Claim Filing Instructions

Transcription

1 laim Filing Instructions evised October 2014

2 NOTES

3 Arbor Health Plan laim Filing Instructions ontents laim Filing... 1 Procedures for laim Submission... 1 laim Mailing Instructions... 2 laim Filing Deadlines... 2 efunds for laims Overpayments or Errors... 2 laim Form Field equirements... 4 equired Fields (MS 1500 laim Form)... 4 EDI Mapping for MS equired Fields (UB-04 laim Forms) EDI Mapping Table (UB04) Special Instructions and Examples for MS 1500, UB-04 and EDI (837) laims Submissions.. 45 I. Supplemental Information A. MS 1500 Paper laims Field 24: B. EDI Field 24D (Professional) EDI Field 33b (Professional) D. EDI Field 45 and 51(Institutional) E. eporting ND on MS-1500 and UB-04 and EDI ommon auses of laim Processing Delays, ejections or Denials Electronic Data Interchange (EDI) for Medical and Hospital laims 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 Exclusions ommon ejections esubmitted Professional orrected laims Supplemental Information Ambulance... 60

4 Ambulatory Surgical enters Anesthesia Audiology Behavioral Health hemotherapy hiropractic are Dental Services Diabetic Self-Management Training Dialysis Durable Medical Equipment EPSDT Supplemental Billing Information EPSDT Medical Screening EPSDT Vision Screening EPSDT Subjective Vision Screening EPSDT Objective Vision Screening EPSDT Hearing Screening EPSDT Subjective Hearing Screening EPSDT Objective Hearing Screening EPSDT Interperiodic Screenings EPSDT egistered Nurse Interperiodic screening codes: HEALTH HEK (EPSDT) eferral Indicators odes: Family Planning H/FQH Billing and eimbursement Home Health are (HH) Immunization Infusion Therapy Injectable Drugs Maternity Physical/Occupational and Speech Therapies Observation Outpatient Hospital Services adiology Services Surgery Swing Bed Services Transplants Tribal linic Services Tribal Hospital-Based Facility Services... 73

5 Tribal Inpatient ehabilitation Services Electronic Billing Inquiries... 74

6 laims Filing Procedure laim Filing Procedures for laim Submission Arbor Health Plan, hereinafter referred to as the Plan or Arbor Health 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 Arbor Health Plan for correction and re-submission. laims for billable services provided to Arbor Health Plan members must be submitted by the provider who performed the services. laims filed with Arbor Health 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 member eligibility for services under Arbor Health 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 is eligible to participate with the Medicaid Program at the time of service. 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 thirdparty resources and, if so, verification that the Plan is the payer of last resort on all claims submitted to the Plan. Plan should not be listed as other payer. IMPOTANT: ejected claims are defined as claims with invalid or required missing 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. 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 Arbor Health Plan guidelines. They should be resubmitted as a corrected claim. Denied claims must be resubmitted as corrected claims within 90 calendar days from the EOB (denial or payment) if the error is a repairable edit. 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. * 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 information 1 Provider Services

7 laims Filing Procedure laim Mailing Instructions Submit claims to Arbor Health Plan at the following address: Arbor Health Plan laims Processing Department P.O. Box 7336 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 Arbor Health Plan EDI Technical Support Hotline at or by at edi.arbor@amerihealthmercy.com laim Filing Deadlines Original invoices must be submitted to the Plan within 365 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 90 calendar days from the EOB (denial or payment). laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 365 days of the date of service or within 60 days of the primary insurer s EOB adjudication, whichever is longer. Timely Filing of laims with asualty Insurance: Providers must submit claims within 24 months of the date of service. Important: equests for adjustments may be submitted electronically, on paper or by telephone. By Telephone: Provider laim Services (Select the prompts for the correct Plan, and then select the prompt for claim issues.) On Paper: If you prefer to write, please be sure to stamp each claim submitted corrected or resubmission and address the letter to: laims Processing Department Arbor Health Plan P.O London, KY Administrative or medical appeals must be submitted in writing to: Provider Appeals Department Arbor Health Plan P.O. Box 7334 London, KY efer to the Provider Handbook or look online at the Provider enter of the Arbor Health Plan website at for complete instructions on submitting appeals. Important: laims originally rejected for missing or invalid data elements must be corrected and re-submitted within 365 calendar days from 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.) Note: Arbor Health Plan EDI Payer 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 information 2 Provider Services

