Provider Manual. Provider Billing Manual

Transcription

1 Provider Manual Section 15.0 Provider Billing Manual Table of ontents 15.1 laim Submission 15.2 Provider/laim Specific Guidelines 15.3 Understanding the emittance Advice 15.4 Denial easons and Prevention Practices 15.5 Timely Filing equirements 15.6 orrected laims and equests for econsideration and/or efunds 15.7 ontact Information for laims Questions Page 1 of 50

2 15.0 Provider Billing Manual 15.1 laim Submission Procedures for laim Submission Passport Health Plan (Passport) 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 in order to ensure timely processing of claims. When required data elements are missing or invalid, claims will be rejected by Passport for correction and resubmission. The provider who performed the service to the Passport member must submit the claim for a billable service. laims filed with Passport 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 the referral for specialist or non-primary care physician (PP) claims. Verification of member eligibility for services under Passport during the time period in which services were provided. Verification that the services were provided by a participating provider or that the out- ofnetwork provider has received authorization to provide services to the eligible member (excluding self-referral types of care). Verification of whether there is Medicare coverage or any other third party resources and, if so, verification that Passport is the payer of last resort on all claims submitted to Passport. Verification that an authorization has been given for services that require prior authorization by Passport. As part of the agreement between Passport and the provider, the provider agrees to cooperate with Passport in its efforts to comply with all applicable Federal and State laws, including specifically the provisions of Section 6032 of the Deficit eduction Act of 2005, PL , False laims Act, Federal emedies for False laims and Statements Act, and KS , et. Seq. (relating to fraud) ejected and Denied laims ejected claims are defined as claims with invalid or missing data elements (such as the provider tax identification number) that are returned to the provider or EDI source without registration in the claims processing system. Since rejected claims are not registered in the claims processing system, the provider must re-submit corrected claims within 180 calendar days from the date of service. This requirement applies to claims submitted on paper or electronically. Page 2 of 50

3 ejected claims are different than denied claims, which are registered in the claims processing system but do not meet requirements for payment Passport guidelines. For more information on denied claims, see Section 15.3 and 15.4 in this Provider Manual laim Mailing Instructions Passport encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or the Emdeon Provider Support Line at (800) to arrange transmission. Additional questions may be directed to the EDI Technical Support Hotline at (877) or via to If you choose to utilize paper claims, please submit to Passport at the following address: Passport Health Plan P. O. Box 7114 London, KY laim Filing Deadlines Original invoices must be submitted to Passport within 180 calendar days from the date services were rendered or compensable items were provided. Previously denied claims (with corrections and requests for adjustments) must be submitted within two years of the process date Exceptions Submission of claims for members retroactively enrolled in Passport by the Department for Medicaid Services is based on the date of notification of enrollment. laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer s EOB laims Status eview Providers may view claims status using any of the following methods: Online check eligibility/claims status by logging into NaviNet at Telephone you may also check eligibility and/or claims status by calling our interactive voice response (IV) system at (800) eal-time depending on your clearinghouse or practice management system, real-time claims status information is available to participating providers. ontact your clearinghouse to access: Emdeon Products for claims status transactions. Page 3 of 50

4 All other clearinghouses: Ask your clearinghouse to access transactions through Emdeon Notification of Denial via emittance Advice When a claim is denied because of missing or invalid mandatory information, the claim should be corrected, marked as a second submission or corrected claim, and resubmitted within two years of the process date to the general claim address: Passport Health Plan P.O. Box 7114 London, KY laims Adjustment/econsideration equests If you believe there was an error made during claims processing or if there is a discrepancy in the payment amount, please call the Provider laims Service Unit (PSU) at (800) Our representatives can help you resolve the issue, process a claim via the phone, and advise whether a corrected claim or a written appeal needs to be submitted laim Submission for New Providers New providers with Passport awaiting receipt of their Medicaid Identification (MAID) number are subject to the timely filing guidelines and may begin to submit claims once their Passport ID number has been assigned. These claims will initially deny for no MAID number. After Passport receives a provider s MAID number, all claims submitted and initially denied will be reprocessed without resubmission laim Forms and Field equirements The following charts describe the required fields that must be completed for the standard 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) laim Data Sets Billed by Providers To facilitate timely and accurate claim processing, you must assure billing on the correct form for your provider type. The table below outlines the requirements as defined by Kentucky Medicaid: Page 4 of 50

