Keystone First. Claim Filing Instructions

Transcription

1 Keystone First Claim Filing Instructions

2 Keystone First Table of Contents Section Title Page # Claim Filing 1 Procedures f Claim Submission 1 Claim Mailing Instructions 2 Claim Filing Deadlines 2 Exceptions 2 Refunds f Claims Overpayment 3 Claim Fm Field Requirements 5 Fields (CMS 1500 Claim Fm) 5 Fields (UB-04 Claim Fm) 18 Instructions & Examples of Supplemental Infmation 40 Repting Supplemental Info on Claims 40 Repting NDC on Professional Claims 41 Repting NDC on Institutional Claims 41 Repting POA on Institutional Claims 45 Common Causes of Claim Processing Delays, Rejections, Denials 49 Electronic Data Interchange (EDI) 49 Hardware and Software Requirements 50 Contracting with Emdeon and Other Electronic Vends 50 Contacting the EDI Technical Suppt Group 50 Specific Data Recd Requirements 51 Electronic Claim Flow Description 51 Invalid Electronic Claim Recd Rejections/Denials 52 Plan Specific Electronic Edit Requirements 52 Exclusions 52 Common Rejections 53 Resubmitted Professional Crected Claims 53 Electronic Billing Inquiries 53 2

3 Table of Contents Section Title Page # Tips f Accurate Diagnosis Coding 56 Appendix Supplemental Infmation 58 Ambulance 59 Anesthesia 59 Audiology 59 Chemotherapy 60 Chiropractic Care 60 Dialysis 60 DME 60 EPSDT Billing Guidelines 60 Fact Drug 63 Family Planning 63 Home Health Care 63 Infusion Therapy 64 Injectable Drugs 64 Maternity 64 Multiple Surgery Reduction Payment Policy 64 Physical Occupational and Speech Therapy 65 Termination of Pregnancy 65 ICD-10 Infmation 65 Most Common Claims Errs 67 3

4 Claim Filing Procedures f Claim Submission Keystone First, hereafter referred to as the Plan, is required by State and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in der to ensure timely processing of claims. When required data elements are missing are invalid, claims will be rejected by the Plan f crection and resubmission. Claims f billable and capitated services provided to Plan members must be submitted by the provider who perfmed the services. Claims filed with the Plan are subject to the following procedures: Verification that all required fields are completed on the CMS 1500 UB-04 fms. Verification that all Diagnosis and Procedure Codes are valid f the date of service. Verification f electronic claims against 837 edits at Emdeon Verification of the referral f Specialist non-primary Care Physician claims. IMPORTANT: Rejected claims are defined as claims with invalid required missing data elements, such as the provider tax identification number, member ID number, that are returned to the provider EDI* source without registration in the claim processing system. Rejected 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 f payment under Plan guidelines. They should be resubmitted as a crected claim. Denied claims must be re-submitted as crected claims within 365 calendar days from the date of service. Set claim frequency code crectly and send the iginal claim number. Note: These requirements apply to claims submitted on paper electronically. * F me infmation on EDI, review the section titled Electronic Data Interchange (EDI) f Medical and Hospital Claims in this booklet. Verification of member eligibility f services under the Plan during the time period in which services were provided. Verification that the services were provided by a participating provider that the out of plan provider has received authization to provide services to the eligible member. Verification that the provider participated with the Medical Assistance Program at the time of service. Verification that an authization has been given f services that require pri authization by the Plan. Verification of whether there is Medicare coverage any other third party resources and, if so, verification that the Plan is the payer of last rest on all claims submitted to the Plan. 1