8 laims Filing Procedure efunds for laims Overpayments or Errors Medicaid Program funds that were improperly paid must be returned. If the provider s practice determines that it has received overpayments or improper payments, the provider is required to make arrangements immediately to return the funds. ontact Provider laim Services at to arrange the repayment. There are two ways to return overpayments: 1. The provider s account will have a balance due. laims overpayments will be deducted from future claims payments. 2. However, if you wish to return the overpayment, please submit a check in the correct amount to: Arbor Health Plan P.O. Box 7336 London, KY Note: Please include the member s name and ID, date of service, and laim 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 information 2 Provider Services

9 MS 1500 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 information. 3 Provider Services

10 MS 1500 laim Form Field equirements 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 365 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 Instructions and omments equired or onditional* 1 Insurance Program Identification heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. 1a Insured ID Number (Arbor Health Plan member s identification number) 2 Patient s Name (Last, First, Middle Initial) Arbor Health Plan member identification number. The newborn will have regular or FFS Medicaid until enrollment in managed care becomes active. harges incurred during this period would be payable to the provider by fee for service (DHHS) since managed care eligibility will not be effective retroactively to the date of birth. Enter the patient s name as it appears on the member s Arbor Health Plan I.D. card. efer to page 45 for additional newborn billing information, including Multiple Births. 3 Patient s Birth Date/Sex MMDDYY / M or F If submitting a claim for a newborn, enter newborn and DOB/Sex * 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 information. 4 Provider Services

11 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 4 Insured s Name (Last, First, Middle Initial) 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (include area code) Enter the patient s name as it appears on the member s Arbor 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.) 6 Patient elationship To Insured Always indicate self. 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) 8 eserved for NU use To be determined. Not equired 9 Other Insured's Name (Last, First, Middle Initial) 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. 9a Other Insured's Policy Or Group # equired if # 9 is completed. 9b eserved for NU use To be determined. Not equired 9c eserved for NU use To be determined. Not equired 9d Insurance Plan Name Or Program Name equired if # 9 is completed. 10a,b,c Is Patient's ondition elated To: Indicate Yes or No for each category. Is condition related to: a) Employment b) Auto Accident c) Other Accident * 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 information. 5 Provider Services

12 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 10d laim odes (Designated by NU) 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: AD Abortion Performed due to a Life Endangering Physical ondition aused by, Arising from or Exacerbated by the Pregnancy Itself W3 Level 1 Appeal 11 Insured's Policy Group Or FEA # equired when other insurance is available. omplete if more than one Other Medical insurance is available, or if yes to 10a, b, c. 11a Insured's Birth Date / Sex Same as # 3. equired if 11 is completed. 11b 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 Enter qualifier to the left of the vertical, dotted line; identifier to the right of the vertical, dotted line. 11c Insurance Plan Name Or Program Name Enter name of Health Plan. equired if 11 is completed. * 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 information. 6 Provider Services

13 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 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) 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 information. 7 Provider Services

14 MS 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 * 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 information. 8 Provider Services

15 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 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 ID Number Of eferring Physician (Arbor Health Plan Provider ID#) Enter the Arbor 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 Arbor Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. equired if # 17 is completed. * 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 information. 9 Provider Services

16 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 17b National Provider Identifier (NPI) (enter the referring provider s NPI) 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU)eserved for Nebraska Medicaid Provider ID 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 (indicate from and to date) Enter the Individual Provider's Medicaid Provider ID. Enter additional claim information with identifying qualifiers as appropriate. For multiple items, enter three blank spaces before entering the next qualifier and data combination. 20 Outside Lab Optional 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) 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. 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 description in this field. Note: laims with invalid diagnosis codes will be denied for payment. * 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 information Provider Services

17 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 22 esubmission ode and/or Original ef. No 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 23 Prior Authorization Number Enter the prior authorization number. efer to the Provider Handbook to determine if services rendered require an authorization 24A Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J From date: MMDDYY. If the service was performed on one day there is no need to complete the to date. See page 41 for Important Note (instructions) for completing the shaded portion of field B Place Of Service 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, Services Or Supplies PT/HPS/ Modifier Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of service. Note: Modifiers affecting reimbursement must be placed in the first modifier position 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 codes for the date of service. * 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 information Provider Services

