Claim Filing Instructions

Transcription

1 laim Filing Instructions evised October 2014

2 NOTES

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

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

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

6 laims Filing Procedure laim Filing Procedures for laim Submission Arbor Health Plan, hereinafter referred to as the Plan or Arbor Health Plan is required by state and federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims. When required data elements are missing or are invalid, claims will be rejected by Arbor Health Plan for correction and re-submission. laims for billable services provided to Arbor Health Plan members must be submitted by the provider who performed the services. laims filed with Arbor Health Plan are subject to the following procedures: Verification that all required fields are completed on the MS 1500 or UB-04 forms. Verification that all Diagnosis and Procedure odes are valid for the date of service. Verification for electronic claims against 837 edits at Emdeon Verification of member eligibility for services under Arbor Health Plan during the time period in which services were provided. Verification that the services were provided by a participating provider or that the out of plan provider has received authorization to provide services to the eligible member. Verification that the provider is eligible to participate with the Medicaid Program at the time of service. Verification that an authorization has been given for services that require prior authorization by the Plan. Verification of whether there is Medicare coverage or any other thirdparty resources and, if so, verification that the Plan is the payer of last resort on all claims submitted to the Plan. Plan should not be listed as other payer. IMPOTANT: ejected claims are defined as claims with invalid or required missing data elements, such as the provider tax identification number or member ID number, that are returned to the provider or EDI* source without registration in the claim processing system. ejected claims are not registered in the claim processing system and can be resubmitted as a new claim. Denied claims are registered in the claim processing system but do not meet requirements for payment under Arbor Health Plan guidelines. They should be resubmitted as a corrected claim. Denied claims must be resubmitted as corrected claims within 90 calendar days from the EOB (denial or payment) if the error is a repairable edit. Note: These requirements apply to claims submitted on paper or electronically. * For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital laims in this booklet. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information 1 Provider Services

7 laims Filing Procedure laim Mailing Instructions Submit claims to Arbor Health Plan at the following address: Arbor Health Plan laims Processing Department P.O. Box 7336 London, KY The Plan encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon s Provider Support Line at to arrange transmission. Any additional questions may be directed to the Arbor Health Plan EDI Technical Support Hotline at or by at [email protected] laim Filing Deadlines Original invoices must be submitted to the Plan within 365 calendar days from the date services were rendered or compensable items were provided. e-submission of previously denied claims with corrections and requests for adjustments must be submitted within 90 calendar days from the EOB (denial or payment). laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 365 days of the date of service or within 60 days of the primary insurer s EOB adjudication, whichever is longer. Timely Filing of laims with asualty Insurance: Providers must submit claims within 24 months of the date of service. Important: equests for adjustments may be submitted electronically, on paper or by telephone. By Telephone: Provider laim Services (Select the prompts for the correct Plan, and then select the prompt for claim issues.) On Paper: If you prefer to write, please be sure to stamp each claim submitted corrected or resubmission and address the letter to: laims Processing Department Arbor Health Plan P.O London, KY Administrative or medical appeals must be submitted in writing to: Provider Appeals Department Arbor Health Plan P.O. Box 7334 London, KY efer to the Provider Handbook or look online at the Provider enter of the Arbor Health Plan website at for complete instructions on submitting appeals. Important: laims originally rejected for missing or invalid data elements must be corrected and re-submitted within 365 calendar days from date of service. ejected claims are not registered as received in the claim processing system. (efer to the definitions of rejected and denied claims on page 1.) Note: Arbor Health Plan EDI Payer ID# * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information 2 Provider Services

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

9 MS 1500 laim Form Field equirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 3 Provider Services

10 MS 1500 laim Form Field equirements laim Form Field equirements The following charts describe the required fields that must be completed for the standard enters for Medicare and Medicaid Services (MS) MS 1500 or UB-04 claim forms. If the field is required without exception, an (equired) is noted in the equired or onditional box. If completing the field is dependent upon certain circumstances, the requirement is listed as (onditional) and the relevant conditions are explained in the Instructions and omments box. The MS 1500 claim form must be completed for all professional medical services, and the UB-04 claim form must be completed for all facility claims. All claims must be submitted within the required filing deadline of 365 days from the date of service. Although the following examples of claim filing requirements refer to paper claim forms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic or paper). equired Fields (MS 1500 laim Form) MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 1 Insurance Program Identification heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. 1a Insured ID Number (Arbor Health Plan member s identification number) 2 Patient s Name (Last, First, Middle Initial) Arbor Health Plan member identification number. The newborn will have regular or FFS Medicaid until enrollment in managed care becomes active. harges incurred during this period would be payable to the provider by fee for service (DHHS) since managed care eligibility will not be effective retroactively to the date of birth. Enter the patient s name as it appears on the member s Arbor Health Plan I.D. card. efer to page 45 for additional newborn billing information, including Multiple Births. 3 Patient s Birth Date/Sex MMDDYY / M or F If submitting a claim for a newborn, enter newborn and DOB/Sex * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 4 Provider Services

11 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 4 Insured s Name (Last, First, Middle Initial) 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (include area code) Enter the patient s name as it appears on the member s Arbor Health Plan I.D. card, or enter the newborn s name when the patient is a newborn. Enter the patient s complete address and telephone number. (Do not punctuate the address or phone number.) 6 Patient elationship To Insured Always indicate self. 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) 8 eserved for NU use To be determined. Not equired 9 Other Insured's Name (Last, First, Middle Initial) efers to someone other than the patient. ompletion of fields 9a through 9d is equired if patient is covered by another insurance plan. Enter the complete name of the insured. 9a Other Insured's Policy Or Group # equired if # 9 is completed. 9b eserved for NU use To be determined. Not equired 9c eserved for NU use To be determined. Not equired 9d Insurance Plan Name Or Program Name equired if # 9 is completed. 10a,b,c Is Patient's ondition elated To: Indicate Yes or No for each category. Is condition related to: a) Employment b) Auto Accident c) Other Accident * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 5 Provider Services

12 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 10d laim odes (Designated by NU) Enter new ondition odes as appropriate. Available 2-digit ondition odes include nine codes for abortion services and four codes for worker s compensation. Please refer to NU for the complete list of codes. Examples include: AD Abortion Performed due to a Life Endangering Physical ondition aused by, Arising from or Exacerbated by the Pregnancy Itself W3 Level 1 Appeal 11 Insured's Policy Group Or FEA # equired when other insurance is available. omplete if more than one Other Medical insurance is available, or if yes to 10a, b, c. 11a Insured's Birth Date / Sex Same as # 3. equired if 11 is completed. 11b Other laim ID Enter the following qualifier and accompanying identifier to report the claim number assigned by the payer for worker s compensation or property and casualty: Y4 Property asualty laim Number Enter qualifier to the left of the vertical, dotted line; identifier to the right of the vertical, dotted line. 11c Insurance Plan Name Or Program Name Enter name of Health Plan. equired if 11 is completed. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 6 Provider Services

13 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 11d Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature 14 Date Of urrent Illness Injury, Pregnancy (LMP) Y or N by check box. If yes, complete # 9 a-d. MMDDYY or MMDDYYYY Enter applicable 3-digit qualifier to right of vertical dotted line. Qualifiers include: 431 Onset of urrent Symptoms or Illness 484 Last Menstrual Period (LMP) Not required Use the LMP for pregnancy. Example: * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 7 Provider Services

14 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 15 Other Date MMDDYY or MMDDYYYY Enter applicable 3-digit qualifier between the left-hand set of vertical dotted lines. Qualifiers include: 454 Initial Treatment 304 Latest Visit or onsultation 453 Acute Manifestation of a hronic ondition 439 Accident 455 Last X-ay 471 Prescription 090 eport Start (Assumed are Date) 091 eport End (elinquished are Date) 444 First Visit or onsultation Example: 16 Dates Patient Unable To Work In urrent Occupation * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 8 Provider Services

15 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 17 Name Of eferring Physician Or Other Source equired if a provider other than the member s primary care physician rendered invoiced services. Enter applicable 2-digit qualifier to left of vertical dotted line. If multiple providers are involved, enter one provider using the following priority order: 1. eferring Provider 2. Ordering Provider 3. Supervising Provider Qualifiers include: DN eferring Provider DK Ordering Provider DQ Supervising Provider Example: 17a Other ID Number Of eferring Physician (Arbor Health Plan Provider ID#) Enter the Arbor Health Plan provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a. If the Other ID number is the Arbor Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. equired if # 17 is completed. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information. 9 Provider Services