5 Claim Mailing Instructions Submit claims to Keystone First at the following address: Claim Processing Department Keystone First P.O. Box 7115 London, KY The Plan encourages all providers to submit claims electronically. F those interested in electronic claim filing, contact your EDI software vend Emdeon s Provider Suppt Line at to arrange transmission. Any additional questions may be directed to the EDI Technical Suppt Hotline at by at edi@keystonefirstpa.com Claim Filing Deadlines Original invoices must be submitted to the Plan within 180 calendar days from the date services were rendered compensable items were provided. Re-submission of previously denied claims with crections and requests f adjustments must be submitted within 365 calendar days from the date services were rendered compensable items were provided. Exceptions Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer s EOB (claim adjudication). Imptant: Claims iginally rejected f missing invalid data elements must be crected and re-submitted within 180 calendar days from the date of service. Rejected claims are not registered as received in the claim processing system. (Refer to the definitions of rejected and denied claims on page 1.) Claims Processing Department Keystone First P.O. Box 7115 London, KY Electronically: Mark claim frequency code 6 and use CLM05-3 to rept claims adjustments electronically. Include the iginal claim number. Outpatient medical appeals must be submitted in writing to: Provider Appeals Department Keystone First PO Box 7316 London, KY Inpatient medical appeals must be submitted in writing to: Provider Appeals Department Keystone First PO Box 7307 London, KY Written Disputes should be mailed to: Infmal Practitioner Dispute Keystone First Airpt Business Center 200 Stevens Drive Philadelphia, PA Refer to the Provider Manual f complete instructions on submitting appeals. Note: Keystone First EDI Payer ID# Imptant: Requests f adjustments may be submitted by telephone to: Provider Claim Services (Select the prompts f the crect Plan, and then, select the prompt f claim issues.) If submitting via paper EDI, please include the iginal claim number. If you prefer to write, please be sure to stamp each claim submitted crected resubmission and address the letter to: 2

6 Refunds f Claims Overpayments Errs Keystone First and the Pennsylvania Department of Human Services encourage providers to conduct regular self-audits to ensure accurate payment. Medicaid program funds that were improperly paid overpaid must be returned. If the provider s practice determines that it has received overpayments improper payments, the provider is required to make immediate arrangements to return the funds to Keystone First follow the DHS protocols f returning improper payments overpayment. A. Contact Keystone First Provider Claim Services at to arrange the repayment. There are two ways to return overpayments to Keystone First: 1. Have Keystone First deduct the overpayment/improper payment amount from future claims payments. 2. Submit a check f the overpayment/improper amount directly to: Claims Processing Department Keystone First PO Box 7115 London, KY Note: Please include the member s name and ID, date of service, and Claim ID B. Providers may follow the Pennsylvania Medical Assistance (MA) Provider Self-audit Protocol to return improper payments overpayments. Access the DHS voluntary protocol process via the following link: DHS Provider Self-Audit Protocol 3 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

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8 CMS-1500 Fm Requirements Claim Fm Field Requirements The following charts describe the required fields that must be completed f the standard Centers f Medicare and Medicaid Services (CMS) CMS 1500 UB-04 claim fms. If the field is required without exception, an R () is noted in the al box. If completing the field is dependent upon certain circumstances, the requirement is listed as C (al) and the relevant conditions are explained in the Instructions and Comments box. The CMS 1500 claim fm must be completed f all professional medical services, and the UB-04 claim fm must be completed f 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 fms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic paper). Fields (CMS 1500 Claim Fm) CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment N/A Carrier Block 2010BB NM103 N301 N302 N401 N402 N403 1 Insurance Program Identification 1a Insured I.D. Number 2 Patient s Name (Last, First, Middle Initial) Check only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Health Plan s member identification number. If submitting a claim f a newbn that does not have an identification number, enter the mother s ID number. F electronic submissions, ID must be less than 13 alphanumeric characters. Innetwk providers: please omit the three alpha characters preceding the member s ID number on the claim. Out of area providers: please enter the three alpha characters preceding the member s ID number on the claim. Enter the patient s name as it appears on the member s Health Plan I.D. card. If submitting a claim f a newbn that does not have an identification number, enter Baby Girl Baby Boy and last name. 5 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. Notes R 2000B SBR09 Title Claim Filing Indicat in 837P. R 2010BA NM109 Titled Subscriber Primary Identifier In the 837P. R 2010CA 2010BA NM103 NM104 NM105 NM107

9 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment Notes Refer to page 22 f additional newbn billing infmation, including Multiple Births. 3 Patient s Birth Date / Sex MMDDYY / M F If submitting a claim f a newbn, enter newbn and DOB/Sex R 2010CA 2010BA DMG02 DMG03 4 Insured s Name (Last, First, Middle Initial) 5 Patient s Address (Number, Street, City, State, Zip) Telephone (include area code) 6 Patient Relationship To Insured 7 Insured s Address (Number, Street, City, State, Zip Code) Telephone (Include Area Code) Enter the patient s name as it appears on the member s Health Plan I.D. card, Enter the newbn s name when the patient is a newbn. Enter the patient s complete address and telephone number. (Do not punctuate the address phone number.) Always indicate self unless covered by someone else s insurance. If same as the patient, enter Same. Otherwise, enter insured s infmation. 8 Patient Status Not R 2010BA NM103 NM104 NM105 NM107 R 2010CA NM302 N402 N403 N404 R 2000B 2000C SBR02 PAT01 C 2010BA N301 N302 N401 N402 N403 Title Subscriber in 837P. Title individual relationship code in 837P. Title subscriber address in 837P. 9 Other Insured's Name (Last, First, Middle Initial) Refers to someone other than the patient. Completion of fields 9a through 9d is if patient is covered by another insurance plan. Enter the complete name of the insured. Note: "COB claims that require attached EOBs must be submitted on paper. C 2330A N103 N104 N105 N10Y If patient can be uniquely identified to the other provider in this loop by the unique member ID then the patient is the subscriber 6 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

