Cost Center Code CMS Cost Center Code CMS Revenue Code. Revenue Code Description (According to CMS)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Cost Center Code CMS 2552-96. Cost Center Code CMS 2552-10. Revenue Code. Revenue Code Description (According to CMS)"

Transcription

1 STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES BUREAU OF FISCAL MANAGEMENT DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY INPATIENT REVENUE CODE CROSSWALK TO SUGGESTED COST CENTERS Key: Green Color - Yellow Color - Noncovered revenue codes Orange Color - Noncovered revenue codes "Reserved for Future Assignment" Blue Color - Noncovered revenue codes for psychiatric hospitals; Noncovered revenue codes for general hospitals billing psychiatric or substance abuse services Pink Color - Restricted revenue codes Revenue Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0001 Total Charge Excluded Header charges excluded 0010 RESERVED Other Ancillary Services 0100 RESERVED Excluded 0101 RESERVED Excluded 0110 Room & Board (Private) Adults and Pediatrics (Routine Care) 0111 Medical/Surgical/Gyn Adults and Pediatrics (Routine Care) 0112 OB Adults and Pediatrics (Routine Care) 0113 Pediatric Adults and Pediatrics (Routine Care) 0114 Psychiatric Subprovider - Psych 0115 Hospice Excluded 0116 Detoxification Adults and Pediatrics (Routine Care) 0117 Oncology Adults and Pediatrics (Routine Care) 0118 Rehab Subprovider - Rehab 0119 Other Adults and Pediatrics (Routine Care) 0120 Room & Board (Semi-Private 2 beds) Adults and Pediatrics (Routine Care) 0121 Medical/Surgical/Gyn Adults and Pediatrics (Routine Care) 0122 OB Adults and Pediatrics (Routine Care) 0123 Pediatric Adults and Pediatrics (Routine Care) 0124 Psychiatric Subprovider - Psych 0126 Detoxification Adults and Pediatrics (Routine Care) 0127 Oncology Adults and Pediatrics (Routine Care) 0128 Rehab Subprovider - Rehab 0129 Other Adults and Pediatrics (Routine Care) 0130 Room&Board (Semi private 3-4 beds) Adults and Pediatrics (Routine Care) 0131 Medical/Surgical/Gyn Adults and Pediatrics (Routine Care) 0132 OB Adults and Pediatrics (Routine Care) 0133 Pediatric Adults and Pediatrics (Routine Care) 0135 Hospice Excluded 0138 Rehab Subprovider - Rehab 0140 Room & Board (Private Deluxe) Excluded Noncovered revenue codes 0141 Medical/Surgical/Gyn Excluded Noncovered revenue codes 0142 OB Excluded Noncovered revenue codes 0143 Pediatric Excluded Noncovered revenue codes 0144 Psychiatric Excluded Noncovered revenue codes 0145 Hospice Excluded Noncovered revenue codes 0146 Detoxification Excluded Noncovered revenue codes 0147 Oncology Excluded Noncovered revenue codes 0148 Rehab Excluded Noncovered revenue codes 0149 Other Excluded Noncovered revenue codes 0152 OB Adults and Pediatrics (Routine Care) 0154 Psychiatric Subprovider - Psych 0155 Hospice Excluded 0157 Oncology Adults and Pediatrics (Routine Care) 0160 Room & Board (other) Adults and Pediatrics (Routine Care) 0164 Sterile Environment Adults and Pediatrics (Routine Care) 0170 Nursery Nursery 0171 Newborn-Level I Nursery 0172 Newborn-Level II Nursery

2 Revenue Description (According to ) 0173 Newborn-Level III Nursery 0174 Newborn-Level IV Intensive Care Unit 0179 Other Nursery Intensive Care Unit 0180 Leave of Absence Excluded Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook Noncovered revenue codes; Billable, noncovered revenue code 0181 RESERVED Excluded Noncovered revenue codes 0182 Patient Convenience Excluded Noncovered revenue codes 0183 Therapeutic Leave Excluded Noncovered revenue codes 0184 RESERVED Excluded Noncovered revenue codes 0185 Hospitalization Excluded Noncovered revenue codes 0186 RESERVED Excluded Noncovered revenue codes 0187 RESERVED Excluded Noncovered revenue codes 0188 RESERVED Excluded Noncovered revenue codes 0189 Other leave of absence Excluded Noncovered revenue codes 0200 Intensive care Intensive Care Unit 0201 Surgical Intensive Care Unit 0202 Medical Intensive Care Unit 0203 Pediatric Intensive Care Unit 0204 Psychiatric Intensive Care Unit 0206 Intermediate ICU Intensive Care Unit 0207 Burn care Intensive Care Unit 0208 Trauma Intensive Care Unit 0209 Other intensive care Intensive Care Unit 0210 Coronary care Intensive Care Unit 0211 Myocardial Infarction Intensive Care Unit 0212 Pulmonary Care Intensive Care Unit 0214 Intermediate CCU Intensive Care Unit 0219 Other Coronary Care Intensive Care Unit 0220 Special charges Excluded Noncovered revenue codes 0221 Admission charge Excluded Noncovered revenue codes 0229 Other special charges Excluded Noncovered revenue codes 0230 Incremental nursing charge rate Excluded Incremental Nursing 0231 Nursery Excluded Incremental Nursing 0232 OB Excluded Incremental Nursing 0233 ICU Excluded Incremental Nursing 0234 CCU Excluded Incremental Nursing 0235 Hospice Excluded Incremental Nursing 0239 Other Excluded Incremental Nursing 0240 All inclusive Ancillary Excluded 0249 Other all inclusive ancillary Excluded 0250 Pharmacy Drugs Charged to Patients 0251 Pharmacy: Generic Drugs Charged to Patients 0252 Pharmacy: Nongeneric Drugs Charged to Patients 0253 Take home drugs Drugs Charged to Patients 0254 Pharmacy: Incident to other diagnostic services Drugs Charged to Patients 0255 Pharmacy: Incident to radiology Drugs Charged to Patients 0256 Pharmacy: Experimental drugs Drugs Charged to Patients 0257 Pharmacy: Non-prescription Drugs Charged to Patients 0258 Pharmacy: IV solutions Drugs Charged to Patients 0259 Pharmacy: Other Drugs Charged to Patients 0260 IV Therapy Intravenous Therapy 0261 IV Therapy: Infusion pump Intravenous Therapy 0262 IV Therapy: IV Therapy, pharm services Intravenous Therapy 0263 IV Therapy: IV Therapy/drug/supp/delivery Intravenous Therapy 0264 IV Therapy: supplies Intravenous Therapy 0269 IV Therapy: Other IV therapy Intravenous Therapy 0270 Medical/Surgical Supplies Medical Supplies 0271 Medical/Surgical Supplies: Nonsterile supplies Medical Supplies 0272 Medical/Surgical Supplies: Sterile supplies Medical Supplies 0273 Medical/Surgical Supplies: Take home supplies Medical Supplies