16 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 17b National Provider Identifier (NPI) (enter the referring provider s NPI) 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU)eserved for Nebraska Medicaid Provider ID Enter the NPI number of the referring provider, ordering provider or other source. equired if #17 is completed. equired when place of service is inpatient. MMDDYY (indicate from and to date) Enter the Individual Provider's Medicaid Provider ID. Enter additional claim information with identifying qualifiers as appropriate. For multiple items, enter three blank spaces before entering the next qualifier and data combination. 20 Outside Lab Optional 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) Enter the applicable ID indicator to identify which version of ID codes is being reported: 9 - ID-9-M 0 - ID-10-M Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient s diagnosis and/or condition. List no more than 12 ID diagnosis codes. elate lines A L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field. Note: laims with invalid diagnosis codes will be denied for payment. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

17 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 22 esubmission ode and/or Original ef. No For resubmissions or adjustments, enter the appropriate bill frequency code (7 or 8 see below) left justified in the Submission ode section, and the laim ID# of the original claim in the Original ef. No. section of this field. Additionally, stamp resubmitted or corrected on the claim 7 eplacement of Prior laim 8 Void/cancel of Prior laim 23 Prior Authorization Number Enter the prior authorization number. efer to the Provider Handbook to determine if services rendered require an authorization 24A Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J From date: MMDDYY. If the service was performed on one day there is no need to complete the to date. See page 41 for Important Note (instructions) for completing the shaded portion of field B Place Of Service Enter the MS standard place of service code. 00 for place of service is not acceptable. 24 EMG This is an emergency indicator field. Enter Y for Yes or leave blank for No in the bottom (unshaded area of the field). 24D Procedures, Services Or Supplies PT/HPS/ Modifier Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of service. Note: Modifiers affecting reimbursement must be placed in the first modifier position 24E Diagnosis Pointer Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). Diagnosis codes must be valid ID codes for the date of service. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

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

19 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 27 Accept Assignment Yes or No must be checked. 28 Total harge Enter the total of all charges listed on the claim. 29 Amount Paid equired when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing the Plan. Medicaid programs are always the payers of last resort. 30 eserved for NU Use To be determined. Not equired 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date 32 Name And Address Of Facility Where Services Were endered (If Other Than Home Or Office). Signature on file, signature stamp, computer generated or actual signature is acceptable. equired. Enter the physical location. (P.O. Box # s are not acceptable here.) 32a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 32b. Other ID# (Arbor Health Plan issued Provider Identification Number) efer to NU MS 1500 claims filing guidelines for the two digit qualifiers used to describe the non- NPI provider ID number. Enter the Arbor Health Plan Provider ID # (strongly recommended) Enter the G2 qualifier followed by the Arbor Health Plan Provider ID # equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the twodigit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

20 MS 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments equired or onditional* 33 Billing Provider Info & Ph # equired Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable 33a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 33b. Other ID# (Arbor Health Plan issued Provider Identification Number) efer to NU MS 1500 claims filing guidelines for the two digit qualifiers used to describe the non- NPI provider ID number. Enter the Arbor Health Plan Provider ID # (strongly recommended.) Enter the G2 qualifier followed by the Arbor Health Plan Provider ID #. equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the twodigit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

21 Professional laims EDI Mapping EDI Mapping for MS 1500 MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 1 Insurance Program Identification 2000B, SB09 = I ommercial Insurance 1a Insured ID Number <Plan Name> Member s identification number 2 Patient s Name (Last, First, Middle Initial) 2010BA/NM1 Use 2330A for OB Data 2010BA/NM1 New Born (2010A/NM1) 2010A/NM1 2010A/NM1 3 Patient s Birth Date/Sex 2010BA/DMG 2010A/DMG - Newborn 4 Insured s Name (Last, First, Middle Initial) 2010BA/NM1 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (Include Area ode) 2010A/N3/N4 6 Patient elationship To Insured 2000/PAT01 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) 2010BA/N3/N4 8 eserved for NU Use Blank N 9 Other Insured's Name (Last, First, Middle Initial) 2330A/NM1 9a Other Insured's Policy Or Group # 2320/SB N 9b eserved for NU Use Not in IG N 9c eserved for NU Use Not in IG N 9d Insurance Plan Name Or Program Name 2330 NM1 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

22 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 10a,b,c Is Patient's ondition elated To: 2300/LM11 10d laim odes (Designated by NU) Not in IG 11 Insured's Policy Group Or FEA # 2000B/SB 11a Insured's Birth Date / Sex 2010BA/DMG A/DMG02 11b Other laim ID Not in IG 11c 11d Insurance Plan Name Or Program Name Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature 14 Date Of urrent Illness Injury, Pregnancy (LMP) 2000B/SB B/SB LM /OI LM /DTP03 N 15 Other Date 2300/DTP 16 Dates Patient Unable To Work In urrent Occupation 17 Name Of eferring Physician Or Other Source 17a 17b Other ID Number Of eferring Physician (Plan Provider ID#) National Provider Identifier (NPI) (Enter the referring provider s NPI) 2300/DTP A/NM1 2310A/EF A/NM109. N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

23 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU) 2300/DTP 2300/NTE01 20 Outside Lab 2400/PS102 N 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) 22 esubmission ode and/or Original ef. NoUsed for Original laim # equired when LM05-3 (laim Frequency ode) indicates this claim is a replacement or void to a previously adjudicated claim. 23 Prior Authorization Number 24A eferral Number Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J N 2300, HIXX 2300/EF/Qualifier F8 2300/EF/Qualifier 9F 2300/EF/Qualifier G1 2300/EF/ Qualifier 9F 2400/DTP 24B Place Of Service 2400/SV EMG 2400/SV109 N N 24D Procedures, Services Or Supplies PT/HPS Modifier 2400/SV1 24E Diagnosis Pointer 2400/SV1 24F harges 2400/SV1 24G Days Or Units 2400/SV1 24H EPSDT Family Plan 2400/SV1 24I ID Qualifier 2310B/EF01 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

24 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 24J endering Provider ID 2310B/NM Federal Tax ID Number SSN/EIN of Billing Provider 2310B/EF AA/EF 26 Patient's Account No. 2300/ML01 27 Accept Assignment Not in IG N 28 Total harge Loop 2300/LM 29 Amount Paid OB data should be submitted as it was received from other payer 2320/AMT Qualifier D 30 eserved for NU Use 2320/AMT Qualifier EAF N 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date 32 Name And Address Of Facility Where Services Were endered (If Other Than Home Or Office). NOTE: Ambulance information should be sent as per 837 IG Loop 2300/LM D/2310E 2300/ & 1 N 32a. NPI number of Supervising Provider name 32b. Other ID# (Arbor Health Plan issued Provider Identification Number) Strongly recommended 2310/NM1 2310/EF01=G2 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

25 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 33 Billing Provider Info & Ph # 2010AA/NM1 2010AA/N3 2010AA/N4 2010AA/PE Submission of Taxonomy is strongly recommended P.O. Box in the Billing Address will cause the claim to be rejected at the clearinghouse. P.O. Box may only be submitted with the Pay to Provider 2000A/PV 33a. NPI number 2010AA 33b. Other ID# Arbor Health Plan issued Provider Identification #) Strongly recommended equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. If Billing is also the endering Provider: 2010BB/EF Enter the Arbor Health Plan Provider ID # (strongly encouraged.) Enter the G2 qualifier followed by the Arbor Health Plan ID #. 2000A/PV equired when the endering Provider is an Atypical Provider and does not have an NPI number. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

26 UB-04 laim Field equirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

27 UB-04 laim Field equirements equired Fields (UB-04 laim Forms) UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 1 Unlabeled Field Billing Provider Name, Address and Telephone Number Service Location, no P.O. Boxes Left justified Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 2 Unlabeled Field Billing Provider s Designated Pay-to Name and Address Line a: Enter the complete provider name. Line b: Enter the complete address. Line c: ity, State, and zip code Line d: Enter the area code, telephone number. Enter emit Address Billing Provider s designated pay-to address Enter the Arbor Health Plan Facility Provider I.D. number. Left justified 3a Patient ontrol No. Provider's patient account/control number. 3b Medical/Health ecord Number The number assigned to the patient s medical/health record by the provider * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