10 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # 9a 9b 9c 9d 10a, b,c Field Description Other Insured's Policy Or Group # Reserved f NUCC use Reserved f NUCC use Insurance Plan Name Or Program Name Is Patient's Related To: Instructions and Comments Loop ID Segment Notes and identified in this loop. if # 9 is completed. C 2320 SBR03 Title Group Policy Number in 837P. Not N/A N/A Does not exist in 837P. Not N/A N/A Does not exist in if # 9 is completed. List name of other health plan, if applicable. when other insurance is available. Complete if me than one other Medical insurance is available, if 9a completed. Indicate Yes No f each categy. Is condition related to: a) Employment b) Auto Accident c) Other Accident 837P. C 2320 SBR04 Title other insurance group in 837P. R 2300 CLM11 Titled related causes code in 873P. 10d Claim Codes (Designated by NUCC) To comply with DHS s EPSDT repting requirements, continue to use this field to rept EPSDT referral codes as follows; YD Dental ( f Age 3 and above) YO Other YV Vision YH Hearing YB Behavial YM - Medical C 2300 K3 This is specific coding f Wkers Comp Codes. F all other claims enter new Codes as appropriate. Available 2-digit Codes include nine codes f abtion services and four codes f wker s compensation. Please refer to NUCC f the complete list of codes. Examples include: AD Abtion Perfmed due to a Life Endangering Physical Caused by, Arising from 7 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

11 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 11 Insured's Policy Group Or FECA # 11a Insured's Birth Date / Sex Instructions and Comments Exacerbated by the Pregnancy Itself W3 Level 1 Appeal when other insurance is available. Complete if me than one other Medical insurance is available, if yes to 10a, b, c. Enter the policy group FECA Loop ID Segment Notes C 2000B SBR03 Subscriber group policy # in 837P. number. Same as # 3. if 11 is completed. C 2010BA DMG02 DMG03 11b Other Claim ID Enter the following qualifier and accompanying identifier to rept the claim number assigned by the payer f wker s compensation property and casualty: Y4 Property Casualty Claim Number C Title Subscriber DOB and Gender on 837P. 11c Insurance Plan Name Or Program Name 11d Is There Another Health Benefit Plan? 12 Patient's Or Authized Person's Signature 13 Insured's Or Authized Person's Signature Enter qualifier to the left of the vertical, dotted line; identifier to the right of the vertical, dotted line. Enter name of Health Plan. if 11 is completed. Y N by check box. If yes, complete # 9 a-d. On the 837, the following values are addressed as follows at Emdeon: A, Y, M, O R, then change to Y, else send I (f N I ). C 2000B SBR04 R 2320 If yes, indicates Y f yes. R 2300 CLM09 Release of infmation code. C 2300 CLM08 Benefit Assignment Indicat 8 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

12 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 14 Date Of Current Illness Injury, Pregnancy (LMP) Instructions and Comments MMDDYY MMDDYYYY Enter applicable 3-digit qualifier to right of vertical dotted line. Qualifiers include: 431 Onset of Current Symptoms Illness 439 Accident Date 484 Last Menstrual Period (LMP) Use the LMP f pregnancy. Example: Loop ID Segment C 2300 DTP03 Notes 15 Other Date MMDDYY MMDDYYYY Enter applicable 3-digit qualifier between the left-hand set of vertical dotted lines. Qualifiers include: 454 Initial Treatment 304 Latest Visit Consultation 453 Acute Manifestation of a Chronic 439 Accident 455 Last X-Ray 471 Prescription 090 Rept Start (Assumed Care Date) 091 Rept End (Relinquished Care Date) 444 First Visit Consultation Example: C 2300 DTP03 16 Dates Patient Unable To Wk In Current Occupation 17 Name Of Referring Physician Or Other Source 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 C 2300 DTP03 Disability Dates Qualifier * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. R 2310A (Referri ng) 2310D N103 N104 N105 N107