3 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0274 Medical/Surgical Supplies: Prosthetic/Orthotic devices Medical Supplies 0275 Medical/Surgical Supplies: Pacemaker Medical Supplies 0276 Medical/Surgical Supplies: Intraocular lens Medical Supplies 0278 Medical/Surgical Supplies: Other implants Medical Supplies 0279 Medical/Surgical Supplies: Other supplies/devices Medical Supplies 0280 Oncology Laboratory 0285 RESERVED Laboratory 0290 Durable Medical Equipment Durable Medical Equip-Rented Non-allowed for 0291 DME Rental Durable Medical Equip-Rented Non-allowed for 0292 Durable Medical Equipment: Purchase - new Non-allowed for Durable Medical Equip-Rented equipment 0293 Purchase of used DME Excluded 0294 Supplies/Drugs for DME effectiveness (HHA only) Durable Medical Equip-Rented Non-allowed for Noncovered revenue codes 0299 Durable Medical Equipment: Other equipment Durable Medical Equip-Rented Non-allowed for 0300 Laboratory - Clinical Diagnostic Laboratory 0301 Laboratory - Clinical Diagnostic: Chemistry Laboratory 0302 Laboratory - Clinical Diagnostic: Immunology Laboratory 0303 Laboratory - Clinical Diagnostic: Renal patient (home) Laboratory 0304 Laboratory - Clinical Diagnostic: Nonroutine dialysis Laboratory 0305 Laboratory - Clinical Diagnostic: Hematology Laboratory 0306 Laboratory - Clinical Diagnostic: Bacteriology/microbiology Laboratory 0307 Laboratory - Clinical Diagnostic: Urology Laboratory 0309 Laboratory - Clinical Diagnostic: Other laboratory Laboratory 0310 Laboratory - Pathology Laboratory 0311 Laboratory - Pathology: Cytology Laboratory 0312 Laboratory - Pathology: Histology Laboratory 0314 Laboratory - Pathology: Biopsy Laboratory 0319 Laboratory - Pathology: Other Laboratory 0320 Radiology - Diagnostic Radiology - Diagnostic 0321 Radiology - Diagnostic: Angiocardiography Radiology - Diagnostic 0322 Radiology - Diagnostic: Arthrography Radiology - Diagnostic 0323 Radiology - Diagnostic: Arteriography Radiology - Diagnostic 0324 Radiology - Diagnostic: Chest X-ray Radiology - Diagnostic 0329 Radiology - Diagnostic: Other Radiology - Diagnostic 0330 Radiology - Therapeutic Radiology - Therapeutic 0331 Radiology - Therapeutic: Chemotherapy - injected Radiology - Therapeutic 0333 Radiology - Therapeutic: Radiation therapy Radiology - Therapeutic 0335 Radiology - Therapeutic: Chemotherapy - IV Radiology - Therapeutic 0340 Nuclear Medicine Radiology - Therapeutic 0341 Nuclear Medicine: Diagnostic Radiology - Diagnostic 0342 Nuclear Medicine: Therapeutic Radiology - Therapeutic 0343 Diagnostic Radiopharms Radiology - Diagnostic 0344 Therapeutic Radiopharms Radiology - Therapeutic 0349 Nuclear Medicine: Other Radiology - Diagnostic 0350 CT Scan Radiology - Diagnostic 0351 CT Scan: Head Radiology - Diagnostic 0352 CT Scan: Body Radiology - Diagnostic 0359 CT Scan: Other CT scans Radiology - Diagnostic 0360 Operating Room Services Operating Room 0361 Operating Room Services: Minor surgery Operating Room

4 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0362 Operating Room Services: Organ trnsplnt, not kidney Lung Acquisition 0367 Operating Room Services: Kidney transplant Lung Acquisition 0369 Operating Room Services: Other operating room services Operating Room 0370 Anesthesia Anesthesiology 0371 Anesthesia: Incident to radiology Anesthesiology 0372 Anesthesia: Incident to other diag services Anesthesiology 0374 Acupuncture Excluded Noncovered revenue codes 0379 Anesthesia: Other anesthesia Anesthesiology 0380 Blood Whole Blood & Packed Red Blood Cells 0381 Blood: Packed red cells Whole Blood & Packed Red Blood Cells 0382 Blood: Whole blood Whole Blood & Packed Red Blood Cells 0383 Blood: Plasma Whole Blood & Packed Red Blood Cells 0384 Blood: Platelets Whole Blood & Packed Red Blood Cells 0385 Blood: Leukocytes Whole Blood & Packed Red Blood Cells 0386 Blood: Other components Whole Blood & Packed Red Blood Cells 0387 Blood: Other derivatives Whole Blood & Packed Red Blood Cells 0389 Blood: Other blood Whole Blood & Packed Red Blood Cells 0390 Blood Storage/Processing Blood Storing, Processing, & Trans 0391 Blood: Administration (e.g. Transfusion) Blood Storing, Processing, & Trans 0399 Other blood handling Blood Storing, Processing, & Trans 0400 Other Imaging Services Radiology - Diagnostic 0401 Other Imaging Services: Diagnostic mammography Radiology - Therapeutic 0402 Other Imaging Services: Ultrasound Radiology - Therapeutic 0403 Other Imaging Services: Screening mammography Radiology - Diagnostic 0404 Other Imaging Services: PET scan Radiology - Diagnostic 0409 Other Imaging Services: Other imaging services Radiology - Diagnostic 0410 Respiratory Services Respiratory Therapy 0411 RESERVED Respiratory Therapy 0412 Respiratory Services: Inhalation services Respiratory Therapy 0413 Respiratory Services: Hyberbaric oxygen therapy Respiratory Therapy 0419 Respiratory Services: Other respiratory services Respiratory Therapy 0420 Physical Therapy Physical Therapy 0421 Physical Therapy: Visit charge Physical Therapy 0422 Physical Therapy: Hourly charge Physical Therapy 0423 Physical Therapy: Group rate Physical Therapy 0424 Physical Therapy: Evaluation/re-evaluation Physical Therapy 0429 Physical Therapy: Other physical therapy Physical Therapy 0430 Occupational Therapy Occupational Therapy 0431 Occupational Therapy: Visit charge Occupational Therapy 0432 Occupational Therapy: Hourly charge Occupational Therapy 0433 Occupational Therapy: Group rate Occupational Therapy 0434 Occupational Therapy: Evaluation/re-evaluation Occupational Therapy 0439 Occupational Therapy: Other occupational therapy Occupational Therapy 0440 Speech-Language Pathology Speech Pathology 0441 Speech-Language Pathology: Visit charge Speech Pathology 0443 Speech-Language Pathology: Group rate Speech Pathology 0444 Speech-Language Pathology: Evaluation/ re-evaluation Speech Pathology 0449 Speech-Language Pathology: Other speech language pathology Speech Pathology 0450 Emergency Room Emergency Room 0451 Emergency Room: EM/EMTALA Emergency Room 0452 Emergency Room: ER/ Beyond EMTALA Emergency Room 0456 Emergency Room: Urgent care Emergency Room 0459 Emergency Room: Other emergency room Emergency Room 0460 Pulmonary Function Respiratory Therapy