5 Hospital - Acute are Inpatient Hospital Outpatient Hospital - Long Term are Inpatient ehabilitation Facility Inpatient Psychiatric Facility Home Health are Skilled Nursing Facility Ambulance (Land and Air) Ambulatory Surgical enter Dialysis Facility (hronic, Outpatient) Durable Medical Equipment Drugs (Part B) Laboratory Physician and Practitioner Services Federally Qualified Health enters ural Health linics MS-1500 X X X X X X X X UB-04 (MS-1450) X X X X X X X X MS-1500 laim Form and equired Fields Use of the MS-1500 form (08/05) was required as of April 1, The form includes several fields that accommodate the use of your National Provider Identifier (NPI). Although the form requires use of the NPI, we recommend you continue to report your current plan-assigned Provider Identification Numbers in the appropriate shaded areas of the form (17A, 24J, 32B, and 33B). urrent Provider Identification Numbers must be preceded by a two-character qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you do not currently bill electronically, please use G2 as your qualifier ID. Providers are also required to populate filed 19 with the ZZ qualifier ID and the Billing & endering Provider s Primary Taxonomy ode (Box 33b for Billing and Box 19 for endering). equired Fields for the MS-1500 laim Form NOTE: *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. MS 1500 laim 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 with whom the claim is being filed. Select D, other. equired or onditional* Page 5 of 50

6 1A INSUED I.D. NUMBE Passport s member identification number as it appears on the member s Passport ID card. EDI details AS X A. Subscriber number less than 11 digits. 2010BA, NM108=MI NM109 less than 11 digits. Subscriber is required. 2 PATIENT S NAME (Last Name, First Name, Middle Initial) Enter the member s name as it appears on the member s Passport ID card. 3 PATIENT S BITH DATE / SEX MMDDYY / M or F 4 INSUED S NAME (Last Name, First Name, Middle Initial) Enter the member s name as it appears on the member s Passport ID card, or enter the mother s name when the member is a newborn PATIENT S ADDESS (Number, Street, ity, State, Zip ode, and Telephone, Including Area ode) PATIENT ELATIONSHIP TO INSUED INSUED S ADDESS (Number, Street, ity, State, Zip ode) Telephone (include area code) Enter the member s complete address and telephone number (Do not punctuate the address or phone number). Always indicate self. Enter the member s complete address and telephone number (Do not punctuate the address or phone number). 8 ESEVED FO NU USE Not equired 9 OTHE INSUED S NAME (Last Name, First Name, Middle Initial) efers to someone other than the member. EQUIED if member is covered by another insurance plan. Enter the complete name of the insured. 9A OTHE INSUED S POLIY O GOUP NUMBE EQUIED if field 9 is completed. Page 6 of 50

7 MS 1500 laim Field Field Description Instructions and omments equired or onditional* 9B ESEVED FO NU USE Not equired 9 ESEVED FO NU USE Not equired 9D INSUANE PLAN NAME O POGAM NAME EQUIED if # 9 is completed. 10A,B, 10D IS PATIENT S ONDITION ELATED Indicate Yes or No for each category. TO: Enter condition codes as approved by the LAIM ODES (Designated by NU) NU in this field. 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 field 10 A, B,. 11A INSUED S BITH DATE / SEX omplete information if other insurance is listed in field B OTHE LAIM ID (Designated by NU) For worker s compensation or property and casualty enter the qualifier to the left of the vertical dotted line and the identifier number to the right of the vertical dotted line. 11 INSUANE PLAN NAME O POGAM NAME Enter name of Health Plan. EQUIED if field 11 is completed. 11D IS THEE ANOTHE HEALTH BENEFIT PLAN? Y or N by check box. If yes, complete 9, 9a and 9d. 12 PATIENT S O AUTHOIZED PESON S SIGNATUE Not required 13 INSUED S O AUTHOIZED PESON S SIGNATUE Not required 14 DATE OF UENT: ILLNESS (First symptom) O INJUY (AIDENT) O PEGNANY (LMP) Enter the three character qualifier to the right of the vertical dotted line to identify which date is being reported. Page 7 of 50