13 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment Notes multiple providers are involved, enter one provider using the following priity der: 1. Referring Provider 2. Ordering Provider 3. Supervising Provider (Superv ising) Qualifiers include: DN Referring Provider DK Ordering Provider DQ Supervising Provider Example: 17a Other I.D. Number Of Referring Physician Enter the Health Plan provider number f the referring physician. The qualifier indicating what the number represents is repted in the qualifier field to the immediate right of 17a. If the Other ID number is the Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NUCC guidelines f the appropriate qualifier. The NUCC defines the following qualifiers: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (This qualifier is used f Supervising Provider only.) C 17b National Provider Identifier (NPI) 18 Hospitalization Dates Related To Current Services 19 Additional Claim Infmation (Designated by if # 17 is completed. Enter the NPI number of the referring provider, dering provider other source. if #17 is completed. when place of service is inpatient. MMDDYY (indicate from and to date) Enter additional claim infmation with identifying qualifiers as appropriate. F multiple items, enter three blank spaces befe entering the next qualifier and data R C 2300 DTP03 Related to Admission and discharge dates on 837P. Not 2300 NTE PWK 10 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

14 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment NUCC) combination. The NUCC defines the following qualifiers: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (This qualifier is used f Supervising Provider only) N5 Provider Plan Netwk Identification Number SY Social Security Number X5 State Industrial Accident Provider Number ZZ Provider Taxonomy 20 Outside Lab Not 2400 PS Diagnosis Or Nature Of Illness Or Injury. (Relate To 24E) Enter the applicable ICD indicat to identify which version of ICD codes is being repted: 9 - ICD-9-CM 0 - ICD-10-CM R 2300 HIXX-02 Notes 22 Resubmission Code and/ Original Ref. No Enter the indicat between the vertical, dotted lines in the upper right-hand ption of the field. Enter the codes to identify the patient s diagnosis and/ condition. List no me than 12 ICD diagnosis codes. Relate 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: Claims with invalid diagnosis codes will be denied f payment. (ICD-9 codes are valid f dates of service up to and including September 30, ICD-10 codes are valid f dates of service on after October 1, "E" codes are not acceptable as a primary diagnosis.) F resubmissions adjustments, enter the appropriate bill frequency code (7 8 see below) left justified in the Submission Code section, and the Claim ID# of the iginal claim in the Original Ref. No. section of this field. Additionally, C CLM05-3 REF (F8) stamp resubmitted crected on the 11 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. Send the iginal claim if this field is used.

15 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 23 Pri Authization Number 24A Date(s) Of Service 24B Place Of Service 24C EMG 24D Procedures, Services Or Supplies CPT/HCPCS Modifier 24E Diagnosis Pointer 24F Charges 24G Days Or Units claim Instructions and Comments 7 Replacement of Pri Claim 8 Void/cancel of Pri Claim Enter the referral authization number. Refer to the Provider Manual to determine if services rendered require an authization referral. From date: MMDDYY. If the service was perfmed on one day leave To blank re-enter From Date. See below f Imptant Note (instructions) f completing the shaded ption of field 24. Enter the CMS standard place of service code. 00 f place of service is not acceptable. This is an emergency indicat field. Enter Y f Yes leave blank f No in the bottom (unshaded area of the field). Procedure codes (5 digits) and modifiers (2 digits) must be valid f date of service. Note: Modifiers affecting reimbursement must be placed in the 1 st modifier position *See additional infmation below f EDI requirements Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, 4). Diagnosis codes must be valid ICD-9 codes f the date of service, and must be entered in field 21. Do not enter diagnosis codes in 24E. Note: Keystone First can accept up to twelve (12) diagnosis pointers in this field. Diagnosis codes must be valid ICD codes f the date of service. (ICD-9 codes are valid f dates of service up to and including September 30, ICD- 10 codes are valid f dates of service on after October 1, 2015.) Enter charges. A value must be entered. Enter zero ($0.00) actual charged amount. (this includes capitated services.) Enter quantity. Value entered must be greater than equal to zero. Blank is not C Loop ID Segment REF REF R 2400 DTP03 12 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. Notes Pri Auth Referral Number. R 2300 CLM05-1 Facility Code Value 2400 SV105 Place of Service Code. C 2400 SV109 Emergency Indicat. R 2400 SV101 (2-6) R 2400 SV107 R 2400 SV102 R 2400 SV104 Service unit count.