5 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0469 Pulmonary Function: Other Respiratory Therapy 0470 Audiology Other Ancillary Services 0471 Audiology: Diagnostic Other Ancillary Services 0479 Audiology: Other audiology Other Ancillary Services 0480 Cardiology Electro cardiology 0481 Cardiology: Cardiac catheter lab Electro cardiology 0482 Cardiology: Stress test Electro cardiology 0483 Cardiology: Echocardiology Electro cardiology 0489 Cardiology: Other cardiology Electro cardiology 0490 Ambulatory Surgery ASC (Distinct Unit) 0500 Outpatient services Clinic 0510 Clinic Clinic Revenue for medication checks 0511 Clinic: Chronic pain center Clinic 0512 Clinic: Dental clinic Clinic 0513 Clinic: Psychiatric clinic Clinic 0514 Clinic: OB/GYN clinic Clinic 0515 Clinic: Pediatric clinic Clinic 0516 Clinic: Urgent care clinic Clinic 0519 Clinic: Other clinic Clinic 0520 Free-Standing Clinic Excluded 0521 Rural health-clinic Rural Health Clinic 0529 Free-Standing Clinic: Other Excluded Non-allowed for Noncovered revenue codes for psychiatric hospitals; Noncovered revenue codes for general hospitals billing psychiatric or substance abuse services Noncovered revenue codes for psychiatric hospitals; Noncovered revenue codes for general hospitals billing psychiatric or substance abuse services 0530 Osteopathic Services Excluded 0531 Osteopathic Services: Osteopathic therapy Excluded 0539 Osteopathic Services: Other osteopathic services Excluded 0540 Ambulance Ambulance Non-allowed for 0541 Supplies Excluded 0542 Medical Transport Ambulance Non-allowed for 0543 Heart Mobile Excluded 0544 Oxygen Excluded 0545 Air ambulance Ambulance Non-allowed for 0546 Neonatal ambulance services Ambulance Non-allowed for 0547 Pharmacy Excluded Noncovered revenue codes 0548 Telephone Transmission EKG Excluded Noncovered revenue codes 0549 Other ambulance Ambulance Non-allowed for 0550 Skilled nursing Excluded Noncovered revenue codes 0551 Visit charge Excluded 0552 Hourly charge Excluded 0559 Other skilled nursing Excluded 0560 Home Health (HH) -- Medical Social Services Other Ancillary Services 0569 Home Health (HH) Medical Social Services: Other Medical Social Services Other Ancillary Services 0570 Home health-home health aide Excluded 0571 Visit charge Excluded 0572 Hourly charge Excluded 0579 Other home health aide Excluded 0580 Home health-other visits Excluded 0581 Visit charge Excluded 0582 Hourly charge Excluded

6 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0589 Other home health visit Excluded 0590 Home health-units of service Excluded 0599 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0600 Home health-oxygen Excluded 0601 Oxygen-state/equip/suppl/ or cont Excluded 0602 Oxygen-state/equip/suppl/ or under 1 LPM Excluded 0603 Oxygen-state/equip/over 4 LPM Excluded 0604 Oxygen-Portable Add-on Excluded 0609 Other oxygen Excluded Noncovered revenue codes 0610 Magnetic Resonance Tech. (MRT) Radiology - Diagnostic 0611 Magnetic Resonance Tech. (MRT): Brain (incl. Brainstem) Radiology - Diagnostic 0612 Magnetic Resonance Tech. (MRT): Spinal cord (incl. spine) Radiology - Diagnostic 0614 Magnetic Resonance Tech. (MRT): MRI - Other Radiology - Diagnostic 0615 Magnetic Resonance Tech. (MRT): MRA - Head and Neck Radiology - Diagnostic 0616 Magnetic Resonance Tech. (MRT): MRA - Lower Ext Radiology - Diagnostic 0618 Magnetic Resonance Tech. (MRT): MRA - Other Radiology - Diagnostic 0619 Magnetic Resonance Tech. (MRT): Other MRT Radiology - Diagnostic 0621 Med - Surg Supplies Ext. of 270: Incident to radiology Medical Supplies 0622 Med - Surg Supplies Ext. of 270: Incident to other diag Medical Supplies 0623 Surgical dressings Medical Supplies 0624 Med - Surg Supplies Ext. of 270: Investigational Device (IDE) Excluded Noncovered revenue codes 0630 RESERVED Drugs Charged to Patients 0631 Drugs Require Specific ID: Single source drug Drugs Charged to Patients 0632 Drugs Require Specific ID: Multiple source drug Drugs Charged to Patients 0634 Drugs Require Specific ID: EPO under 10,000 units Drugs Charged to Patients 0635 Drugs Require Specific ID: EPO over 10,000 units Drugs Charged to Patients 0636 Drugs Require Specific ID: Drugs requiring detail coding Drugs Charged to Patients 0637 Drugs Require Specific ID: Self admin drugs (insulin admin in emergency-diabetes coma) Drugs Charged to Patients Noncovered revenue codes 0650 Hospice service Excluded 0651 routine home care Excluded 0652 continuous home care Excluded 0653 RESERVED Excluded 0654 RESERVED Excluded 0655 inpatient respite care Excluded 0656 general inpatient care (non-respite) Excluded 0657 physician services Excluded 0659 Other hospice service Excluded 0660 Respite Care Excluded Noncovered revenue codes 0661 Hourly Repite Care Charge Nursing Excluded Noncovered revenue codes 0662 Hourly Respite Care Charge Aide/Homemaker/Companion Excluded Noncovered revenue codes 0663 Daily Respite Charge Excluded Noncovered revenue codes 0664 RESERVED Excluded Noncovered revenue codes 0665 RESERVED Excluded Noncovered revenue codes 0666 RESERVED Excluded Noncovered revenue codes 0667 RESERVED Excluded Noncovered revenue codes 0668 RESERVED Excluded Noncovered revenue codes 0669 Other respite care Excluded Noncovered revenue codes 0670 Outpatient Special Residence Charges Excluded Noncovered revenue codes 0671 Hospital based Excluded Noncovered revenue codes 0672 Contracted Excluded Noncovered revenue codes