8 15 OTHE DATE Enter additional date information about the patient s condition or treatment. Enter the three character qualifier between the vertical dotted lines to identify which date is being reported. MS 1500 laim Field Field Description Instructions and omments DATES PATIENT UNABLE TO WOK IN UENT OUPATION NAME OF EFEING PHYSIIAN O OTHE SOUE EQUIED if a provider other than the member s primary care physician rendered invoiced services. equired or onditional* 17A I.D. NUMBE OF EFEING PHYSIIAN Enter Passport provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of field 17A. 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. EQUIED if field 17 is completed. 17B NATIONAL POVIDE IDENTIFIE (NPI) Enter the NPI number of the referring provider, ordering provider or other source. EQUIED if field 17 is completed. 18 HOSPITALIZATION DATES ELATED TO UENT SEVIES EQUIED when place of service is inpatient. MMDDYY 19 BILLING POVIDE S TAXONOMY ODE 20 OUTSIDE LAB HAGES Populate field with the ZZ qualifier ID and the Billing Provider s Primary Taxonomy ode. For billing diagnostic tests subject to purchase price limitations. 21 DIAGNOSIS O NATUE OF ILLNESS O INJUY (elate A-L to service line below (24E). All diagnosis codes must be valid for the date of service. E codes are NOT acceptable as a primary diagnosis. List in priority order. Page 8 of 50

9 22 ESUBMISSION ODE AND OIGINAL EFEENE NUMBE For resubmissions or adjustments, enter the appropriate bill frequency code and the claim ID number of the original claim. NOTE: esubmissions may NOT currently be submitted via EDI. Original claim ID is required if claim is a corrected or resubmitted claim. MS 1500 laim Field Field Description Instructions and omments equired or onditional* 23 PIO AUTHOIZATION NUMBE Enter the referral or authorization number. efer to Section 18.6 in this Provider Manual to determine if services rendered require an authorization or referral. 24A DATE (S) OF SEVIE From date: MMDDYY. 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. 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 POEDUES, SEVIES O SUPPLIES PT/HPS MODIFIE Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of service. NOTE: Modifiers affecting reimbursement must be placed in the 1st position. 24E DIAGNOSIS ODE Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (A-L). All diagnosis codes must be valid for the date of service. Page 9 of 50

10 24F HAGES Enter charges for each line item. Value entered must be greater than zero ($0.01) 24G DAYS O UNITS Enter quantity for each line item. Value entered must be greater than zero (EDI allows two characters). 24H EPSDT FAMILY PLAN Not required MS 1500 laim Field Field Description Instructions and omments 24I ID QUALIFIE If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is reported in the qualifier in field 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 shaded area allows you to identify the two-character qualifier ID of the endering Provider (G2). The un-shaded area is pre-filled with NPI. equired or onditional* 24J ENDEING POVIDE ID The shaded area allows you to submit Passport assigned provider ID number of the endering Provider which coincides with the two- character qualifier ID reported in 24I. The unshaded area accommodates the endering Provider s NPI. 25 FEDEAL TAX I.D. NUMBE SSN/ EIN Physician or supplier s Federal Tax ID number. 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 form for the section pertaining to Medicaid payments. Page 10 of 50

11 28 TOTAL HAGE 29 AMOUNT PAID Enter the total of all charges listed on the claim. Value entered must be greater than zero dollars ($0.00). EQUIED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing Passport. Medicaid programs are always the payers of last resort. 30 ESEVED FO NU USE Not equired MS 1500 laim Field Field Description Instructions and omments equired or onditional* 31 SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS / DATE Signature on file, signature stamp, computer generated or actual signature is acceptable A NAME AND ADDESS OF FAILITY WHEE SEVIES WEE ENDEED (if other than home or office). SEVIE FAILITY NPI NUMBE EQUIED unless field 33 is the same information. Enter the physical location (P.O. Box Numbers are not acceptable here). equired unless rendering provider is atypical and is not required. 32B 33 SEVIE FAILITY TWO HAATE QUALIFIED ID AND UENT POVIDES ID NUMBES BILLING POVIDE INFO & TELEPHONE NUMBE EQUIED - 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 BILLING POVIDE NPI NUMBE EQUIED Page 11 of 50