28 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 4 Type Of Bill Enter the appropriate three or four -digit code. First position is a leading zero Do not include the leading zero on electronic claims. Second position indicates type of facility. Third position indicates type of care. Fourth position indicates billing sequence. 5 Fed. Tax No. Enter the number assigned by the federal government for tax reporting purposes. 6 Statement overs Period From/Through Enter dates for the full ranges of services being invoiced. MMDDYY 8a Patient Identifier Patient Arbor Health Plan ID is conditional if number is different from field 60 Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

29 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 8b Patient Name Patient name is required. Last name, first name, and middle initial. Enter the patient name as it appears on the Arbor Health Plan ID card. Use a comma or space to separate the last and first names. Titles (Mr., Mrs., etc.) should not be reported in this field. 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. Newborns and Multiple Births: efer to page 45 for additional newborn billing information, including Multiple Births. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

30 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 9a-e Patient Address The mailing address of the patient 9a. Street Address 9b.ity 9c. State 9d. ZIP ode 9e. ountry ode (report if other than U.S.A.) 10 Patient Birth Date The date of birth of the patient. ight-justified; MMDDYYYY 11 Patient Sex The sex of the patient recorded at admission, outpatient service, or start of care. 12 Admission Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 12 Admission Date The start date for this episode of care. For inpatient services, this is the date of admission. ightjustified 13 Admission Hour The code referring to the hour during which the patient was admitted for inpatient or outpatient care. Left Justified 14 Admission Type A code indicating the priority of this admission/visit. 15 Source of eferral for Admission or Visit A code indicating the source of the referral for this admission or visit. Not equired Not equired * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

31 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 16 Discharge Hour ode indicating the discharge hour of the patient from inpatient care. 17 Patient Discharge Status A code indicating the disposition or discharge status of the patient at the end service for the period covered on this bill, as reported in Field ondition odes A code used to identify conditions or events relating to the bill that may affect processing. Please see NU Specifications Manual Instructions for condition codes and descriptions to complete fields Accident State The accident state field contains the two-digit state abbreviation where the accident occurred. equired when applicable. 30 Unlabeled Field Leave Blank. 31a,b 34a,b 35a,b 36a,b Occurrence odes and Dates Enter the appropriate occurrence code and date. equired when applicable. Occurrence Span odes And Dates A code and the related dates that identify an event that relates to the payment of the claim. equired when applicable. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 37a,b eserved Leave Blank. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

32 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 38 esponsible Party Name and Address 39a,b,c,d 41a,b,c,d Value odes and Amounts The name and address of the party responsible for the bill. A code structure to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization. Value odes and amounts. If more than one value code applies, list in alphanumeric order. equired when applicable. Note: If value code is populated then value amount must also be populated and vice versa. Please see NU Specifications Manual Instructions for value codes and descriptions to complete fields Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 42 evenue ode odes that identify specific accommodation, ancillary service or unique billing calculations or arrangements. efer to the DHHS web site for a list of billable revenue codes: cuments/ pdf * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

33 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 43 evenue Description The standard abbreviated description of the related revenue code categories included on this bill. See NUB instructions for Field 42 for description of each revenue code category. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 44 HPS/Accommodation ates/hipps ate odes 1. The Healthcare ommon Procedure oding system (HPS) applicable to ancillary service and outpatient bills. 2. The accommodation rate for inpatient bills. 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems. Enter the applicable rate, HPS or HIPPS code and modifier based on the Bill Type of Inpatient or Outpatient. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

34 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 45 Serv. Date eport line item dates of service for each revenue code or HPS/HIPPS code. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 46 Serv. Units eport units of service. A quantitative measure of services rendered by revenue category or for the patient to include items such as number of accommodation days, miles, pints of blood, renal dialysis treatments, observation hours etc. 47 Total harges Total charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total charges include both covered and non-covered charges. eport grand total of submitted charges. Value entered must be greater than zero ($0.00). 48 Non-overed harges To reflect the non-covered charges for the destination payer as it pertains to the related revenue code. equired when Medicare is Primary. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

35 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 49 Unlabeled Field Not 50 Payer Enter the name for each payer being invoiced. When the patient has other coverage, list the payers as indicated below. Line A refers to the primary payer; Line B refers to the, secondary; and Line refers to the tertiary. required Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * Not required 51 Arbor Health Plan Identification Number The number used by the health plan to identify itself. Arbor Health Plan s Payer ID is # el. Info elease of Information ertification Indicator. This field is required on Paper and Electronic Invoices. Line A refers to the primary payer; Line B refers to the secondary; and Line refers to the tertiary. It is expected that the provider have all necessary release information on file. It is expected that all released invoices contain "Y". 53 Asg. Ben. Valid entries are "Y" (yes) and "N" (no). 54 Prior Payments The A, B, indicators refer to the information in Field 50. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

36 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 55 Est. Amount Due Enter the estimated amount due (the difference between Total harges and any deductions such as other coverage). 56 National Provider Identifier Billing Provider The unique NPI identification number assigned to the provider submitting the bill; NPI is the national provider identifier. equired if the health care provider is a overed Entity as defined in HIPAA egulations. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 57 A,B, Other (Billing) Provider Identifier Arbor Health Plan issued Provider Identification Number A unique identification number assigned to the provider submitting the bill to Arbor Health Plan. omplete if NPI is not mandated in Field 56. The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider Identifier. Use this field to report other provider identifiers as assigned by the health plan listed in Field 50 A,B, * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

37 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 58 Insured's Name Information 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 indicated here. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 59 Patient el Enter the patient s relationship to insured. For Medicaid programs the patient is the insured. ode 01: Patient is Insured 60 Insured s Unique Identifier Arbor Health Plan member s Identification number Enter the patient's Arbor Health Plan ID exactly as it appears on the patient's ID card on line B or. When other insurance is present, enter the plan ID on line A. 61 Group Name Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B, secondary; and, tertiary. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

38 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 62 Insurance Group No. Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B, secondary; and, tertiary. 63 Treatment Authorization odes Enter the Arbor Health Plan prior authorization number. Line A refers to the primary payer; B, secondary; and, tertiary. Field 63A is required. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 64 DN Document ontrol Number. New field. The control number assigned to the original bill by the health plan or the health plan s fiscal agent as part of their internal control. Note: esubmitted claims must contain the original claim ID. 65 Employer Name The name of the employer that provides health care coverage for the insured individual identified in field 58. equired 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, tertiary. 66 Diagnosis and Procedure ode Qualifier (ID Version Indicator) The qualifier that denotes the version of International lassification of Diseases (ID) reported. Not equired Not equired * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

39 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 67 Prin. Diag. d. and Present on Admission (POA) Indicator The ID codes describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for occasioning the admission of the patient for care). 67 A - Q Other Diagnosis odes The ID diagnoses codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital stay. 68 Unlabeled Field Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 69 Admitting Diagnosis ode The ID diagnosis code describing the patient s diagnosis at the time of admission. equired for inpatient and outpatient admissions. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

40 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 70 Patient s eason for Visit The ID diagnosis codes describing the patient s reason for visit at the time of outpatient registration. equired for all outpatient visits. Up to three ID codes may be entered in fields a,b,c. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 71 Prospective Payment System (PPS) ode The PPS code assigned to the claim to identify the DG based on the grouper software called for under contract with the primary payer. equired when the Health Plan/ Provider contract requires this information. Up to 4 digits. 72a-c External ause of Injury (EI) ode The ID diagnosis codes pertaining to external cause of injuries, poisoning, or adverse effect. External ause of Injury E diagnosis codes should not be billed as primary and/or admitting diagnosis. equired if applicable. 73 Unlabeled Field * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

41 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 74 Principal Procedure ode and Date The ID code that identifies the principal procedure performed at the claim level during the period covered by this bill and the corresponding date. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * Inpatient facility ID 9 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID 9 is required when a surgical procedure is performed. 74a-e Other Procedure odes and Dates The ID codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Inpatient facility ID 9 is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID 9 is required when a surgical procedure is performed. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

42 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 76 Attending Provider Name and Identifiers NPI#/Qualifier/Other ID# Enter the NPI number of the attending physician Enter the Arbor Health Plan issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the Arbor Health Plan issued Provider ID number Enter the NPI of the physician who has primary responsibility for the patient s medical care or treatment in the upper line, and their name in the lower line, last name first. If the attending physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the Attending Physician. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * 77 Operating Physician Name and Identifiers NPI#/Qualifier/Other ID# Enter the NPI number of the physician who performed surgery Enter the Arbor Health Plan issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the Arbor Health Plan issued Provider ID number Enter the NPI of the physician who performed surgery on the patient in the upper line, and their name in the lower line, last name first. If the operating physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the Attending Physician. equired when a surgical procedure code is listed. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