7 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0673 RESERVED Excluded Noncovered revenue codes 0674 RESERVED Excluded Noncovered revenue codes 0675 RESERVED Excluded Noncovered revenue codes 0676 RESERVED Excluded Noncovered revenue codes 0677 RESERVED Excluded Noncovered revenue codes 0678 RESERVED Excluded Noncovered revenue codes 0679 Other special residence charge Excluded Noncovered revenue codes 0681 Trauma Response: Level I Emergency Room 0682 Trauma Response: Level II Emergency Room 0683 Trauma Response: Level III Emergency Room 0700 Cast Room Recovery Room 0709 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0710 Recovery Room Recovery Room 0719 RESERVED Recovery Room Noncovered revenue codes "Reserved for Future Assignment" 0720 Labor Room Delivery Room & Labor Room 0721 Labor Room: Labor Delivery Room & Labor Room 0722 Labor Room: Delivery Delivery Room & Labor Room 0723 Labor Room: Circumcision Delivery Room & Labor Room 0724 Labor Room: Birthing center Delivery Room & Labor Room 0729 Labor Room: Other labor room/delivery Delivery Room & Labor Room 0730 EKG/ECG Electro cardiology 0731 EKG/ECG: Holter monitor Electro cardiology 0732 EKG/ECG: Telemetry Electro cardiology 0739 EKG/ECG: Other EKG/ECG Electro cardiology 0740 EEG Electroencephalography 0749 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0750 Gastrointestinal Laboratory 0759 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0760 Treatment/Observation Room Observation Beds 0761 Treatment/Observation Room: Treatment room Observation Beds 0762 Treatment/Observation Room: Observation room Observation Beds 0769 Treatment/Observation Room: Other treatment room Observation Beds 0770 Preventive Care Services Clinic 0771 Preventive Care Services: Admin. of vaccine Clinic 0779 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0780 Telemedicine Excluded Noncovered revenue codes 0781 RESERVED Excluded Noncovered revenue codes 0782 RESERVED Excluded Noncovered revenue codes 0783 RESERVED Excluded Noncovered revenue codes 0784 RESERVED Excluded Noncovered revenue codes 0785 RESERVED Excluded Noncovered revenue codes 0786 RESERVED Excluded Noncovered revenue codes 0787 RESERVED Excluded Noncovered revenue codes 0788 RESERVED Excluded Noncovered revenue codes 0789 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0790 Extra-Corp Shock Wave Therapy Radiology - Therapeutic 0799 RESERVED Excluded Noncovered revenue codes "Reserved for Future Assignment" 0800 Inpatient Dialysis Renal Dialysis 0801 Inpatient Hemodialysis Renal Dialysis 0802 Inpatient peritoneal dialysis Renal Dialysis 0803 inpatient dialysis CAPD Renal Dialysis 0804 Inpatient dialysis CCPD Renal Dialysis 0809 Other inp dialysis Renal Dialysis 0810 Organ Acquisition Lung Acquisition 0811 Organ Acquisition: Living donor Lung Acquisition 0812 Organ Acquisition: Cadaver donor Lung Acquisition 0813 Organ Acquisition: Unknown donor Lung Acquisition 0819 Organ Acquisition: Other donor Lung Acquisition 0820 Hemo OPD/Home Renal Dialysis

8 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0821 Hemo OPD/Home: Hemodialysis comp or other rate Renal Dialysis 0829 Hemo OPD/Home: Other HEMO outpatient Renal Dialysis 0830 Peritoneal OPD/Home Renal Dialysis 0880 Miscellaneous Dialysis Excluded Noncovered revenue codes 0881 Miscellaneous Dialysis: Ultrafiltration Renal Dialysis 0889 Miscellaneous Dialysis: Other misc dialysis Renal Dialysis 0900 Psychiatric/Psychological Trt Other Ancillary Services 0901 Psychiatric/Psychological Trt: Electroshock treatment Other Ancillary Services 0904 Psychiatric/Psychological Trt: Activity therapy Other Ancillary Services 0910 RESERVED Other Ancillary Services 0911 Psychiatric/Psychological Svcs: Rehabilitation Other Ancillary Services 0912 Psychiatric/Psychological Svcs: Partial Hosp - less intensive Excluded 0913 Psychiatric/Psychological Svcs: Partial Hosp - Intensive Excluded 0914 Psychiatric/Psychological Svcs: Individual therapy Other Ancillary Services 0915 Psychiatric/Psychological Svcs: Group therapy Other Ancillary Services 0916 Psychiatric/Psychological Svcs: Family therapy Other Ancillary Services 0917 Psychiatric/Psychological Svcs: Biofeedback Other Ancillary Services 0918 Psychiatric/Psychological Svcs: Testing Other Ancillary Services 0919 Psychiatric/Psychological Svcs: Other behavioral treat/serv Other Ancillary Services 0920 Other Diagnostic Services Other Ancillary Services 0921 Other Diagnostic Services: Peripheral vascular lab Other Ancillary Services 0922 Other Diagnostic Services: Electromyelogram Other Ancillary Services 0923 Other Diagnostic Services: Pap smear Other Ancillary Services 0924 Other Diagnostic Services: Allergy test Other Ancillary Services 0925 Other Diagnostic Services: Pregnancy test Other Ancillary Services 0929 Other Diagnostic Services: Other diagnostic services Other Ancillary Services 0940 Other Therapeutic Serv Other Ancillary Services 0941 Other Therapeutic Serv: Recreation Rx Other Ancillary Services 0942 Other Therapeutic Serv: Educ/training Other Ancillary Services 0943 Other Therapeutic Serv: Cardiac rehab Other Ancillary Services 0944 Other Therapeutic Serv: Drug rehab Other Ancillary Services 0945 Other Therapeutic Serv: Alcohol rehab Other Ancillary Services 0946 Complex medical equipment-routine Other Ancillary Services 0947 Complex medical equipment-ancillary Other Ancillary Services 0949 Other Therapeutic Serv: Additional RX SVS Other Ancillary Services Noncovered revenue codes for psychiatric hospitals; Noncovered revenue codes for general hospitals billing psychiatric or substance abuse services Noncovered revenue codes for psychiatric hospitals; Noncovered revenue codes for general hospitals billing psychiatric or substance abuse services 0960 Professional fees Excluded 0961 Psychiatric Excluded 0962 Ophthalmology Excluded 0963 Anesthesiologist (MD) Excluded 0964 Anesthetist (CRNA) Excluded 0969 Other professional fee Excluded 0971 Professional fees (096x) Laboratory Excluded 0972 Professional fees (096x) Radiology-Diagnostic Excluded 0973 Professional fees (096x) Radiology-Therapeutic Excluded 0974 Professional fees (096x) Radiology-nuclear medicine Excluded 0975 Professional fees (096x) Operating room Excluded 0976 Professional fees (096x) Respiratory Therapy Excluded 0977 Professional fees (096x) Physical therapy Excluded

9 Revenue Description (According to ) Description Comment Non-Allowed Per Wisconsin ForwardHealth Online Handbook 0978 Professional fees (096x) Occupational therapy Excluded 0979 Professional fees (096x) Speech pathology Excluded 0981 Professional fees (096x) Emergency room Excluded 0982 Professional fees (096x) Outpatient services Excluded 0983 Professional fees (096x) clinic Excluded 0984 Professional fees (096x) medical social services Excluded 0985 Professional fees (096x) EKG Excluded 0987 Professional fees (096x) Hospital visit Excluded 0988 Professional fees (096x) Consultation Excluded 0989 Private duty nurse Excluded 0990 Patient convenience items Excluded Noncovered revenue codes 0991 Cafeteria/guest tray Excluded Noncovered revenue codes 0992 private linen service Excluded Noncovered revenue codes 0993 telephone/telegraph Excluded Noncovered revenue codes 0994 TV/radio Excluded Noncovered revenue codes 0995 Nonpatient room rentals Excluded Noncovered revenue codes 0996 Late discharge charge Excluded Noncovered revenue codes 0997 admission kits Excluded Noncovered revenue codes 0998 Beauty shop/barber Excluded Noncovered revenue codes 0999 Other patient convenience item Excluded Noncovered revenue codes

Expanded List of Valid Revenue Codes

Expanded List of Valid Revenue Codes 681 Not assigned 682 Not assigned 683 Not assigned 684 Not assigned 685 Not assigned 686 Not assigned 687 Not assigned 688 Not assigned 689 Not assigned 691 Not assigned 692 Not assigned 693 Not assigned

More information

Oregon Health Authority Division of Medical Assistance Programs Revenue Center Code Table

Oregon Health Authority Division of Medical Assistance Programs Revenue Center Code Table 11X ROOM AND BOARD PRIVATE (MEDICAL OR GENERAL) 110# 111# 112# 113# 114# 115 116# 117# 118# 119# Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehab/Private