16 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 24H EPSDT Family Plan Instructions and Comments acceptable. (Field allows up to 3 digits) In Shaded area of field: AV - Patient refused referral; S2 - Patient is currently under treatment f referred diagnostic crective health problems; NU - No referral given; ST - Referral to another provider f diagnostic crective treatment. Not required 2300 Loop ID Segment 2400 CRC SV111 Notes In unshaded area of field: Y f Yes if service relates to a pregnancy family planning N f No if service does not relate to pregnancy family planning 24I ID Qualifier If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is repted in the qualifier field in 24I. 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number If the rendering provider does have an NPI see field 24J below.. R 2310B REF NM108 XX required f NPI in NM J Rendering Provider ID If the Other ID number is the Health Plan ID number, enter G2. The individual rendering the service is repted in 24J. Enter the Provider Health Plan legacy ID number in the shaded area of the field. Use Qualifier G2 f Provider Health Plan legacy ID. See 24I f the crect qualifier f non NPI values. R 2310B Emdeon will pass this ID on the claim when present. 25 Federal Tax I.D. Number SSN/EIN Enter the NPI number in the unshaded area of the field. Use qualifier Physician Supplier's Federal Tax ID numbers. R 2010AA REF EI Tax SY SSN 13 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

17 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 26 Patient's Account No. 27 Accept Assignment Instructions and Comments Loop ID Segment The provider's billing account number. R 2300 CLM01 Always indicate Yes. Refer to the back of the CMS 1500 (08-05) fm f the section pertaining to Medicaid Payments. R 2300 CLM07 Notes 28 Total Charge Enter charges. A value must be entered. Enter zero (0.00) actual charges (this includes capitated services. Blank is not acceptable. 29 Amount Paid when another carrier is the primary payer. Enter the payment received from the primary payer pri to invoicing the Plan. Medicaid programs are always the 30 Reserved f NUCC Use payers of last rest. R 2300 CLM02 May be $0. C 2300 AMT02 Patient Paid 2320 AMT02 Payer Paid Not 31 Signature Of Physician Or Supplier Including Degrees Or Credentials / Date 32 Name and Address of Facility Where Services Were Rendered (If other than Home Actual signature is required. R 2300 CLM06 unless #33 is the same infmation. Enter the physical location. (P.O. Box # s are not acceptable here) Office) 32a. NPI number unless Rendering Provider is an Atypical Provider and is not required to have an NPI number. 32b. Other ID# Enter the Health Plan ID # (strongly recommended) Enter the G2 qualifier followed by the Health Plan ID # The NUCC defines the following qualifiers used in 5010A1: 0B State License Number R 2310C NM103 N301 N401 N402 N403 R 2310C SBR09 C Recommended 2310C REF01 REF02 14 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

18 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment Notes G2 Provider Commercial Number LU Location Number 33 Billing Provider Info & Ph # when the Rendering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, other separat between the qualifier and number. Identifies the provider that is requesting to be paid f the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable 33a. NPI number unless Rendering Provider is an Atypical Provider and is not required to have an NPI number 33b. Other ID# Enter the Health Plan ID # (strongly recommended) Enter the G2 qualifier followed by the Health Plan ID # R 2010AA NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04 R 2010AA NN109 C Recommended 2010BB REF (G2) The NUCC defines the following qualifiers: 0B State License Number G2 Provider Commercial Number ZZ Provider Taxonomy when the Rendering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, other separat between the qualifier and number. 15 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

19 UB-04 Fm Requirements 16 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

20 UB-04 Fm Requirements Fields (UB-04 Claim Fms) UB-04 Claim Fm Field # Field Description Instructions and Comments 1 Unlabeled Field NUBC Billing Provider Name, Address and Telephone Number 2 Unlabeled Field NUBC Pay-to Name and Address 3a 3b Patient Control No. Medical/Health Recd Number Service Location, no PO Boxes Left justified Line a: Enter the complete provider name. Line b: Enter the complete address Line c: City, State, and zip code Line d: Enter the area code, telephone number. Enter Remit Address Enter the Facility PROMISe Provider I.D. (PPID) number. Left justified Provider's patient account/control number The number assigned to the patient s medical/health recd by the provider Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X R R 2010A A R R 2010B A Loop Segment Notes NM1/85 N3 N4 NM1/87 N3 N4 R R 2300 CLM R R 2300 REF/EA/02 4 Type Of Bill Enter the R R 2300 CLM05 appropriate three four -digit 1/2/3 code. 1 st position is a 17 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