43 UB-04 laim Field equirements UB-04 laim Form Field equirements Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Other Provider (Individual) Names and Identifiers NPI#/Qualifier/Other ID# Enter the NPI number of another attending physician Enter the Arbor Health Plan issued Provider ID number Enter the two digit qualifier that identifies the Other ID number as the Arbor Health Plan issued Provider ID number Enter the NPI# of any physician, other than the attending physician, who has responsibility for the patient s medical care or treatment in the upper line, and their name in the lower line, last name first. If the other physician has another unique ID#, enter the appropriate descriptive twodigit qualifier followed by the other ID# 80 emarks Field Area to capture additional information necessary to adjudicate the claim. 81,a-d ode-ode Field To report additional codes related to Form Locator (overflow) or to report externally maintained codes approved by the NUB for inclusion in the institutional data set. Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional * * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

44 Institutional laims EDI Mapping EDI Mapping Table (UB04) UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 1 Unlabeled Field Billing Provider Name, Address and Telephone Number Submission of Taxonomy is strongly recommended 2010AA/NM1 201AA/N3 & N4 2000A Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 2 Unlabeled Field Billing Provider s Designated Pay-to Name and Address 2010AB/N3 & N4 3a Patient ontrol No LM01 3b Medical/Health ecord Number 2300/EF Qualifier EA 4 Type Of Bill LM05 5 Fed. Tax No. 2010AA 6 Statement overs Period From/Through 2300/DTP * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

45 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 7 Unlabeled Not in IG N N 8a Patient Identifier 2010BA 8b Patient Name 2010BA/NM1 2010A/NM1 - Newborn 9a-e Patient Address 2010BA 10 Patient Birth Date 2010BA/DMG 2010A/DMG - Newborn 11 Patient Sex 2010BA/DMG 2010A/DMG - Newborn 12 Admission Admission Date 2300/DTP 13 Admission Hour 2300/DTP 14 Admission Type 2300/L1 Not equired 15 Source of eferral for Admission or Visit 2300/L1 Not equired 16 Discharge Hour (Date) 2300/DTP 17 Patient Discharge Status 2300/DTP * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

46 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* ondition odes HIXX where HI01= BG 29 Accident State 2300/EF 30 Unlabeled Field Not in IG N N 31a,b 34a,b Occurrence odes and Dates HIXX where H101 = BH 35a,b 36a,b Occurrence Span odes And Dates HIXX where H101 = BI 37a,b eserved Not in IG N N 38 esponsible Party Name and Address 39a,b,c,d 41a,b,c,d Not in IG N N Value odes and Amounts HIXX where H101 = BE 42 ev. d. 2400/SV2 43 evenue Description Not in IG N N 44 HPS/Accommodation ates/hipps ate odes 2400/SV2 45 Serv. Date 2400/DTP 46 Serv. Units 2400/SV2 47 Total harges 2300/LM0 48 Non-overed harges OB data should be submitted as received by other payer 2300/AMT01 49 Unlabeled Field Not in IG N N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

47 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 50 Payer 2010BB/ref Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 51 Health Plan Identification Number Plan Payer ID 2010BB 52 el. Info Not in IG N N 53 Asg. Ben. Not in IG N N 54 Prior Payments Not in IG N N 55 Est. Amount Due Not in IG N N 56 National Provider Identifier Billing Provider 2010AA/NM1 57 A,B, Other (Billing) Provider Identifier 2010BB/EF 2310A/EF QUALIFIE G2 58 Insured's Name 2010BA/NM1 2010A/NM1 - Newborn 59 P. el If 2000/PAT01 60 Insured s Unique Identifier 2010BA/NM1 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

48 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 61 Group Name 2000B/SB 62 Insurance Group No. Not in IG N N 63 Treatment Authorization odes Not in IG N N 64 DN Use for submission of original claim number for adjusted or voided claims 2300/EF02 where EF01= F8 (Original eference number) 65 Employer Name Not in IG N N 66 Diagnosis and Procedure ode Qualifier (ID Version Indicator) Use ID code qualifiers per IG Not equired Not equired 67 Prin. Diag. d. and Present on Admission (POA) Indicator 2300/HIXX Qualifier BK 67 A - Q Other Diagnosis odes 2300/HIXX Qualifier BF 68 Unlabeled Field Not in IG N N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

49 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 69 Admitting Diagnosis ode 2300/HIXX Qualifier BJ 70 Patient s eason for Visit 2300/HIXX Qualifier P 71 Prospective Payment System (PPS) ode 2300/HIXX Qualifier D 72a-c External ause of Injury (EI) ode 2300HIXX Qualifier BN 73 Unlabeled Field Not in IG N N 74 Principal Procedure code and Date 74a-e Other Procedure odes and Dates 2300/HIXX Qualifier B 2300/HIXX Qualifier BQ 75 Unlabeled Field Not in IG N N 76 Attending Provider Name and Identifiers NPI#/Qualifier/Other ID# Enter the NPI number of the attending physician 2310A/NM1 2310/EF Qualifier G2 Attending Provider is required * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

50 Institutional laims EDI Mapping UB-04 laim Form EDI Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # Field Description Instructions and omments equired or onditional* 77 Operating Physician Name and Identifiers NPI#/Qualifier/Other ID# Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 2310B/NM1 Enter the NPI number of the physician who performed surgery Other Provider (Individual) Names and Identifiers NPI#/Qualifier/Other ID# 2310/NM1 Enter the NPI number of another attending physician 80 emarks Field 2300/NTE 81,a-d ode-ode Field Not in IG N N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional information Provider Services

51 Supplemental Information Special Instructions and Examples for MS 1500, UB-04 and EDI (837) laims Submissions I. Supplemental Information A. MS 1500 Paper laims Field 24: Important Note: All unspecified Procedure or HPS codes require a narrative description be reported in the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry of 61 characters from the beginning of 24A to the end of 24G. The following are types of supplemental information that can be entered in the shaded lines of Item Number 24: Anesthesia duration in hours and/or minutes with start and end times Narrative description of unspecified codes National Drug odes (ND) for drugs Vendor Product Number Health Industry Business ommunications ouncil (HIB) Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN) formerly Universal Product ode (UP) for products ontract rate The following qualifiers are to be used when reporting these services. 7 Anesthesia information ZZ N4 VP OZ T Narrative description of unspecified code (all miscellaneous fields require this section be reported) National Drug odes Vendor Product Number Health Industry Business ommunications ouncil (HIB) Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN) ontract rate To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the number/code/information. Do not enter hyphens or spaces within the number/code. More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the first qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information. B. EDI Field 24D (Professional) Details pertaining to Anesthesia Minutes, and corrected claims may be sent in Notes (NTE). Details sent in claim level NTE that will be included in claim processing (837): Please include L1, L2, etc. to show line numbers related to the details. Please include these letters AFTE those specified below: o Anesthesia Minutes need to begin with the letters ANES followed by the specific times o o orrected claims need to begin with the letters P followed by the details of the original claim (as per contract instructions) DME laims requiring specific instructions should begin with DME followed by specific details 45 Provider Services

52 Supplemental Information. EDI Field 33b (Professional) Field 33b Other ID# - Professional: 2310B loop, EF01=G2, EF02+ Plan s Provider Network Number. Less than 17 Digits Alphanumeric. Field is required. Note: do not send the provider on the 2400 loop. This loop is not used in determining the provider ID on the claim. D. EDI Field 45 and 51(Institutional) Field 45 Service Date must not be earlier than the claim statement date. Service Line Loop 2400, DTP*472 laim statement date Loop 2300, DTP*434 Field 51 Health Plan ID the number used by the health plan to identify itself. Arbor Health Plan s Health Plan EDI Payer ID# is 52312E. EDI eporting DME DME laims requiring specific instructions should begin with DME followed by specific details. Example: NTE* DME AEOSOL MASK, USED W/DME NEBULIZE Example: NTE*ADD* NO LIABILITY, PATIENT FELL AT HOME~ E. eporting ND on MS-1500 and UB-04 and EDI 1. ND on MS 1500 ND should be entered in the shaded sections of item 24A through 24G To enter ND information, begin at 24A by entering the qualifier N4 and then the 11 digit ND information o Do not enter a space between the qualifier and the 11 digit ND number o o Enter the 11 digit ND number in the format (no hyphens) Do not use for a compound medication, bill each drug as a separate line item with its appropriate ND Enter the drug name and strength Enter the ND quantity unit qualifier o F2 International Unit o o o G Gram ML Milliliter UN Unit Enter the ND quantity o Note: The ND quantity is frequently different than the HP code quantity 46 Provider Services