More information

Pharmacy. IV Therapy. Medical/Surgical Supplies and Devices

Pharmacy. IV Therapy. Medical/Surgical Supplies and Devices 26.3.2.2 Revenue s (Outpatient Hospital) HCFA-1450 (UB-92) revenue codes must be used to bill outpatient hospital facility services. In some instances, a HCPCS procedure code is required in addition to

More information

ENACTED Appendix 5101:3-2-02 APPENDIX A Revenue Codes and Descriptions

ENACTED Appendix 5101:3-2-02 APPENDIX A Revenue Codes and Descriptions ACTION: Final 5101:3-2-02 ENACTED Appendix 5101:3-2-02 DATE: 11/26/2010 10:28 AM Page 1 of 13 Health Insurance - PPS 002 2 - Skilled Nursing Facility PPS N N 3 - Home Health PPS N N 4 - Inpatient Rehabilitation

More information

Inpatient Revenue Codes for Fee-for-Service Providers

Inpatient Revenue Codes for Fee-for-Service Providers Inpatient Codes for Fee-for-Service Providers 0001 Total Charge 0100 All-Inclusive Room and Board Plus All Inclusive Rate 0110 General Classification ROOM-BOARD/PVT Room & Board - Private 0111 Medical/Surgical/GYN

More information

Outpatient Hospital and Ambulatory Surgical Center Services

Outpatient Hospital and Ambulatory Surgical Center Services INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Outpatient Hospital and Ambulatory Surgical Center Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 4 1 P U B L I S H

More information

2009 Cost Center Setup Cross Reference Exhibit 3, 4, 11, 19, 20, 30, 31A, and 46. Exh 4, S-3. 30 & 31A Line

2009 Cost Center Setup Cross Reference Exhibit 3, 4, 11, 19, 20, 30, 31A, and 46. Exh 4, S-3. 30 & 31A Line Setup Cross Reference General Service Assignments (95) (38) Standard 001-026, 029-030, 033, 040-047, 095 (57)Variable 027-028, 031-032, 034-039, 048-094 (Program Capabilities 200) 1 0100 Old Capital Related

More information

Revenue Code Listing Code Description 0254 0255 0260 0300 0301 0302 0305 0309 0310 0311 0312 0314 0319 0320 0321 0322 0323 0324 0329 0330 0331 0332

Revenue Code Listing Code Description 0254 0255 0260 0300 0301 0302 0305 0309 0310 0311 0312 0314 0319 0320 0321 0322 0323 0324 0329 0330 0331 0332 Code Description 0254 Pharmacy 0255 Pharmacy 0260 IV Therapy 0300 Laboratory 0301 Laboratory 0302 Laboratory 0305 Laboratory 0309 Laboratory 0310 Laboratory Pathology 0311 Laboratory Pathology 0312 Laboratory

More information

Inpatient Hospital Prospective Payment Billing Manual

Inpatient Hospital Prospective Payment Billing Manual Inpatient Hospital Prospective Payment Billing Manual July 2006 INPATIENT HOSPITAL SERVICES Under West Virginia Public Payers prospective payment system (PPS), payments are made prospectively on a per-drg

More information

Iowa Medicaid Enterprise UB-04 Claim Form Instructions Health Insurance Claim Form (10/15)

Iowa Medicaid Enterprise UB-04 Claim Form Instructions Health Insurance Claim Form (10/15) Iowa Medicaid Enterprise UB-04 Claim Form Instructions Health Insurance Claim Form (10/15) Field No. Field Name/ Description Requirements Instructions 1 (Untitled) - Provider name, address, and telephone

More information

1. Section Modifications

1. Section Modifications Table of Contents 1. Section Modifications... 1 2. UB04 Claim Form... 4 3. Completing the UB04... 5 3.1. Helpful Tips for Filling out a Paper Claim... 5 3.2. Claim Form Field s... 5 4. Billing Information...

More information

MassHealth Billing Guide for the UB-04. Executive Office of Health and Human Services MassHealth September 2015 BG-UB-04 (09/15)

MassHealth Billing Guide for the UB-04. Executive Office of Health and Human Services MassHealth September 2015 BG-UB-04 (09/15) MassHealth Billing Guide for the UB-04 Executive Office of Health and Human Services MassHealth September 2015 BG-UB-04 (09/15) Table of Contents Introduction... 1 General Instructions for Submitting Paper

More information

Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance Claim Form

Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance Claim Form Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance Claim Form The following Iowa Medicaid provider types bill for services on the UB-04 claim form: Hospital Rehab Agencies Home Health Skilled Nursing

More information

REVENUE CODE TABLE. Use for Dates of Services on and after 4/1/2007 HCPCS REQ COV SVC UNITS REQ UNITS REQ COV SVC REQ

REVENUE CODE TABLE. Use for Dates of Services on and after 4/1/2007 HCPCS REQ COV SVC UNITS REQ UNITS REQ COV SVC REQ The descriptions and code ranges are subject to change by National Uniform Billing s (NUBC) direction and does not supersede MDHHS published policy 0001 TOTAL CHARGE Y NA - - Y Y Y Y Y 001X Reserved for

More information

REVENUE CODES CODE DESCRIPTION STANDARD ABBREVIATION 100 ALL INCLUSIVE RATE, ROOM AND BOARD PLUS ALL INCL R&B/ANC

REVENUE CODES CODE DESCRIPTION STANDARD ABBREVIATION 100 ALL INCLUSIVE RATE, ROOM AND BOARD PLUS ALL INCL R&B/ANC 100 ALL INCLUSIVE RATE, ROOM AND BOARD PLUS ALL INCL R&B/ANC ANCILLARY 101 ALL INCLUSIVE ROOM AND BOARD ALL INCL R&B 110 ROOM AND BOARD, PRIVATE, ROOM-BOARD/PVT 111 MEDICAL/SURGICAL/GYNE MED-SUR-GY/PVT

More information

Preauthorization Requirements * (as of January 1, 2016)

Preauthorization Requirements * (as of January 1, 2016) OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations

More information

General Hospital Inpatient Responsibility

General Hospital Inpatient Responsibility = Medical ASO All diagnoses = BHP (ValueOptions) - All diagnoses 3= BHP for Primary Diagnoses 9-36, Medical ASO all other diagnoses 4= Not covered 5=DHP (Benecare) 6=PASRR ASO (Ascend) 7=Pharmacy benefit

More information

APPENDIX C Description of CHIP Benefits

APPENDIX C Description of CHIP Benefits Inpatient General Acute and Inpatient Rehabilitation Hospital Unlimited. Includes: Hospital-provided physician services Semi-private room and board (or private if medically necessary as certified by attending)

More information

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey

More information

Summary of PNM Resources Health Care Benefits Active Employees 2011

Summary of PNM Resources Health Care Benefits Active Employees 2011 of PNM Resources Health Care Benefits Active Employees 2011 The following charts show deductibles, limits, benefit levels and amounts for the PNM Resources medical, dental and vision programs. For more

More information

Cost Sharing Definitions

Cost Sharing Definitions SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable

More information

2015 Medical Plan Summary

2015 Medical Plan Summary 2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is

More information

Objective of This Lecture

Objective of This Lecture Component 2: The Culture of Health Care Unit 3: Health Care Settings The Places Where Care Is Delivered Lecture 5 This material was developed by Oregon Health & Science University, funded by the Department

