjustified 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 U N Submission of POA Indicators for Primary and Secondary Diagnoses General POA equirements 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. onditions 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 oding and eporting) and the external cause of injury codes. MS 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 = linically Undetermined = provider is unable to clinically determine whether condition was present at time of inpatient admission or not. 1 = Exempt from POA reporting. POA oding Use the UB-04 Data Specifications Manual and the ID Official Guidelines for oding and eporting to facilitate the assignment of the POA indicator for each principal diagnosis and other ID diagnosis codes reported on the UB-04 and AS 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. eporting POA on the UB-04 laim Form Fields 67 A Q: valid primary and secondary diagnosis 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: FL 67 Primary Diagnosis ode DX 2449 Y 25001A N 29620B U V1581 W D I J K L M 69 ADMIT 70 PATIENT DX EASON DX a b c FL 67 POA FL 67 A-Q Secondary Diagnosis odes FL 67 A-Q POA 71 PPS ODE eporting 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. No additional K3 segments with the letters POA will be laim Form Field equirements Submission of POA Indicators for Primary and Secondary Diagnoses 17

18 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 ause 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-ode indicator. POA Indicator Example: POA Indicators for an electronic claim with one principal and five secondary diagnoses should be coded as: K3* POAYNUW1YZ.POA The principal diagnosis is always the first indicator after Y POA. In this example, the principal diagnosis was present on admission. The first secondary diagnosis was not present on admission, N designated by N. U W 1 Y Z It was unknown if the second secondary diagnosis was present on admission, designated by U. It is clinically undetermined if the third secondary diagnosis was present on admission, designated by W. 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. The fifth secondary diagnosis was present on admission, designated by Y. 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. MS POA Indicator Options and Definitions ode eason for ode Y N U W 1 Diagnosis was present at time of inpatient admission. MS will pay the complicating condition/major complicating condition (/M) DG for those selected Hospital Acquired onditions (HAs) that are coded as Y for the POA Indicator. Diagnosis was not present at time of inpatient admission. MS will not pay the /M DG for those selected HAs that are coded as N for the POA Indicator. Documentation insufficient to determine if the condition was present at the time of inpatient admission. MS will not pay the /M DG for those selected HAs that are coded as U for the POA. linically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. MS will pay the /M DG for those selected HAs that are coded as W for the POA Indicator. 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. MS will not pay the /M DG for those selected HAs that are coded as 1 for the POA Indicator. The 1 POA Indicator should not be applied to any codes on the HA list. Key Points: IPPS hospitals will no longer report the POA Indicator of 1. ID-M 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 efined Diagnosis elated Groups (AP-DG) Effective with dates of service Jan. 1, 2012, Select Health moved to the All Patient efined Diagnosis elated Groups (AP-DGs) method of paying for hospital inpatient services. The goals of the AP-DGs payment are to employ a methodology that is sustainable and more appropriate to Medicaid using a modern DG algorithm, which enables reduced payment for hospital-acquired conditions and simplifies the current payment method. 18 Select Health laims Filing Manual

19 AP-DGs version 28 replaced the current 3M grouper version 24. AP-DGs is a classification system that classifies patients according to: eason for admission. Severity of illness (SOI). AP-DGs 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 hospitals 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 arolina 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 AP-DGs 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 ID M code ranges V21.30-V21.35 or as appropriate and/or Birth weight can be reported through use of Value ode 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 ID code, populate field 67. DX A B D I J K L M 69 ADMIT 70 PATIENT DX EASON DX a b c PPS ODE 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. a b c d 39 VALUE ODES 40 VALUE ODES 41 VALUE ODES ODE AMOUNT ODE AMOUNT ODE AMOUNT Electronic Billing If billing electronically in addition to reporting the diagnosis 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. ommon auses of laim Processing Delays, ejections or Denials Authorizations or eferral 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 harges Missing or Incomplete A billed charge amount must be included for each service/procedure/ supply on the claim form. Diagnosis ode Missing 4th or 5th Digit Precise coding sequences must be used to accurately complete processing. eview the ID-M 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 odes Invalid or Missing oding From the most current coding manuals (ID-M, PT or HPS) or appropriate unique coding is required to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. DG odes Missing or Invalid Hospitals contracted for payment based on DG codes should include this information on the claim form. EOBs (Explanation of Benefits) from Primary Insurers laim Form Field equirements ommon auses of laim Processing Delays, ejections or Denials 19

20 Missing or Incomplete A copy of the EOB from all thirdparty insurers must be submitted with the original claim form. Include pages with run dates, coding explanations and messages. EPSDT Information Missing or Incomplete EPSDT information should be billed in accordance with the South arolina Medicaid Physician Provider Manual. Immunization administration, topical fluoride varnish, laboratory tests, blood level assessments, age limited screenings and elective tests are covered separately utilizing the appropriate PT code and billed according to the periodicity schedule. EPSDT services may be submitted electronically or on paper. The administration PT codes are covered for the administration of vaccines provided through the VF program for beneficiaries age 19 and older. For the administration of vaccines by injection, the following PT codes must be used: Immunization administration This code will only cover the first vaccine administered Each additional vaccine List separately in addition to code for primary procedure. Note: Use code in conjunction with code 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 PV by intranasal or oral, the following PT codes must be used: Immunization administrations by intranasal or oral, one vaccine. This code will only cover the first vaccine administered per visit Each additional intranasal or oral vaccine. For members under 19 years of age, you must use the new administration codes: 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) Each additional vaccine/toxoid component (two units per date of service). PT advises to bill these codes based on the number of components. At this time, SDHHS will continue to use these codes per admin istration of each vaccine/toxoid and not per compo nent for the VF program. The administration of VF 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. egardless 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 HPS 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. efer to the section entitled Submitting Secondary laims Electronically. EPSDT oding Tips Modifiers 01 and 02 are not required for EPSDT claim submission to First hoice. Primary care physicians can bill for topical fluoride varnish treatments, PT code D1206 as part of the EPSDT exam. laims for VF vaccine administration must include: The appropriate vaccination product (toxoid) PT code. The appropriate vaccination administration code for this code combination, only the adminis tration code will be reimbursable. When billing First hoice, Federally Qualified Health enters (FQHs) and ural Health enters (Hs) must also submit PT codes for the vaccination products. When billing for vaccines not covered under the VF program or for beneficiaries over the age of 19, the provider may bill for the vaccine and the administration code Select Health laims Filing Manual