Online Claim Entry UB-04. Presented by: Xerox State Healthcare, LLC Provider Relations

Transcription

1 Online Claim Entry UB-04 Presented by: Xerox State Healthcare, LLC Provider Relations

2 Resources When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section

3 Purpose of the Workshop Provide complete explanation of how to fill out the UB-04 paper claim form for: Claim Form Instructions Timely Filing NCCI National Corrective Coding Initiative New Hospital Outpatient Payment Method Add/Manage Templates Medicaid Primary Claims Medicaid secondary to a Third Party Liability (TPL) HMO co-payments Medicare Replacement Plans Medicare Primary Claims 3

4 Important State Websites STATE WEBSITES: PROGRAM POLICY MANUAL BILLING INSTRUCTIONS REGISTERS AND SUPPLEMENTS:

5 Important Update On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services. 5 November 20, 2013

6 Claim Form Instructions

7 Where to get a copy of claim form instructions Click Forms, Publications, and Instructions under Provider Information

8 Where to get a copy of claim form instructions Scroll down Open file

9 Timely Filing

10 What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: The first digit indicates what the claim media is: Batch number 1= Debit 2= Credit 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim The last two digits of the year the claim was received The numeric day of the year. The claim number within the batch. 9 = Web portal claim entry This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87 th day of 2013, or March 28,

11 Timely Filing Denials Re-filing Claims and Submitting Adjustments UB-04 form: Put the TCN in block 64 on the paper form MEDICAID , CONNIE CLIENT 11

12 NCCI National Corrective Coding Initiative

13 NCCI (National Corrective Coding Initiative) Is a CMS program that consists of coding policies and edits. Medicaid NCCI Edits consist of two types: (1) NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and (2) Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas). 13

14 NCCI (National Corrective Coding Initiative) RA EOB Codes: 6501 or Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service through Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit. Please visit the link below for any additional information: Topics/Data-and-Systems/National-Correct-Coding-Initiative.html 14

15 New Hospital Outpatient Payment Method

16 New Hospital Outpatient Payment Method for New Mexico Medicaid All General Acute Hospitals and Rehabilitation Hospitals must include a procedure code on every line item to receive payment. It is recommended that you bill all outpatient services for the same date of service on the same claim form all inclusive.

17 New Hospital Outpatient Payment Method for New Mexico Medicaid The following resources are available on the HSD/MAD website located at: Hospital Outpatient Payment Method FAQ Hospital Outpatient Payment Method Revenue Codes Hospital Outpatient Payment Method Procedure Codes Notice of Hospital Outpatient Prospective payment System Rates Explanation of Simulation Spreadsheet for Outpatient services

18 Add/Manage Templates

19 UB-04 - Add Claim Template Please note template are limited to 25 per user. HINT: think about use procedure code, or dates (billing range dates) The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice. 19

20 UB-04 - Add Claim Template Fill out any information you would like included in your template 20

21 UB-04 - Add Claim Template Fill out any information you would like included in your template 21

22 UB-04 - Add Claim Template Fill out any information you would like included in your template 22

23 UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text. View next slide for additional fields. 23

24 UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text. 24

25 UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text. 25

26 UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text. 26

27 UB-04 - Add Claim Template Fill out any information you would like included in your template. 27 Sections can be expanded by checking all sections with Red Text.

28 UB-04 - Manage Claim Template Edit or Delete created templates 28

29 Medicaid Primary Claim Forms

30 Online Claims Entry To begin the claim submission, all field with a RED asterisk (*) must be completed 30 November 20, 2013

31 Online Claims Entry Primary Claim (Cont.) Click on the Red Text for the UB-04 Claim form instructions 31 November 20, 2013

32 Additional Information Option Sections can be expanded by selecting all sections with Red Text 32 November 20, 2013

33 Online Claims Entry Primary Claim (Cont.) Sections can be expanded by selecting all sections with Red Text 33 November 20, 2013

34 Online Claims Entry Primary Claim (Cont.) Sections can be expanded by selecting all sections with Red Text 34 November 20, 2013