More information

Benefit Summary - A, G, C, E, Y, J and M

Benefit Summary - A, G, C, E, Y, J and M Benefit Summary - A, G, C, E, Y, J and M Benefit Year: Calendar Year Payment for Services Deductible Individual $600 $1,200 Family (Embedded*) $1,200 $2,400 Coinsurance (the percentage amount the Covered

More information

AVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible

AVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific

More information

HCUP Methods Series Development of Utilization Flags for Use with UB-92 Administrative Data Report # 2006-04 Appendices: A-F

HCUP Methods Series Development of Utilization Flags for Use with UB-92 Administrative Data Report # 2006-04 Appendices: A-F HCUP Methods Series Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.hcup-us.ahrq.gov For Technical

More information

Provider Identifier Code

Provider Identifier Code Provider Identifier Code Description: Code identifying an organizational entity, a physical location, or an individual Allowable Values: 1G, 1H, 1O, 1Q - 1X, 1Z, 2P, 2S, 2Y, 2Z, 3A - 3Z, 4A 4J, 4L 4S,

More information

Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered.

Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered. Covered Benefits Services Abortions Allergy Testing Audiology Birth Control Services Blood & Blood Plasma Bone Mass Measurement (bone density) Case Management Chemotherapy Chiropractor Services (manipulation/subluxation)

More information

Cigna Supported Service Types for Eligibility and Benefit Inquiries

Cigna Supported Service Types for Eligibility and Benefit Inquiries This document lists the service type codes that can be submitted to Cigna on an eligibility and benefit inquiry transaction. If a service type code not included on this list is submitted, Cigna's general

More information

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE ID: MD0000003228_B3 X Schedule of s Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE Coverage under this Plan is under the jurisdiction

More information

The MITRE Corporation Plan Benefit Summary Effective Date: 1/1/2015 Administered by Kaiser Permanente PLAN FEATURES You Pay and/or Maximums

The MITRE Corporation Plan Benefit Summary Effective Date: 1/1/2015 Administered by Kaiser Permanente PLAN FEATURES You Pay and/or Maximums Benefit Type Plan Year Type Calendar Year Annual Medical Out of (for certain services) Employee Employee + 1 Family Annual Prescription Drug Out of Employee Employee + 1 Family The MITRE Corporation Plan

More information

REVENUE CODES AND DESCRIPTIONS

REVENUE CODES AND DESCRIPTIONS 001 Total charges 01X Reserved for internal payer use 02X Health Insurance Prospective Payment Systems (HIPPS) 0 - RESERVED 1 - RESERVED 2 - Skilled Nursing Facility Prospective Payment SNF PPS (RUG) 3

More information

North Division Telephone Directory

North Division Telephone Directory MONTEFIORE MEDICAL CENTER NORTH DIVISION 600 E. 233 RD STREET BRONX, NEW YORK 10466 North Division Telephone Directory (When calling internally, use all five digits of the extension. When calling from

More information

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first

PREVENTIVE CARE See the REHP Benefits Handbook for a list of preventive benefits* MATERNITY SERVICES Office visits Covered in full including first Network Providers Non Network Providers** DEDUCTIBLE (Per Calendar Year) None $250 per person $500 per family OUT-OF-POCKET MAXIMUM (When the out-of-pocket maximum is reached, benefits are paid at 100%

More information

VACAVILLE MEDICAL CENTER. Staff Navigator

VACAVILLE MEDICAL CENTER. Staff Navigator VACAVILLE MEDICAL CENTER Staff Navigator VACAVILLE MEDICAL CENTER Hospital VACAVILLE MEDICAL CENTER - Hospital Department Floor Bldg Pg Administration - HIMS 4 H 9 Admitting 1 H 6 Bed Repair B H 5 Cafeteria

More information

IDENTIFYING INFORMATION SOURCES: FORM HCFA 2552-92, WORKSHEET S-2, AND HCFA RECORDS FIELD FIELD NAME DESCRIPTION LINE(S) COL(S) SIZE USAGE LOCATION

IDENTIFYING INFORMATION SOURCES: FORM HCFA 2552-92, WORKSHEET S-2, AND HCFA RECORDS FIELD FIELD NAME DESCRIPTION LINE(S) COL(S) SIZE USAGE LOCATION Minimum Data Set 08/22/96 IDENTIFYING INFORMATION SOURCES: FORM HCFA 2552-92, WORKSHEET S-2, AND HCFA RECORDS F 1 Provider Number - Hospital 2 2 6 X 1-6 F 2 Provider Number - Subprovider 3 2 6 X 7-12 F

More information

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable

More information

Hawaii Benchmarks Benefits under the Affordable Care Act (ACA)

Hawaii Benchmarks Benefits under the Affordable Care Act (ACA) Hawaii Benchmarks Benefits under the Affordable Care Act (ACA) 10/2012 Coverage for Newborn and Foster Children Coverage Outside the Provider Network Adult Routine Physical Exams Well-Baby and Well-Child

More information

Hospital Statement of Cost BHF Page 1 Healthcare and Family Services, Bureau of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763

Hospital Statement of Cost BHF Page 1 Healthcare and Family Services, Bureau of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763 Hospital Statement of Cost BHF Page 1 Healthcare and Family Services, Bureau of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763 General Information Name of Hospital: Jackson Park Hospital 14-0177

More information

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions: Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization,

More information

Iowa Wellness Plan Benefits Coverage List

Iowa Wellness Plan Benefits Coverage List Iowa Wellness Plan Benefits Coverage List Service Category Covered Duration, Scope, exclusions, and Limitations Excluded Coding 1. Ambulatory Services Primary Care Illness/injury Physician Services Should

More information

Summary of Services and Cost Shares

Summary of Services and Cost Shares Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

More information

Dickinson Wright, PLLC 03956-006

Dickinson Wright, PLLC 03956-006 Dickinson Wright, PLLC 03956-006 Flexible Blue SM Plan 3 Medical Coverage with Preventive Care and Mammography Benefits Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only

More information

SECTION A. Summary of Benefits LW-V, 10/09

SECTION A. Summary of Benefits LW-V, 10/09 SECTION A. Summary of Benefits LW-V, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your

More information

2015 Health Benefits

2015 Health Benefits 2015 Health Benefits Product Cost Sharing - Member's Responsibility Health Care Reform Compliant Health Care Reform Compliant Health Care Reform Compliant Deductible (DED) (Per Person/Family Aggregate)

More information

Medicare Benefit Review

Medicare Benefit Review Medicare Benefit Review What is Medicare? Medicare is Health Insurance For people 65 or older For people under 65 with certain disabilities For people at any age with End-Stage Renal Disease (permanent

More information

Every New Hampshire Resident Qualifies For Health Insurance. About NHHP. Eligibility

Every New Hampshire Resident Qualifies For Health Insurance. About NHHP. Eligibility About NHHP New Hampshire Health Plan (NHHP) is a non-profit organization formed by the New Hampshire legislature. NHHP provides health coverage to New Hampshire residents who otherwise may have trouble

More information

Blue Cross Premier Bronze Extra

Blue Cross Premier Bronze Extra An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network