53 Supplemental Information Example of entering the identifier N4 and the ND number on the MS 1500 claim form: N4 qualifier ND Unit Qualifier 11 digit ND ND Quantity 2. ND on UB-04 ND should be entered in Form Locator 43 in the evenue Description Field eport the N4 qualifier in the first two (2) positions, left-justified o Do not enter spaces o o Enter the 11 character ND number in the format (no hyphens) Do not use for a compound medication, bill each drug as a separate line item with its appropriate ND Immediately following the last digit of the ND (no delimiter), enter the Unit of Measurement Qualifier o F2 International Unit o o o G Gram ML Milliliter UN Unit Immediately following the Unit of Measure Qualifier, enter the unit quantity with a floating decimal for fractional units limited to 3 digits (to the right of the decimal) o Any unused spaces for the quantity are left blank Note that the decision to make all data elements left-justified was made to accommodate the largest quantity possible. The description field on the UB-04 is 24 characters in length. An example of the methodology is illustrated below. N U N ND via EDI The ND is used to report prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting/adjudication processes. EDI claims with ND info should be reported in the LIN segment of Loop ID This segment is used to specify billing/reporting for drugs provided that may be part of the service(s) described in SV2. Please consult your EDI vendor if not submitting in X12 format for details on where to submit the ND number to meet this specification. When LIN02 equals N4, LIN03 contains the ND number. This number should be 11 digits sent in the format with no hyphens. Submit one occurrence of the LIN segment per claim line. laims requiring multiple ND s sent at claim line level should be submitted using MS-1500 or UB-04 paper claim Provider Services

54 Supplemental Information When submitting ND in the LIN segment, the TP segment is required with 5010 HIPAA. This segment is to be submitted with the Unit of Measure and the Quantity. Federal Tax ID on UB04: Federal Tax ID on UB04 (Box# 5) will come from Loop 2010AA, EF02. ondition codes ondition codes (Box number 18 thru 29) will come from Patient reason DX Patient reason DX (Box 70) qualifier will be P qualifier from 2300, HI Provider Services

55 ommon auses of laim Processing Delays, ejections or Denials ommon auses of laim Processing Delays, ejections or Denials Authorization Number Invalid or Missing A valid authorization number must be included on the claim form for all services requiring prior authorization from Arbor Health Plan. Attending Physician ID Missing or Invalid Inpatient claims must include the name of the physician who has primary responsibility for the patient's medical care or treatment, and the medical license number on the appropriate lines in field number 82 (Attending Physician ID) of the UB-04 claim form. A valid medical license number is formatted as two alpha, six numeric, and one alpha character (AANNNNNNA) O two alpha and six numeric characters (AANNNNNN). Billed harges Missing or Incomplete A billed charge amount must be included for each service/procedure/supply on the claim form. Diagnosis ode Missing 4 th or 5 th Digit Precise coding sequences must be used in order to accurately complete processing. eview the ID-9-M or ID-10-M manual for the 4 th and 5 th digit extensions. Look for the th or th symbols in the coding manual to determine when additional digits are required. Diagnosis, Procedure or Modifier odes Invalid or Missing oding from the most current coding manuals (ID-9-M or ID-10-M, PT or HPS) is required in order to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. EOBs (Explanation of Benefits) from Primary Insurers Missing or Incomplete A copy of the EOB from all third party insurers must be submitted with the original claim form for paper claims. Include pages with run dates, coding explanations and messages. Arbor Health Plan accepts EOBs via paper or electronic format. External ause of Injury odes External ause of Injury E diagnosis codes should not be billed as primary and/or admitting diagnosis. Future laim Dates laims submitted for Medical Supplies or Services with future claim dates will be denied, for example, a claim submitted on October 1 for bandages that are delivered for October 1 through October 31 will deny for all days except October 1 Important: Include all primary and secondary diagnosis codes on the claim. Important: Missing or invalid data elements or incomplete claim forms will cause claim processing delays, inaccurate payments, rejections or denials. Important: egardless of whether reimbursement is expected, the billed amount of the service must be documented on the claim. Missing charges will result in rejections or denials. Important: All billed codes must be complete and valid for the time period in which the service is rendered. Incomplete, discontinued, or invalid codes will result in claim rejections or denials. Important: State level HPS coding takes precedence over national level codes unless otherwise specified in individual provider contracts. Important: The services billed on the claim form should exactly match the services and charges detailed on the accompanying EOB. If the EOB charges appear different due to global coding requirements of the primary insurer, submit claim with the appropriate coding which matches the total charges on the EOB. Important: EPSDT services may be submitted electronically or on paper Provider Services

56 ommon auses of laim Processing Delays, ejections or Denials Handwritten laims ompletely handwritten claims will be rejected. Legible handwritten claims are acceptable on resubmitted claims. (See Illegible laim Information) Highlighted laim Fields (See Illegible laim Information) Illegible laim Information Information on the claim form must be legible in order to avoid delays or inaccuracies in processing. eview billing processes to ensure that forms are typed or printed in black ink, that no fields are highlighted (this causes information to darken when scanned or filmed), and that spacing and alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. Incomplete Forms All required information must be included on the claim forms in order to ensure prompt and accurate processing. Member Name Missing The name of the member must be present on the claim form and must match the information on file with the Plan. Member Plan Identification Number Missing or Invalid Arbor Health Plan s assigned identification number must be included on the claim form or electronic claim submitted for payment. Newborn laim Information Missing or Invalid Always include the first and last name of the mother and baby on the claim form. Verify that the appropriate last name is recorded for the mother and baby. Payer or Other Insurer Information Missing or Incomplete Include the name, address and policy number for all insurers covering the Plan member. Place of Service ode Missing or Invalid A valid and appropriate two digit numeric code must be included on the claim form. efer to MS 1500 coding manuals for a complete list of place of service codes. Provider Name Missing The name of the provider of service must be present on the claim form and must match the service provider name and TIN on file with the Plan. Important: For claims with OB, the adjudication date of the other payer is required for EDI and paper claims Important: Submitting the original copy of the claim form will assist in assuring claim information is legible. Important: The individual provider name and NPI number as opposed to the group NPI number must be indicated on the claim form. Important: Do not highlight any information on the claim form or accompanying documentation. Highlighted information will become illegible when scanned or filmed. Important: Do not attach notes to the face of the claim. This will obscure information on the claim form or may become separated from the claim prior to scanning. Important: The newborn will have regular or FFS Medicaid until enrollment in managed care becomes active. harges incurred during this period would be payable to the provider by fee for service (DHHS) since managed care eligibility will not be effective retroactively to the date of birth. Important: Date of service and billed charges should exactly match the services and charges detailed on the accompanying EOB. If the EOB charges appear different due to global coding requirements of the primary insurer, submit claim with the appropriate coding which matches the total charges on the EOB Provider Services

57 ommon auses of laim Processing Delays, ejections or Denials Provider NPI Number Missing or Invalid The individual NPI and group NPI numbers for the service provider must be included on the claim form. evenue odes Missing or Invalid Facility claims must include a valid four-digit numeric revenue code. efer to UB-04 coding manuals for a complete list of revenue codes. Spanning Dates of Service Do Not Match the Listed Days/Units Span-dating is only allowed for identical services provided on consecutive dates of service. Always enter the corresponding number of consecutive days in the days/unit field. Tax Identification Number (TIN) Missing or Invalid - The Tax ID number must be present and must match the service provider name and payment entity (vendor) on file with the Plan. Third Party Liability (TPL) Information Missing or Incomplete Any information indicating a work related illness/injury, no fault, or other liability condition must be included on the claim form. Additionally, a copy of the primary insurer s explanation of benefits (EOB) or applicable documentation must be forwarded along with the claim form. Type of Bill A code indicating the specific type of bill (e.g., hospital inpatient, outpatient, adjustments, voids, etc). The first digit is a leading zero. Do not include the leading zero on electronic claims. Taxonomy The provider s taxonomy number is required if needed by the plan to determine the provider s plan ID when using NPI only is not effective. Important: The individual service provider name and NPI number must be indicated on all claims, including claims from outpatient clinics. Using only the group NPI or billing entity name and number will result in rejections, denials, or inaccurate payments. Important: When the provider or facility has more than one NPI number, use the NPI number that matches the services submitted on the claim form. Imprecise use of NPI numbers results in inaccurate payments or denials. Important: When submitting electronically, the provider NPI number must be entered at the claim level as opposed to the claim line level. Failure to enter the provider NPI number at the claim level will result in rejection. Please review the rejection report from the EDI software vendor each day. Important: laims without the provider signature will be rejected. The provider is responsible for re-submitting these claims within 365 calendar days from the date of service. Important: laims without a tax identification number (TIN) will be rejected. The provider is responsible for re-submitting these claims within 365 calendar days from the date of service. Important: Any changes in a participating provider s name, address, NPI number, or tax identification number(s) must be reported to Arbor Health Plan immediately. ontact your Network Management epresentative to assist in updating the Arbor Health Plan s records Provider Services