18 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 24F harges Enter charges. Value entered must be greater than zero ($0.00) 24G Days Or Units Enter quantity. Value entered must be greater than zero. 24H EPSDT Family Plan In unshaded area, enter last digit of appropriate HEALTH HEK (EPSDT) referral indicator code with the PT well-child preventive procedure codes with the required EP modifier. See page 67 in Supplemental section for additional guidance on reporting EPSDT referrals (Field allows up to 3 digits). Preventive care for persons under 21: One of the following referral indicator codes MUST be included on claims using PT well-child preventive procedure codes (Electronic 837P or MS 1500 box 24H). AV - Patient refused referral; S2 - Patient is currently under treatment for referred diagnostic or corrective health problems; NU - No referral given; or ST - eferral to another provider for diagnostic or corrective treatment. onditional 24I ID Qualifier If the rendering provider does not have a NPI number, the qualifier indicating what the number represents is reported in the qualifier field in 24I. If the Other ID number is the Arbor Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. 24J endering Provider ID In the top (shaded) portion, enter the Arbor Health Plan Provider ID number In the bottom (unshaded) portion, enter the NPI The individual rendering the service is reported in 24J. Enter the Arbor Health Plan ID number in the shaded area of the field. Enter the NPI number in the unshaded area of the field. 25 Federal Tax ID Number SSN/EIN Physician or Supplier's Federal Tax ID number. 26 Patient's Account No. Enter the patient s account number assigned by the provider ecommended * 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 information Provider Services

19 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 27 Accept Assignment Yes or No must be checked. 28 Total harge Enter the total of all charges listed on the claim. 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 To be determined. Not equired 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). Signature on file, signature stamp, computer generated or actual signature is acceptable. equired. Enter the physical location. (P.O. Box # s are not acceptable here.) 32a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 32b. Other ID# (Arbor Health Plan issued Provider Identification Number) efer to NU MS 1500 claims filing guidelines for the two digit qualifiers used to describe the non- NPI provider ID number. Enter the Arbor Health Plan Provider ID # (strongly recommended) Enter the G2 qualifier followed by the Arbor Health Plan Provider ID # equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the twodigit 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 () 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 information Provider Services

20 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 33 Billing Provider Info & Ph # 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# (Arbor Health Plan issued Provider Identification Number) efer to NU MS 1500 claims filing guidelines for the two digit qualifiers used to describe the non- NPI provider ID number. Enter the Arbor Health Plan Provider ID # (strongly recommended.) Enter the G2 qualifier followed by the Arbor Health Plan Provider ID #. equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the twodigit 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 () 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 information Provider Services

21 Professional laims EDI Mapping EDI Mapping for MS 1500 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) 2010BA/N3/N4 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 * 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 information Provider Services

22 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 10a,b,c Is Patient's ondition elated To: 2300/LM11 10d laim odes (Designated by NU) Not in IG 11 Insured's Policy Group Or FEA # 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 /DTP03 N 15 Other Date 2300/DTP 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 * 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 information Provider Services

23 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU) 2300/DTP 2300/NTE01 20 Outside Lab 2400/PS102 N 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) 22 esubmission ode and/or Original ef. NoUsed for Original laim # 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 N 2300, HIXX 2300/EF/Qualifier F8 2300/EF/Qualifier 9F 2300/EF/Qualifier G1 2300/EF/ Qualifier 9F 2400/DTP 24B Place Of Service 2400/SV EMG 2400/SV109 N N 24D Procedures, Services Or Supplies PT/HPS Modifier 2400/SV1 24E Diagnosis Pointer 2400/SV1 24F harges 2400/SV1 24G Days Or Units 2400/SV1 24H EPSDT Family Plan 2400/SV1 24I ID Qualifier 2310B/EF01 * 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 information Provider Services

24 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 24J endering Provider ID 2310B/NM Federal Tax ID Number SSN/EIN of Billing Provider 2310B/EF AA/EF 26 Patient's Account No. 2300/ML01 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 2320/AMT Qualifier D 30 eserved for NU Use 2320/AMT Qualifier EAF 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 Loop 2300/LM D/2310E 2300/ & 1 N 32a. NPI number of Supervising Provider name 32b. Other ID# (Arbor Health Plan issued Provider Identification Number) Strongly recommended 2310/NM1 2310/EF01=G2 * 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 information Provider Services

25 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 33 Billing Provider Info & Ph # 2010AA/NM1 2010AA/N3 2010AA/N4 2010AA/PE 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 2000A/PV 33a. NPI number 2010AA 33b. Other ID# Arbor Health Plan issued Provider Identification #) Strongly recommended equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. If Billing is also the endering Provider: 2010BB/EF Enter the Arbor Health Plan Provider ID # (strongly encouraged.) Enter the G2 qualifier followed by the Arbor 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 information Provider Services

26 UB-04 laim 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 information Provider Services