More information

I. SUMMARY OF CHANGES: Chapter 25 Revenue Code 076X"s description is changing.

I. SUMMARY OF CHANGES: Chapter 25 Revenue Code 076Xs description is changing. CMS Manual System Pub 100-04 Medicare Claims Processing Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1767 Date: JULY 10, 2009 Change Request 6561

More information

Hospital Statement of Cost OHF Page 1 Illinois Department of Public Aid, Office of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763

Hospital Statement of Cost OHF Page 1 Illinois Department of Public Aid, Office of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763 Hospital Statement of Cost OHF Page 1 Illinois Department of Public Aid, Office of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763 General Information Name of Hospital: Provena United Samaritans

More information

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not

More information

Moses Telephone Directory

Moses Telephone Directory MONTEFIORE MEDICAL CENTER THE HENRY AND LUCY MOSES DIVISION 111 EAST 210TH STREET BRONX, NEW YORK 10467 Moses Telephone Directory (When calling from the outside use 920 before extension) NUMBER TIE-LINE

More information

Regulatory Compliance Policy No. COMP-RCC 4.07 Title:

Regulatory Compliance Policy No. COMP-RCC 4.07 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.07 Page: 1 of 7 This policy applies to (1) any Hospital in which Tenet Healthcare Corporation or an affiliate owns a direct or indirect equity interest

More information

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20 PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA2000-20 Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when

More information

(A) Information needed to identify and classify the hospital, include the following: (b) The hospital number assigned by the department;

(A) Information needed to identify and classify the hospital, include the following: (b) The hospital number assigned by the department; 3701-59-05 Hospital registration and reporting requirements. Every hospital, public or private, shall, by the first of March of each year, register with and report to the department of health the following

More information

2015 Pre-Authorization Requirements

2015 Pre-Authorization Requirements 2015 orization Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete pre-authorization

More information

New York State Medicaid EHR Incentive Program Amendments to Hospital Incentive Payment Calculation

New York State Medicaid EHR Incentive Program Amendments to Hospital Incentive Payment Calculation New York State Medicaid EHR Incentive Program Amendments to Hospital Incentive Payment Calculation February 13, 2012 Effective immediately, the NYS Department of Health (DOH) is amending the guidance set

More information

MyHPN Solutions HMO Silver 4

MyHPN Solutions HMO Silver 4 MyHPN Solutions HMO Silver 4 Attachment A Schedule Calendar Year Deductible (CYD): $2,250 of EME per Member and $4,500 of EME per family. The Calendar Year Out of Pocket Maximum includes the CYD and is

More information

CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance

CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview

More information

Institutional Claim Billing Reimbursement. HP Provider Relations/October 2013

Institutional Claim Billing Reimbursement. HP Provider Relations/October 2013 Institutional Claim Billing Reimbursement HP Provider Relations/October 2013 Agenda Objectives Institutional Claim Basics Inpatient Claim Payment Outpatient Claim Payment Enhanced Code Auditing Billing

More information

PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE SPECIALITY CODE DESCRIPTION OF PROVIDER SPECIALITY 01 INPATIENT FACILITY 010 ACUTE CARE HOSPITAL 01

PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE SPECIALITY CODE DESCRIPTION OF PROVIDER SPECIALITY 01 INPATIENT FACILITY 010 ACUTE CARE HOSPITAL 01 PROVIDER TYPE CODE DESCRIPTION OF PROVIDER TYPE SPECIALITY CODE DESCRIPTION OF PROVIDER SPECIALITY 01 INPATIENT FACILITY 010 ACUTE CARE HOSPITAL 01 011 PRIVATE PSYCHIATRIC HOSPITAL 01 012 INPATIENT MEDICAL

More information

Site view of VA San Diego Healthcare System Campus Map

Site view of VA San Diego Healthcare System Campus Map Site view of VA San Diego Healthcare System Campus Map Vicinity view of VA San Diego Healthcare System Campus Map Access Clinic / Pulmonary Clinic / CPAP Main Building Third Floor (3) Alcohol Drug Treatment

More information

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests) A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual

More information

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY PPO PLAN MAINE ID: MD0000000750_F2 X This Schedule of s summarizes your benefits under The HPHC Insurance Company PPO Plan (the Plan)

More information

General Cost Sharing Features In-Network Out-of-Network

General Cost Sharing Features In-Network Out-of-Network SECTION A. Summary of Benefits 9-RCF, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your

More information

STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS

STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS CALIFORNIA STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS These services are covered as indicated when authorized through your Primary Care Physician in your Participating Medical Group. General Features

More information

Coventry Health Care of Missouri

Coventry Health Care of Missouri Small Group PPO Schedule of Benefits: Coventry Health Care of Missouri Plan ID#: Platinum Carelink from Coventry A000-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain

More information

UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits

UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits Please refer to your Provider Directory for listings of Participating Physicians, Hospitals, and other Providers.

More information

Membership has its benefits.

Membership has its benefits. Membership has its benefits. Providing the health coverage you and your family need from a name you know and trust. Presbyterian Health Plan, Inc. Visit your web site for APS employees! www.phs.org/aps

More information

HCPCS codes should be used to describe outpatient diagnostic laboratory procedures (revenue codes 300 to 319).

HCPCS codes should be used to describe outpatient diagnostic laboratory procedures (revenue codes 300 to 319). 6How Do I Bill Tribal Outpatient Hospital Services? Complete the UB-04 form for outpatient hospital services. Refer to How do I complete the UB-04? in the Billing Guidelines section for specific information

More information

REPORT ON THE COST REPORT REVIEW EDGEMOOR HOSPITAL SANTEE, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1962556290 FISCAL PERIOD ENDED JUNE 30, 2012

REPORT ON THE COST REPORT REVIEW EDGEMOOR HOSPITAL SANTEE, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1962556290 FISCAL PERIOD ENDED JUNE 30, 2012 REPORT ON THE COST REPORT REVIEW EDGEMOOR HOSPITAL SANTEE, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 196255629 FISCAL PERIOD ENDED JUNE 3, 212 DISTINCT PART NURSING FACILITY OF SAN DIEGO COUNTY PSYCHIATRIC

More information

ALL PROVIDERS IV. BILLING IOWA MEDICAID

ALL PROVIDERS IV. BILLING IOWA MEDICAID ALL PROVIDERS IV. BILLING IOWA MEDICAID Provider TABLE OF CONTENTS 1 January 1, 2016 Preamble... 1 CHAPTER IV. BILLING IOWA MEDICAID... 1 A. INTRODUCTION... 1 B. TIMELY FILING REQUIREMENTS... 1 1. Paper

More information

Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider

Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider Schedule of Benefits UPMC Consumer Advantage HSA PPO - Premium Network Primary Care Provider: 10% after Deductible Specialist: 10% after Deductible Deductible: $1,950 / $3,900 Rx: 10% after Deductible

More information

StaffingForce direct and interim staffing services are available throughout the U.S. and in 45 other countries on six continents.