58 Electronic Data Interchange (EDI) Quick Tips Electronic Data Interchange (EDI) for Medical and Hospital laims Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry s efforts to reduce administrative costs. The benefits of billing electronically include: eduction of overhead and administrative costs. EDI eliminates the need for paper claim submission. It has also been proven to reduce claim re-work (adjustments). eceipt of clearinghouse reports makes it easier to track the status of claims. Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to 48 hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that occur when completing paper claim forms. Quicker claim completion. laims that do not need additional investigation are generally processed quicker. eports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. All the same requirements for paper claim filing apply to electronic claim filing. Important: Please allow for normal processing time before resubmitting the claim either through EDI or paper claim. This will reduce the possibility of your claim being rejected as a duplicate claim. Important: In order to verify satisfactory receipt and acceptance of submitted records, please review both the Emdeon Acceptance report, and the 059 Plan laim Status eport. efer to the laim Filing section for general claim submission guidelines Provider Services

59 Electronic Data Interchange (EDI) Quick Tips Electronic laims Submission (EDI) The following sections describe the procedures for electronic submission for hospital and medical claims. Included are a high level description of claims and report process flows, information on unique electronic billing requirements, and various electronic submission exclusions. Hardware/Software equirements There are many different products that can be used to bill electronically. As long as you have the capability to send EDI claims to Emdeon, whether through direct submission or through another clearinghouse/vendor, you can submit claims electronically. ontracting with Emdeon and Other Electronic Vendors If you are a provider interested in submitting claims electronically to the Plan but do not currently have Emdeon EDI capabilities, you can contact the Emdeon Provider Support Line at You may also choose to contract with another EDI clearinghouse or vendor who already has Emdeon capabilities. ontacting the EDI Technical Support Group Providers interested in sending claims electronically may contact the EDI Technical Support Group for information and assistance in beginning electronic submissions. When ready to proceed: ead over the instructions within this booklet carefully, with special attention to the information on exclusions, limitations, and especially, the rejection notification reports. ontact your EDI software vendor and/or Emdeon to inform them you wish to initiate electronic submissions to the Plan. Be prepared to inform the vendor of the Plan s electronic payer identification number. Important: Emdeon is the largest clearinghouse for EDI Healthcare transactions in the world. It has the capability to accept electronic data from numerous providers in several standardized EDI formats and then forwards accepted information to carriers in an agreed upon format. Important: ontact Arbor Health Plan s EDI Technical Support at: Or by at [email protected] Important: Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have rejection reports forwarded to the appropriate billing or open receivable departments. Important: The Payer ID for Arbor Health Plan is NOTE: Plan payer specific edits are described in Exhibit 99 at Emdeon Provider Services

60 Electronic Data Interchange (EDI) Quick Tips Specific Data ecord equirements laims transmitted electronically must contain all the same data elements identified within the EDI laim Filing sections of this booklet. EDI guidance for Professional Medical Services claims can be found beginning on page 10. EDI guidance for Facility laims can be found beginning on page 34. Emdeon or any other EDI clearing-house or vendor may require additional data record requirements. Electronic laim Flow Description In order to send claims electronically to the Plan, all EDI claims must first be forwarded to Emdeon. This can be completed via a direct submission or through another EDI clearinghouse or vendor. Once Emdeon receives the transmitted claims, the claim is validated for HIPAA compliance and the Plan s Payer Edits as described in Exhibit 99 at Emdeon. laims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon error report. The name of this report can vary based upon the provider s contract with their intermediate EDI vendor or Emdeon. Accepted claims are passed to the Plan, and Emdeon returns an acceptance report to the sender immediately. laims forwarded to the Plan by Emdeon are immediately validated against provider and member eligibility records. laims that do not meet this requirement are rejected and sent back to Emdeon, which also forwards this rejection to its trading partner the intermediate EDI vendor or provider. laims passing eligibility requirements are then passed to the claim processing queues. laims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted EDI software vendors, must be reviewed and validated against transmittal records daily. Since Emdeon returns acceptance reports directly to the sender, submitted claims not accepted by Emdeon are not transmitted to the Plan. Important: ejected electronic claims may be resubmitted electronically once the error has been corrected. Important: Emdeon will produce an Acceptance report * and a 059 Plan laim Status eport** for its trading partner whether that is the EDI vendor or provider. Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have these reports forwarded to the appropriate billing or open receivable departments. * An Acceptance report verifies acceptance of each claim at Emdeon. ** A 059 Plan laim Status eport is a list of claims that passed Emdeon s validation edits. However, when the claims were submitted to the Plan, they encountered provider or member eligibility edits. Important: laims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. Timely filing Note: Your claims must be received by the EDI vendor by 9:00 p.m. in order to be transmitted to the Plan the next business day. If you would like assistance in resolving submission issues reflected on either the Acceptance or 059 Plan laim Status reports, contact the Emdeon Provider Support Line at If you need assistance in resolving submission issues identified on the 059 Plan laim Status report, contact the Arbor Health Plan EDI Technical Support Hotline at or by at [email protected] 54 Provider Services

61 Electronic Data Interchange (EDI) Quick Tips Invalid Electronic laim ecord ejections/denials All claim records sent to the Plan must first pass Emdeon HIPAA edits and Plan specific edits prior to acceptance. laim records that do not pass these edits are invalid and will be rejected without being recognized as received at the Plan. In these cases, the claim must be corrected and re-submitted within the required filing deadline of 365 calendar days from the date of service. It is important that you review the Acceptance or 059 Plan laim Status reports received from Emdeon or your EDI software vendor in order to identify and re-submit these claims accurately. Plan Specific Electronic Edit equirements The Plan currently has two specific edits for professional and institutional claims sent electronically. 837P X098A1 Provider ID Payer Edit states the ID must be less than 13 alphanumeric digits. 837I X096A1 Provider ID Payer Edit states the ID must be less than 13 alphanumeric digits. Member Number must be less than 17 AN Statement date must be not be earlier than the date of Service Plan Provider ID is strongly encouraged Taxonomy ID is strongly encouraged laim line may be zero for encounters elease of Information permits a Y or I Only one ND number is permitted per claim line Exclusions ertain claims are excluded from electronic billing. These exclusions fall into two groups: These exclusions apply to inpatient and outpatient claim types. Excluded laim ategories At this time, these claim records must be submitted on paper. laim records requiring supportive documentation (Projects). laim records for medical, administrative or claim appeals Excluded Provider ategories laims issued on behalf of the following providers must be submitted on paper. Providers not transmitting through Emdeon or providers sending to Vendors that are not transmitting (through Emdeon) NPDP laims Pharmacy (through Emdeon) Important: equests for adjustments may be submitted electronically, on paper or by telephone. By Telephone: Provider laim Services (Select the prompts for the correct Plan, and then, select the prompt for claim issues.) On Paper: If you prefer to write, please be sure to stamp each claim submitted corrected or resubmission and address the letter to: laims Processing Department Arbor Health Plan P.O London, KY Administrative or medical appeals must be submitted in writing to: Provider Appeals Department Arbor Health Plan PO Box 7334 London, KY efer to the Provider Handbook or the Provider enter online at for complete instructions on submitting administrative or medical appeals. Important: ontact Emdeon Provider Support Line at Important: laims submitted can only be verified using the Accept and/or eject eports. ontact your EDI software vendor or Emdeon to verify you receive the reports necessary to obtain this information. Important: When you receive the ejection report from Emdeon or your EDI vendor, the plan does not receive a record of the rejected claim. Important: Plan expects claims to be submitted for the subscriber, including newborns. The use of the 2010A loop should be limited Provider Services