35 Online Claims Entry Primary Claim (Cont.) Click upload 35 November 20, 2013

36 Online Claims Entry Primary Claim (Cont.) Review the Uploading Attachments Restrictions. You can attach files up to 10 MB Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files. 36 November 20, 2013

37 Online Claims Entry Primary Claim (Cont.) All field with a Red Asterisk (*) are REQUIRED fields Diagnosis codes do not require a period(.) Only enter the numeric value 37 November 20, 2013

38 Online Claims Entry Primary Claim (Cont.) Indicate the Total charge x Verify Total charge is correct If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits. 38 November 20, 2013

39 Medicaid Third Party Liability (TPL) Claim

40 Third Party Liability (TPL) Tips TPL is commercial insurance TPL must be billed primary to Medicaid Medicaid does not consider Medicare TPL 40

41 Third Party Liability (TPL) Tips Always enter the amount paid in the Paid Amount field provided in the Other Insurance Info section of claim. If Medicaid requires a PA for the service, then a PA issued by Medicaid Utilization Review is always required when TPL is involved, no matter if TPL paid or denied the service. Attach the TPL EOB showing the payment/denial with the claim. Always include the explanation page of the EOB along with the page of the EOB that shows payment/denial. 41

42 Medicaid TPL Claim Example Indicate Paid Amount 42 November 20, 2013

43 Medicaid TPL Claim Example Indicate the Total charge x TPL Payment Co-pay/Co-insurance/ Deductible Verify Total charge is correct If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits. 43 November 20, 2013

44 Medicaid Co-payment Claim Forms

45 PPO/HMO Co-Pay Tips Indicate PPO/HMO under Other Insurance Info section of the claim. Indicate Co-pay amount in the Co-pay field provided in the Other Insurance Info section of claim. Attach the EOB. In the Prior Payment Amount enter the difference between the billed amount and the co-payment\amount Due. Enter the co-payment amount in the Amount Due field. 45

46 HMO Co-pay Claim Example Indicate Copay amount 46 November 20, 2013

47 HMO Co-pay Claim Example Indicate the Total charge x Difference Co-pay/Co-insurance/ Deductible Verify Total charge is correct If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits. 47

48 Medicare Replacement Plan Claim Forms

49 Medicare Replacement Plan Indicate Medicare Advantage for Medicare Replacement Plan 49 November 20, 2013

50 Medicare Replacement Plan Attach Copy of EOB 50 November 20, 2013

51 Medicare Replacement Plan X Total Charge Difference between total charge and the co-payment amount Co-Payment Amount 51

52 Medicare Primary Claim Forms

53 Medicare Primary Claims Indicate Medicare for Medicare Crossover submissions 53 November 20, 2013

54 Medicare Primary Claims Attach Copy of EOB 54 November 20, 2013

55 Medicare Primary Claims Only Indicate Total charge on Medicare Crossovers Leave the Prior Payment Amount and Amount Due Blank X 55

56 Inpatient claims for Medicare Part B-only clients

57 Inpatient Claims for Medicare Part B-only clients Certain Medicaid/Medicare clients only have Medicare Part B coverage. Medicare may cross over the Part B claim with type of bill 121. This claim does not have an accommodation revenue code on it. The claim will deny and the provider will need to resubmit and include the following four things on the claim: 57

58 Inpatient claims for Medicare Part Use type of bill 121. B-only clients Attach a copy of the EOMB indicate Medicare paid amount in previous payment box (form locator 54). 58

59 Inpatient Claims for Medicare Part B- only clients Indicate Medicare for Inpatient Claims for Medicare Part B-Only Recipients 59 November 20, 2013

60 Inpatient Claims for Medicare Part B- only clients Attach Copy of EOB 60 November 20, 2013

61 Inpatient Claims for Medicare Part B- only clients Total Charge TPL Payment Amount X Difference between Total Charge and Prior Payment Amount 61

62 UB-04 Tips

63 UB-04 Tips Ensure the line item charges are correct and match the total charge. 63

64 UB-04 Tips Include all appropriate EOB s for TPL, HMO, etc. If you are a for profit organization, make sure gross receipts tax is included in the line items, if required. Rev codes, diagnosis codes, etc., are entered correctly. 64

65 Resources When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section

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