21 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments leading zero Do not include the leading zero on electronic claims. 2nd position indicates type of facility. 3rd position indicates type of care. 4th position indicates billing sequence. 5 Fed. Tax No. Enter the number assigned by the federal government f tax repting purposes. 6 Statement Covers Period From/Through Enter dates f the full ranges of services being invoiced. MMDDYY 7 Unlabeled Field Not Used. Leave Blank. 8a Patient Identifier Patient Health Plan ID is conditional if number is different from field 60 8b Patient Name Patient name is required. Last name, first name, and middle initial. Enter the patient name as it appears on the Health Plan ID Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X R R 2010A A 2010B A Loop Segment Notes REF/EI/02 REF/EI_02 R R 2300 DTP/434/0 3 R R 2010B A 2010C A R R 2010B A 2010C A NM1/IL 09 NM1/QC 09 NM1/IL 03/04/07 NM1/QC 03/04/01 Pay to provider = Billing Prov use 2010AA MMDDCC YY Patient =Subscribe r Use 2010BA Patient =Subscribe r Use 2010BA 18 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

22 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments card. Use a comma space to separate the last and first names. Titles (Mr., Mrs., etc.) should not be repted 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. Newbns and Multiple Births: If submitting a claim f a newbn that does not have an identification number, enter Baby Girl Baby Boy and last name. Refer to page 42 f additional newbn billing infmation, including Multiple Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes 19 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

23 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments Births. 9a-e Patient Address The mailing address of the patient 9a. Street Address 9b. City 9c. State 9d. ZIP Code 9e. Country Code (rept if other than USA) 10 Patient Birth Date The date of birth of the patient Right-justified; MMDDYYYY 11 Patient Sex The sex of the patient recded at admission, outpatient service, start of care. 12 Admission Date The start date f this episode of care. F inpatient services, this is the date of admission. Right-justified 13 Admission Hour The code referring to the hour during which the patient was admitted f inpatient outpatient care. Left Justified Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X R R 2010B A 2010C A R R 2010B A 2010C A R R 2010B A 2010C A Loop Segment Notes N301 N401, 02, 03, 04 N301 N401, 02, 03, 04 DMG02 DMG02 DMG03 DMG03 R R 2300 DTP/435/0 3 R f bill types other than 21X. Not DTP/435/0 3 on inpatient. on inpatient. 14 Admission Type A code indicating R R 2300 CL101 the priity of this admission/visit. 20 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

24 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 15 Point of Origin f Admission Visit A code indicating the source of the referral f this admission visit. 16 Discharge Hour Code indicating the discharge hour of the patient from inpatient care. 17 Patient Discharge Status Codes The following is unique to Medicare eligible Nursing Facilities. codes should be billed when Medicare Part A does not cover Nursing Facility Services Applicable Codes: X2 Medicare EOMB on File X4 Medicare Denial on File A code indicating the disposition discharge status of the patient at the end service f the period covered on this bill, as repted in Field 6. When submitting claims f services not covered by Medicare and the resident is eligible f Medicare Part A, the following instructions should be followed: codes: Enter condition code X2 X4 when one of the following criteria is applicable to the nursing facility service f which you are billing: o There was no Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2300 CL102 R R 2300 DTP/096/0 3 R R 2300 CL103 C C 2300 HIXX-2 HIXX-1=BF OR ABF 21 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

25 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 3-day pri hospital stay o The resident was not transferred within 30 days of a hospital discharge o The resident s 100 benefit days are exhausted o There was no 60 day break in daily skilled care o Medical Necessity Requirements are not met o Daily skilled care requirements are not met All other fields must be completed as per the appropriate billing guide 29 Accident State The accident state field contains the twodigit state abbreviation where the accident occurred. when applicable. 30 Unlabeled Field Leave Blank Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 CLM * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

26 UB-04 Fm Requirements UB-04 Claim Fm Field # 31a,b 34a,b 35a,b 36a,b 37a,b Field Description Instructions and Comments Occurrence Codes and Dates Occurrence Span Codes And Dates EPSDT Referral Code 38 Responsible Party Name and Address 39a,b,c, d 41a,b,c, d Value Codes and Amounts Enter the appropriate occurrence code and date. when applicable. A code and the related dates that identify an event that relates to the payment of the claim. when applicable. when applicable. Enter the applicable 2- character EPSDT Referral Code f referrals made needed as a result of the screen. YD Dental *( f Age 3 and Above) YO Other YV Vision YH Hearing YB Behavial YM medical The name and address of the party responsible f the bill. A code structure to relate amounts values to identify data Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 HIXX-2 HIXX- 1=BH OR ABH C C 2300 HIXX-2 HIXX- 1=BH OR ABH HIXX-4 C C* C C C C C C C* C C C C C C C Not required Not mapped 837I C C 2300 HIXX-2 HIXX-5 HIXX-1 BE OR ABE 23 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