62 Electronic Data Interchange (EDI) Quick Tips oordination of Benefits information should be submitted to Arbor Health Plan as it was received from the other payer. If received at line level, please submit the claim s OB information at line level. If received at claim level, please submit the claim s OB information at claim level. Normally, 837P claims OB is sent at line level, where the 837I is usually at claim level. OB data must include the adjudication data at the other payer. Arbor Health Plan is not be included as another payer for OB data Provider Services

63 ommon ejections ommon ejections Invalid Electronic laim ecords ommon ejections from Emdeon laims with missing or invalid batch level records laim records with missing or invalid required fields laim records with invalid (unlisted, discontinued, etc.) codes (PT-4, HPS, ID-9 or ID-10, etc.) laims without member numbers Invalid Electronic laim ecords ommon ejections from the Plan (EDI Edits within the laim System) laims received with invalid provider numbers laims received with invalid member numbers laims received with invalid member date of birth esubmitted Professional orrected laims Providers using electronic data interchange (EDI) can submit professional corrected claims* electronically rather than via paper to Arbor Health Plan. * A corrected claim is defined as a resubmission of a claim with a specific change that you have made, such as changes to PT codes, diagnosis codes or billed amounts. It is not a request to review the processing of a claim. Your EDI clearinghouse or vendor needs to: Use frequency code 6 for replacement of a prior claim or frequency code 7 for adjustment of prior claims utilizing bill type in loop 2300, LM05-03 (837P) Include the original claim number in Loop 2300, segment EF01=F8 and EF02=the original claim number; no dashes or spaces Do include the plan s claim number in order to submit your claim with the 6 or 7 Do use this indicator for claims that were previously processed (approved or denied) Do not use this indicator for claims that contained errors and were not processed (rejected upfront) Do not submit corrected claims electronically and via paper at the same time o For more information, please contact the Arbor Health Plan EDI Hotline at or [email protected] o Providers using our NaviNet portal ( can view their corrected claims faster than available with paper submission processing. Important: laims originally rejected for missing or invalid data elements must be corrected and re-submitted within 365 calendar days from the date of service. ejected claims are not registered as received in the claim processing system. (efer to the definitions of rejected and denied claims on page 1.) Important: Before resubmitting claims, check the status of your submitted claims online at Important: orrected Professional laims may be sent in on paper via MS 1500 or via EDI. If sending paper, please stamp each claim submitted corrected or resubmission and send all corrected or resubmitted claims to: laims Processing Department Arbor Health Plan P.O. Box 7336 London, KY Important: orrected Institutional and Professional claims may be resubmitted electronically using the appropriate bill type to indicate that it is a corrected claim. Adjusted claims must be identified in the bill type Provider Services

64 ommon ejections ommon ejections, continued NPI Processing The Plan s Provider Number is determined from the NPI number using the following criteria: 1. Plan ID, Tax ID and NPI number 2. If no single match is found, the Service Location s ZIP code is used 3. If no service location is include, the billing address ZIP code will be used 4. If no single match is found, the Taxonomy is used 5. If no single match is found, the claim is sent to the Invalid Provider queue (IPQ) for processing 6. If a plan provider ID is sent using the G2 qualifier, it is used as provider on the claim The legacy Plan ID is used as the primary ID on the claim 7. If you have submitted a claim, and you have not received a rejection report, but are unable to locate your claim via NaviNet, it is possible that your claim is in review by Arbor Health Plan. Please check with provider services and update you NPI data as needed. It is essential that the service location of the claim match the NPI information sent on the claim in order to have your claim processed effectively. ontact the Emdeon Provider Support Line at: ontact Arbor Health Plan EDI Technical Support at: Important: Provider NPI number validation is not performed at Emdeon. Emdeon will reject claims for provider NPI only if the provider number fields are empty. Important: The Plan s Provider ID is recommended as follows: 837P Loop 2310B, EF*G2[PIN] 837I Loop 2310A, EF*G2[PIN] 58 Provider Services

65 Appendix Supplemental Information Ambulance Ambulatory Surgical enters Anesthesia Audiology Behavioral Health hemotherapy hiropractic are Dental Services Diabetic Self-Management Dialysis Durable Medical Equipment (DME) EPSDT Supplemental Billing Information EPSDT Medical Screening EPSDT Vision Screening EPSDT Subjective Vision Screening EPSDT Objective Vision Screening EPSDT Hearing Screening EPSDT Subjective Hearing Screening EPSDT Objective Hearing Screening EPSDT Interperiodic Screening HEALTH HEK (EPSDT) eferral Indicator odes onsultation Family Planning FQH/H EPSDT Home Health are (HH) Immunization Infusion Therapy Injectable Drugs Maternity Physical/Occupational and Speech Therapies Observation Outpatient Hospital Services adiology Services Surgery Transplants Tribal Health Services 59 Provider Services

66 Appendix Ambulance Ground and Air Ambulance Services are billed on MS 1500 or 837 Format When billing for Procedure odes A0425 A0429 and A0433 A0434 for Ambulance Transportation services, the provider must also enter a valid 2-digit modifier at the end of the associated 5-digit Procedure ode. Different modifiers may be used for the same Procedure ode. Providers must bill the transport codes with the appropriate destination modifier. Mileage must also be billed with the ambulance transport code and be billed with the appropriate transport codes. Providers who submit transport codes without a destination modifier will be denied for invalid/missing modifier. Providers who bill mileage alone will be denied for invalid/inappropriate billing. Mileage when billed will only be paid when billed in conjunction with a PAID transport code. A second trip is reimbursed if the recipient is transferred from first hospital to another hospital on same day in order to receive appropriate treatment. Second trip must be billed with a (HH) destination modifier. For 837 claims, all ambulance details are required. Ambulance Transport information; Ambulance ertification; pick-up and drop-off locations Procedure ode Modifiers: The following procedure code modifiers are required with all transport procedure codes. The first place alpha code represents the origin and the second place alpha code represents the client's destination. odes may be used in any combination unless otherwise noted. D - Diagnostic or therapeutic site (other than physician's office or hospital) E - esidential, domiciliary or custodial facility (other than skilled nursing facility) G - Hospital-based dialysis facility (hospital or hospital-related) H - Hospital I - Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport J - Non hospital-based dialysis facility N - Skilled nursing facility P - Physician's office (includes HMO non-hospital facility, clinic, etc.) - esidence S - Scene of accident or acute event X - (DESTINATION ODE ONLY) Intermediate stop at physician's office enroute to the hospital (includes HMO non-hospital facility, clinic, etc.) 60 Provider Services

67 Appendix Ambulatory Surgical enters Ambulatory Surgical enters (AS) are required to bill on MS 1500 or 837P electronic format. Providers are to bill compensable surgical codes and all ancillary services. Outpatient hospitals are to bill on the UB-04 or via 837I electronic format and only one 490 or 499 rev code line along with the highest compensable surgical code present on the Nebraska Ambulatory Surgical Fee Schedule. If provider is looking to perform a service in the Ambulatory Surgical enter that is not on the Nebraska Medicaid Fee Schedule, provider must obtain prior authorization and rate negotiation prior to service being rendered. Failure to obtain prior authorization for procedures not on Ambulatory Surgical Fee Schedule will result in claim denial. Anesthesia Procedure codes in the Anesthesia section of the urrent Procedural Terminology manual are to be used to bill for surgical anesthesia procedures. eimbursement for surgical anesthesia procedures will be based on formulas utilizing base units, time units (1= 15 min) and a conversion factor. Minutes must be reported on all anesthesia claims except where policy states otherwise. The following modifiers are to be used to bill for surgical anesthesia services: Modifier Servicing Provider Surgical Anesthesia Service AA Anesthesiologist Anesthesia services performed personally by the anesthesiologist QY Anesthesiologist Medical direction* of one NA QK Anesthesiologist Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QX NA NA service with direction by an anesthesiologist QZ NA The following is an explanation of billable modifiers: NA service without medical direction by an anesthesiologist Modifiers which can stand alone: AA, QZ, QK, QX and QY All ASA codes still require a valid ASA modifier to be billed in first position in conjunction with the ASA code Provider Services