12 33B POVIDE S GOUP TAXONOMY ODE Populate field with the ZZ qualifier ID and the Group Provider s Primary Taxonomy ode UB-04 laim Form and equired Fields Although the UB-04 claim form accommodates the NPI, you are encouraged to report your current Passport Provider Identification Numbers in the appropriate areas of the form. equired Fields UB-04 laim Form NOTE: *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. equired fields for the UB-04 laim Form Field Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X equired or equired or onditional* onditional* 1 Billing Provider Name, Address and Telephone Number Line A: Enter the complete provider name. Line B: Enter the complete address or post office number. Line : ity, State, and Zip ode Line D: Enter the area code, telephone number. Left justified. Page 12 of 50

13 2 Pay-to Name and Address Enter the facility Medical Assistance I.D. (MAID) number. Left Justified. 3A PATIENT ONTOL NO. Provider s patient account/control number 3B MEDIAL/HEALTH EOD NUMBE The number assigned to the member s medical/health record by the provider. 4 TYPE OF BILL Enter the appropriate three-digit or four-digit code. 1st position is a leading zero. (Note: 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. Page 13 of 50

14 Field Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X equired or onditional* 5 FED. TAX NO. 6 STATEMENT OVES PEIOD FOM/ THOUGH Enter the number assigned by the federal government for tax reporting purposes. Enter dates for the full ranges of services being invoiced. MMDDYY 7 UNLABELED Not used leave blank. 8A 8B PATIENT IDENTIFIE PATIENT NAME Patient ID is conditional if the number is different from field 60. Last name, first name, and middle initial. Enter the member s name as it appears on the member s Passport 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. No space should be left after the prefix of a name (e.g. McKendrick). Both names should be capitalized and separated by a hyphen (no space). A space should separate a last name and suffix. 9A-E PATIENT ADDESS Enter the member s complete mailing address. 9A. Street Address 9B. ity 9. State 9D. ZIP ode 9E. ountry code (report if other than USA) 10 BITH DATE Member s Date of Birth MMDDYYYY 11 SEX Enter the member s sex as recorded at the time of admission, outpatient service or start of care. Only M and F are acceptable. Page 14 of 50

15 Field Field Description Instructions and omments 12A ADMISSION B ADMISSION DATE 13 ADMISSION HOU 14 ADMISSION TYPE 15 ADMISSION S (Source of eferral for Admission or Visit) 16 D H (Discharge Hour) 17 Patient Discharge Status ONDITION ODES (the following is unique to Medicare eligible Nursing Facilities; condition codes should be billed when Medicare Part A does not cover Nursing Facility Services) The start date for this episode of care. For inpatient services, this is the date of admission. ight Justified. The code referring to the hour during which the member was admitted for inpatient or outpatient care. Left justified. A code indicating the priority of this admission/visit. A code indicating the source of the referral for the admission or visit. A code indicating the discharge hour of the member from inpatient care. A code indicating the disposition or discharge status of the member at the end service for the period covered on this bill, as reported in field 6. A code(s) used to identify conditions or events relating to this bill that may affect processing. Enter one of the following codes in the second column as a eason ode: 35 if Medicare benefits are exhausted. 50 if one of the following applies to why Medicare does not cover the services: No 3-day prior hospital stay; Not within 30-days of hospital discharge; 100 benefit days are exhausted ; No 60 day break in daily skilled care; Medical necessity requirements are not met; and/or, Daily skilled requirements are not met. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X equired or equired or onditional* onditional* Not required Page 15 of 50

16 Field Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X equired or onditional* 29 AIDENT STATE The accident state field contains the two digit state abbreviation where the accident occurred. EQUIED when applicable. 30 UNLABELED FIELD Enter DG on the lower line. EQUIED when applicable. 31A, B- 34A, B OUENE ODES AND DATES Enter the appropriate occurrence code and date. EQUIED when applicable. 35A, B- 36A, B OUENE SPAN ODES AND DATES A code and the related dates that identify an event that relates to the payment of the claims. EQUIED when applicable. 37A, B UNLABELED FIELD 38 ESPONSIBLE PATY The name and address of the party responsible for the bill. 39A, B,, D- 41A, B,, 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. EQUIED when applicable. NOTE: If a value code is populated, then the 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. Page 16 of 50