27 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments elements necessary to process this claim as qualified by the payer ganization. Value Codes and amounts. If me than one value code applies, list in alphanumeric der. when applicable. Note: If value code is populated then value amount must also be populated and vice versa. Please see NUCC Specifications Manual Instructions f value codes and descriptions. Documenting covered and non-covered days: Value Code 81 noncovered days; 82 to rept coinsurance days; 83- Lifetime reserve days. Code in the code ption and the Number of Days in the Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes 24 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

28 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments Dollar ption of the Amount section. Enter 00 in the Cents field. 42 Rev. Cd. Codes that identify specific accommodation, ancillary service unique billing calculations arrangements. 43 Revenue Description 44 HCPCS/Accommo dation Rates/HIPPS Rate Codes The standard abbreviated description of the related revenue code categies included on this bill. See NUBC instructions f Field 42 f description of each revenue code categy. 1. The Healthcare Common Procedure Coding system (HCPCS) applicable to ancillary service and outpatient bills. 2. The accommoda tion rate f inpatient Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2400 SV201 R R N/A N/A Not mapped 837I R R 2400 SV202-2 SV202-1=HC/HP 25 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

29 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments bills. 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristi cs ( casemix groups) on which payment determinatio ns are made under several prospective payment systems. Enter the applicable rate, HCPCS HIPPS code and modifier based on the Bill Type of Inpatient Outpatient. HCPCS are required f all Outpatient Claims. (Note: NDC numbers are required f physician administered drugs.) Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes 26 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

30 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 45 Serv. Date Rept line item dates of service f each revenue code HCPCS/HIPPS code. 46 Serv. Units Rept units of service. A quantitative measure of services rendered by revenue categy to f the patient to include items such as number of accommodation days, miles, pints of blood, renal dialysis treatments, etc. 47 Total Charges Total charges f the primary payer pertaining to the related revenue code f the current billing period as entered in the statement covers period. Total Charges includes both covered and noncovered charges. Rept grand total of submitted charges. Enter a zero ($0.00) actual charged amount. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2400 DTP/472/0 3 R R 2400 SV205 R R 2300 SV * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

31 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 48 Non-Covered Charges To reflect the non-covered charges f the destination payer as it pertains to the related revenue code. when Medicare is Primary. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X 49 Unlabeled Field Not required 50 Payer Enter the name f each Payer being invoiced. When the patient has other coverage, list the payers as indicated below. Line A refers to the primary payer; B, secondary; and C, tertiary. 51 Health Plan Identification Number The number used by the health plan to identify itself. Keystone First s Payer ID is # Rel. Info Release of Infmation Certification Indicat. This field is required on Paper and Electronic Invoices. Line A refers to the primary payer; B, Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2400 SV207 Not required R R 2330B NM1/PR/0 3 R R 2330B NM1/PR/0 9 R R 2300 CLM07 28 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

32 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments secondary; and C, tertiary. It is expected that the provider have all necessary release infmation on file. It is expected that all released invoices contain "Y" 53 Asg. Ben. Valid entries are "Y" (yes) and "N" (no). The A, B, C indicats refer to the infmation in Field 50. Line A refers to the primary payer; Line B refers to the secondary; and Line C refers to the tertiary. 54 Pri Payments The A, B, C indicats refer to the infmation in Field 50. The A, B, C indicats refer to the infmation in Field 50. Line A refers to the primary payer; Line B refers to the secondary; and Line C refers to the Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2300 CLM08 R R 2320 AMT/D/02 29 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

33 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments tertiary. 55 Est. Amount Due Enter the estimated amount due (the difference between Total Charges and any deductions such as other coverage). 56 National Provider Identifier Billing Provider 57 A,B,C Other (Billing) Provider Identifier The unique identification number assigned to the provider submitting the bill; NPI is the national provider identifier. if the health care provider is a Covered Entity as defined in HIPAA Regulations. A unique identification number assigned to the provider submitting the bill by the health plan. 58 Insured's Name Infmation 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 Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 AMT/EAF/ 02 R R 2010A A C C 2010A A 2010B B R R 2010B A 2330A NM1/85/09 REF/EI/02 REF/02=G 2 REF/03 Legacy ID NM1/IL 03/04/05 NM1/IL 03/04/05 Tax ID Only sent if need to determine the Plan ID Use 2010BA is insured is subscriber 30 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