StaffingForce direct and interim staffing services are available throughout the U.S. and in 45 other countries on six continents. StaffingForce Healthcare Solutions Our search, recruitment and staffing services are specifically designed to reduce your cost per hire while expediting the time it takes to fill your direct and interim

More information

Charge Master Comprehensive Audit

Charge Master Comprehensive Audit The PARA charge master audit process utilizes the PARA Data Editor (PDE) to create a series of focused screens and reports utilized by the PARA HIM Coding Staff to identify and correct charge master errors,

More information

National PPO 1000. PPO Schedule of Payments (Maryland Small Group)

National PPO 1000. PPO Schedule of Payments (Maryland Small Group) PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer

More information

Flexible Blue SM Plan 2 Medical Coverage with Flexible Blue SM RX Prescription Drugs Benefits-at-a-Glance for Western Michigan Health Insurance Pool

Flexible Blue SM Plan 2 Medical Coverage with Flexible Blue SM RX Prescription Drugs Benefits-at-a-Glance for Western Michigan Health Insurance Pool Flexible Blue SM Plan 2 Medical Coverage with Flexible Blue SM RX Prescription Drugs Benefits-at-a-Glance for Western Michigan Health Insurance Pool The information in this document is based on BCBSM s

More information

NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS

NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS WASHINGTON NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS General Features Calendar Year Deductible Lifetime Benefit Maximum (Does not apply to Chemical Dependency) ($5,000.00

More information

Benefit. Benefits Covered by UnitedHealthcare Community Plan

Benefit. Benefits Covered by UnitedHealthcare Community Plan Benefits Covered by UnitedHealthcare Community Plan As member of UnitedHealthcare Community Plan, you are covered for the following services. (Remember to always show your current member ID card when getting

More information

Health Insurance Benefits Summary

Health Insurance Benefits Summary Independent licensee of the Blue Cross and Blue Shield Association Health Insurance Benefits Summary Community Blue SM PPO Health Maintenance Exam (1) Covered 100%, one per calendar year, includes select

More information

Final. $2,500 per member $5,000 per family

Final. $2,500 per member $5,000 per family Final PPO PPO Medical, Rx, Dental Core, Dental Buy Up Benefits-at-a-Glance City of Pontiac Group Number: 71489 Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Copays/Coinsurance

More information

PRIORITY HEALTH priorityhealth.com HealthbyChoice Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13

PRIORITY HEALTH priorityhealth.com HealthbyChoice Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13 PRIORITY HEALTH priorityhealth.com Healthby Incentives Summary of Benefits TRINITY HEALTH -HbCI 2 1/1/13 12/31/13 The Healthby Incentives HMO plan is a Consumer Engaged Health plan that offers a choice

More information

GIC Medicare Enrolled Retirees

GIC Medicare Enrolled Retirees GIC Medicare Enrolled Retirees HMO Summary of Benefits Chart This chart provides a summary of key services offered by your HNE plan. Consult your Member Handbook for a full description of your plan s benefits

More information

Compare your plan options

Compare your plan options SMALL BUSINESS GROUP Compare your plan options 2014 plans for businesses with 1 50 employees I SMALL BUSINESS GROUP Group Health plans offer value, choice, and more A well-run business takes a lot of time,

More information

California Small Group MC Aetna Life Insurance Company

California Small Group MC Aetna Life Insurance Company PLAN FEATURES Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate separately

More information

Coventry Health and Life Insurance Company PPO Schedule of Benefits

Coventry Health and Life Insurance Company PPO Schedule of Benefits State(s) of Issue: Oklahoma PPO Plan: OI08C30050 30 Coventry Health and Life Insurance Company PPO Schedule of Benefits Covered Services Contract Year Deductible For All Eligible Expenses (unless otherwise

More information

Code Correlations: Inpatient Revenue Codes (Formerly Accommodation Codes)

Code Correlations: Inpatient Revenue Codes (Formerly Accommodation Codes) Code Correlations: Inpatient Revenue Codes (Formerly Accommodation Codes) Medi-Cal has developed a service code set correlation table for provider use to begin to prepare for business and billing operation

More information

University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance

University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.

More information

Services Requiring Preauthorization for the CoventryCares of West Virginia Program 2016

Services Requiring Preauthorization for the CoventryCares of West Virginia Program 2016 Services Requiring Preauthorization for the CoventryCares of West Virginia Program 2016 CoventryCares of West Virginia must preauthorize certain services and supplies for Medicaid members. Automatic Internal

More information

EA Conway Cross Walk. EA Conway DEPT EA Conway Title NewCo DEPT NewCo Title

EA Conway Cross Walk. EA Conway DEPT EA Conway Title NewCo DEPT NewCo Title SOCIAL SERVICES DEPARTMENT SOCIAL SERVICE COUNSELOR 3 Social Services Counselor - LCSW INFORMATION TECHNOLOGY ASSISTANT DIRECTOR OF DATA PRO Technical Services Operations Director INFORMATION TECHNOLOGY

More information

2015 Medicare Advantage Summary of Benefits

2015 Medicare Advantage Summary of Benefits 2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015

More information

2014 Summary of benefits plan comparison

2014 Summary of benefits plan comparison 2014 Summary of benefits plan comparison The tables below summarize the 2014 Benefits for the Samaritan Choice Medical Plan options (Basic, Wellness and High-Deductible Plans). Pease refer to your plan

More information

ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area

ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area Contacting the Carrier Voice: (877) 883-9577 TTY: (585) 454-2845 Website: Voice: (800) 665-7924 TTY: (800) 252-2452 Website: www.excellusbcbs.com www.mvphealthcare.com Deductible Carry Over None None Deductible,

More information

Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016

Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pplusic.com or by calling 1-800-545-5015. Important Questions

More information

Western Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/2016-12/31/2016

Western Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/2016-12/31/2016 Coverage For: Self Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.westernhealth.com or

More information

How Premier Members access the Verizon Member Agreement from the Premier website.

How Premier Members access the Verizon Member Agreement from the Premier website. How Premier Members access the Verizon Member Agreement from the Premier website. These instructions are designed to connect your organization to the Verizon Wireless Agreement via the Premier Inc website

More information

University Hospital. Valet Parking. Directions from University Hospital to:

University Hospital. Valet Parking. Directions from University Hospital to: version 7 MAPversion 1 Directions from University Hospital to: Huntsman Cancer Institute and Clinical Neurosciences Center Take the visitor elevators to Level 3. Turn left out of the elevators and follow

More information

YOUR TALENT SEARCH, SIMPLIFIED

YOUR TALENT SEARCH, SIMPLIFIED YOUR TALENT SEARCH, SIMPLIFIED ACADEMIA & RESEARCH American Association for the Study of Liver Diseases American Association of Colleges of Osteopathic Medicine American Association of Diabetes Educators

More information

DRAFT. Select VHA ENTERPRISE STANDARD TITLE:??

DRAFT. Select VHA ENTERPRISE STANDARD TITLE:?? Select VHA ENTERPRISE STANDARD TITLE:?? Choose from: ACUPUNCTURE CONSULT ACUPUNCTURE NOTE ADDENDUM ADDICTION PSYCHIATRY ADDICTION SEVERITY INDEX NOTE ADDICTION PSYCHIATRY ADMINISTRATIVE NOTE ADDICTION

More information

Primary and Acute Medical Services

Primary and Acute Medical Services Primary and Acute Medical Ambulance Medically necessary emergent ground and air ambulance transport. Air (fixed wing and air) ambulance Ground ambulance Chemotherapy Outpatient hospital for radiation therapy

More information