17 Field Field Description Instructions and omments 43 DESIPTION 44 HPS/ATE S/ HIPPS ODE 45 SEV. DATE 46 SEV. UNITS 47 TOTAL HAGES The standard abbreviated description of related revenue code categories is included on this bill. See the NUB instructions for field 42 for a description of each revenue/code category. 1. The Healthcare ommon Procedure oding System (HPS) is applicable to ancillary services 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 casemix 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. eport line item dates of service for each revenue code or HPS/PT code. eport units of service. A quantitative measure of service rendered by revenue category to or for the patient to include items such as number of accommodations days, miles, pints of blood, renal dialysis treatments, etc. 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 charges include both covered and non-covered charges. eport grand total of submitted charges. Value entered must be greater than zero dollars ($0.00). Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X equired or equired or onditional* onditional* Page 17 of 50

18 Field Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X equired or equired or onditional* onditional* 48 NONOVEED HAGES To reflect the non-coverage charges for the destination payer as it pertains to the related revenue code. EQUIED when Medicare is primary. 49 UNLABELED FIELD Not required Not required 50 PAYE Enter the name for each payer being invoiced. When the member has other coverage, list the payers as indicated below. Line A refers to the primary payer; B, secondary; and, tertiary. 51 HEALTH PLAN ID The number used by the health plan to identify itself. Passport 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 refers to secondary; and refers to tertiary. It is expected that the provider/ practitioner 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). 54 PIO PAYMENTS The A, B, indicators refer to the information in Field EST. AMOUNT DUE Enter the estimated amount due (the difference between total charges and any deductions such as other coverage). Page 18 of 50

19 Field Field Description Instructions and omments 56 57A, B NATIONAL POVIDE IDENTIFIE-BILLING POVIDE OTHE (BILLING) POVIDE IDENTIFIE 58 INSUED S NAME 59 P. EL 60 INSUED S UNIQUE ID 61 GOUP NAME The unique identification number assigned to the provider submitting the bill; NPI is the national provider identifier. EQUIED if the health care provider is a overed Entity as defined in HIPAA egulation. A unique identification number assigned by the health plan to the provider submitting the bill. EQUIED on or after May 23, 2007 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,. Information refers to the payers listed in field 50. In most cases, this will be the member s name. When other coverage is available, the insured is indicated here. Enter the member s relationship to insured. For Medicaid programs the member is the insured. (ode 01: Patient is Insured) Enter the member s Passport ID, exactly as it appears on the member s ID card, on line B or. When other insurance is present, enter the Passport 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, secondary; and, tertiary. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X equired or onditional* Page 19 of 50

20 Field Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X equired or equired or onditional* onditional* 62 INSUANE GOUP NO. Use this field only when a member has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B refers to secondary; and refers to tertiary. 63 TEATMENT AUTHOIZATI ON ODES Enter the Passport referral or authorization number. Line A refers to the primary payer; B refers to secondary; and refers to tertiary. 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 (ES). The ES field has been eliminated. NOTE: esubmitted claims must contain the original claim ID. 65 EMPLOYE NAME The name of the employer that provides health care coverage for the insured individual identified in field 58. EQUIED when the employer of the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer; B refers to secondary; and refers to tertiary. 66 DIAGNOSIS AND POEDUE ODE QUALIFIE (ID VESION INDIATO) The qualifier that denotes the version of International lassification of Diseases (ID) reported. Not required. Page 20 of 50

21 Field Field Description Instructions and omments 67 PIN. DIAG. D. AND PESENT ON ADMISSION (POA) INDIATO 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 member for care). Present on Admission (POA) 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 POA. The POA Indicator is applied to the principal diagnosis as well as all secondary diagnoses reported. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X equired or onditional* 67 A-Q OTHE DIAG. ODES 67A-Q 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 ADM. DIAG. D. 70 PATIENT S EASON FO VISIT The ID diagnosis code describing the member s diagnosis at the time of admission. EQUIED for inpatient admissions. Each diagnosis code must be valid for the date of service. The ID-9-M diagnosis codes describing the member s reason for visit at the time of outpatient registration. EQUIED for all unscheduled outpatient visits. Up to three ID-9-M codes may be entered in fields A,B, &. Page 21 of 50