34 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments indicated here. 59 P. Rel Enter the patient s relationship to insured. F Medicaid programs the patient is the insured. Code 01: Patient is Insured Code 18: Self 60 Insured s Unique Identifier Enter the patient's Health Plan ID on the appropriate line, exactly as it appears on the patient's ID card on line B C.Line A refers to the primary payer; B, secondary; and C, tertiary. 61 Group Name Use this field only when a patient has other insurance and group coverage applies. Do not use this field f individual coverage. Line A refers to the primary payer; B, secondary; and C, tertiary. 62 Insurance Group No. Use this field only when a patient Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2000B SBR02 R R 2010B A NM1/IL/09 REF/SY/02 C C 2000B SBR04 C C 2000B SBR03 31 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

35 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 63 Treatment Authization Codes has other insurance and group coverage applies. Do not use this field f individual coverage. Line A refers to the primary payer; B, secondary; and C, tertiary. Enter the Health Plan referral authization number. Line A refers to the primary payer; B, secondary; and C, tertiary. 64 DCN Document Control Number. New field. The control number assigned to the iginal bill by the health plan the health plan s fiscal agent as part of their internal control. Previously, field 64 contained the Employment Status Code. The ESC field has been eliminated. Note: Resubmitted claims must contain the iginal claim ID Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2300 REF/G2/02 C C 2320 REF/F8/02 Original Claim Number 32 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

36 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 65 Employer Name The name of the employer that provides health care coverage f the insured individual identified in field 58. when the employer of the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer; B, secondary; and C, tertiary. 66 Diagnosis and Procedure Code Qualifier (ICD Version Indicat) The qualifier that denotes the version of International Classification of Diseases (ICD) repted. Note: Claims with invalid codes will be denied f payment. ICD-9 codes are valid f dates of service up to and including September 30, ICD-10 codes are valid f dates of service on after October 1, Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X C C 2320 Not Not Loop Segment Notes 2300 Determine d by the qualifier submitted on the claim 67 Prin. Diag. Cd. and The appropriate R R 2300 HIXX-2/BK POA 33 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

37 UB-04 Fm Requirements UB-04 Claim Fm Field # 67 A - Q Field Description Instructions and Comments Present on Admission (POA) Indicat Other Diagnosis Codes ICD codes cresponding to all conditions that coexist at the time of service, that develop subsequently, that affect the treatment received and/ the length of stay. Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital service. The appropriate ICD codes cresponding to all conditions that coexist at the time of service, that develop subsequently, that affect the treatment received and/ the length of stay. Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital service. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes abk HIXX-9 C C 2300 HIXX-2/BK abk HIXX-9 POA 34 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

38 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 68 Unlabeled Field 69 Admitting Diagnosis Code 70 Patient s Reason f Visit 71 Prospective Payment System (PPS) Code The appropriate ICD code describing the patient s diagnosis at the time of admission as stated by the physician. f inpatient and outpatient The appropriate ICD code(s) describing the patient s reason f visit at the time of outpatient registration. f all outpatient visits. Up to three ICD codes may be entered in fields A, B and C. The PPS code assigned to the claim to identify the DRG based on the grouper software called f under contract with the primary payer. when the Health Plan/ Provider contract requires this infmation. Up to 4 digits. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes R R 2300 HI02-2 HI01-1=BJ ABJ C R 2300 HI02-2 HI01-1=PR APR C C 2300 HI01-2 HI01-1=DR ADR 35 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

39 UB-04 Fm Requirements UB-04 Claim Fm Field # 72a-c Field Description Instructions and Comments External Cause of Injury (ECI) Code 73 Unlabeled Field 74 Principal Procedure code and Date The appropriate ICD code(s) pertaining to external cause of injuries, poisoning, adverse effect. External Cause of Injury E diagnosis codes should not be billed as primary and/ admitting diagnosis. if applicable. The appropriate ICD code that identifies the principal procedure perfmed at the claim level during the period covered by this bill and the cresponding date. Inpatient facility Surgical procedure code is required if the operating room was used. Outpatient facility Ambulaty Surgical Center Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 HI03-2 HI03-1=BN ABN C R R C 2300 HI01-2 HI01-4 HI01-1=BR ABR 36 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.