68 Appendix Audiology Audiology services must be billed on a MS 1500 claim form or via 837P. Behavioral Health Not covered by Arbor Health Plan. Nebraska contracts with Magellan of Nebraska for authorization and coordination of Behavioral Health (Mental Health/Substance Abuse)(MH/SA) services. hemotherapy Services may be billed electronically via 837 electronic format or via paper on a MS 1500 or UB-04. hemotherapy administration is covered by Nebraska Medicaid. Providers are to use the appropriate chemotherapy administration procedure code in addition to the J-code for the chemotherapeutic agent. If a significant separately identifiable Evaluation and Management service is performed, the appropriate E/M procedure code may also be reported. hiropractic are laims for chiropractic services are billed on a MS 1500 or via 837 electronic format. Must bill appropriate PT code and diagnosis which includes the level of subluxation and symptom(s) that directly relate to the diagnosis of subluxation. Dental Services Services are not covered by Arbor Health Plan. Diabetic Self-Management Training Services may be billed on either a MS 1500 or UB04 or via 837 electronic formats. Services billed on UB04 should be billed with revenue code Dialysis eimbursement for dialysis services must be billed using the UB-04 claim form or via 837I electronic format. Epogen must be reported using procedure code Q4081 in conjunction with revenue code 634 and revenue code 635. The following formula is used in calculating Epogen units of service: (Total number of Epogen units/100) = units of services 62 Provider Services

69 Appendix The units of service field for Epogen must be reported based on the HPS code dosage description as is done with all other physician administered drugs. For example: The HPS code description for Q4081 is Injection, Epogen. If the provider administers 12,400 units of Epogen on that date of service, then 124 should be entered as unit of service. Standard rounding should be applied to the nearest whole number. Durable Medical Equipment Services are billed on a MS 1500 claim form An NU modifier is used for all purchases An modifier is required for all rentals epair codes on the DME Fee Schedule require the submission of procedure code K0739 in conjunction with P modifier for payment consideration Provider are required to bill DME codes with appropriate modifiers per the DHHS DME Fee Schedule Providers should submit invoice with claim for any services indicating ate Not Established (NE) on the NE DHHS Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics EPSDT Supplemental Billing Information EPSDT Medical Screening Billing for these screenings should be completed on the MS 1500 laim Form or electronically with the 837P claim transaction. Providers must use the age appropriate code in order to avoid claim denial. Billing may not be submitted for a medical screening unless all of the following components are administered: OMPONENTS OF THE MEDIAL SEENING 1. omprehensive health and developmental history (including assessment of both physical and mental health and development) 2. omprehensive unclothed physical exam or assessment 3. Appropriate immunizations according to age and health history (unless medically contraindicated or parents or guardians refuse at the time) 4. Laboratory tests (including appropriate neonatal, iron deficiency anemia, urine, and blood lead screening) 5. Health education (including anticipatory guidance) NOTE: All components, including specimen collection, must be provided on-site during the same medical screening visit. Providers must bill with the V20.0 through V20.3 in the primary diagnosis position 63 Provider Services

70 Appendix These codes are billed hard copy on the MS-1500 form or electronically using the 837 claim transaction. Age appropriate preventative medicine screening codes for initial/subsequent visits with EP modifier must be submitted.. At least one of the defined referral codes is required. Vaccines available VF must be billed with vaccine code and modifier SL All providers required to bill on MS1500 format. The following procedure codes are used to bill for the medical screening: Initial comprehensive preventive medicine; Infant (age under 1 year) Initial comprehensive preventive medicine; Early hildhood (ages 1-4) Initial comprehensive preventive medicine; Late hildhood (ages 5-11) Initial comprehensive preventive medicine; Adolescent (ages 12-17) Initial comprehensive preventive medicine; Adult (ages 18-20) Periodic comprehensive preventive medicine; Infant (age under 1 year) Periodic comprehensive preventive medicine; Early hildhood (ages 1-4) Periodic comprehensive preventive medicine; Late hildhood (ages 5-11) Periodic comprehensive preventive medicine; Adolescent (ages 12-17) Periodic comprehensive preventive medicine; Adult (ages 18-20) * Note: Providers must bill the age appropriate code in order to avoid claim denial. EPSDT Vision Screening The purpose of the vision screening is to detect potentially blinding diseases and visual impairments, such as congenital abnormalities and malfunctions, eye diseases, strabismus, amblyopia, refractive errors, and color blindness. EPSDT Subjective Vision Screening The subjective vision screening is part of the comprehensive history and physical exam or assessment component of the medical screening and must include the history of any eye disorders of the child or his family any systemic diseases of the child or his family which involve the eyes or affect vision behavior on the part of the child that may indicate the presence or risk of eye problems medical treatment for any eye condition EPSDT Objective Vision Screening EPSDT objective vision screenings ( EP) may be performed by trained office staff under the supervision of a LIENSED Medicaid physician, physician assistant, registered nurse, or optometrist. Objective vision screenings begin at age 4. The objective vision screening must include tests of: 64 Provider Services

71 Appendix visual acuity (Snellen Test or Allen ards for preschoolers and equivalent tests such as Titmus, HOTV or Good Light, or Keystone Telebinocular for older children); color perception (must be performed at least once after the child reaches the age of 6 using polychromatic plates by Ishihara, Stilling, or Hardy-and-itter); and muscle balance (including convergence, eye alignment, tracking, and a cover-uncover test). The following procedure code is used to bill for vision screening: with EP modifier Vision Screening EPSDT Hearing Screening The purpose of the hearing screening is to detect central auditory problems, sensorineural hearing loss, conductive hearing impairments, congenital abnormalities, or a history of conditions which may increase the risk of potential hearing loss. EPSDT Subjective Hearing Screening The subjective hearing screening is part of the comprehensive history and physical exam or assessment component of the medical screening and must include the history of: the child s response to voices and other auditory stimuli delayed speech development chronic or current otitis media other health problems that place the child at risk for hearing loss or impairment EPSDT Objective Hearing Screening EPSDT objective hearing screenings may be performed by trained office staff under the supervision of a licensed Medicaid audiologist or speech pathologist, physician, physician assistant, or registered nurse. Objective hearing screenings begin at age 4. The objective hearing screening must test at 1000, 2000, and 4000 Hz at 20 decibels for each ear using the puretone audiometer, Welsh Allyn audioscope, or other approved instrument. The following procedure code is used to bill for hearing screening: with EP Modifier Hearing Screening EPSDT Interperiodic Screenings An interperiodic screening can only be billed if the recipient has received an age-appropriate medical screening. If their medical screening has not been performed, the provider should bill an ageappropriate medical screening. It is not acceptable to bill for an interperiodic screening if the ageappropriate medical screening had not been performed. An interperiodic screening by an Arbor Health Plan provider must include all of the components required in the periodic screening. This includes a complete unclothed exam or 65 Provider Services

72 Appendix assessment, health and history update, measurements, immunizations, health education, and other age appropriate procedures. Medically necessary laboratory, radiology, or other procedures may also be performed and should be billed separately. These codes are billed hard copy on the MS-1500 form or via using the 837P electronic format. EPSDT egistered Nurse Interperiodic screening codes: Procedure Modifier Description ode TD plus TS Interperiodic e-evaluation and Management (infant under 1 year) TD plus TS Interperiodic e-evaluation and Management (ages 1-4) TD plus TS Interperiodic e-evaluation and Management (ages 5-11) TD plus TS Interperiodic e-evaluation and Management (ages 12-17) TD plus TS Interperiodic e-evaluation and Management (ages 18-21) TD: To be used to report services provided by N TS: To be used to report interperiodic screenings Physician Interperiodic screening codes: Procedure Modifier Description ode TS Interperiodic e-evaluation and Management (infant under 1 year) TS Interperiodic e-evaluation and Management (ages 1-4) TS Interperiodic e-evaluation and Management (ages 5-11) TS Interperiodic e-evaluation and Management (ages 12-17) TS Interperiodic e-evaluation and Management (ages 18-21) TS: To be used to report Interperiodic screening HEALTH HEK (EPSDT) eferral Indicators odes: One of the following referral indicator codes MUST be included on claims using PT well-child preventive procedure codes EP through EP (Electronic 837P or MS 1500 box 24H). Enter the last digit of the appropriate HEALTH HEK (EPSDT) referral indicator listed below: AV = V Patient refused referral; S2 = 2 Patient is currently under treatment for referred diagnostic or corrective health problems; NU = U No referral given; or ST = T eferral to another provider for diagnostic or corrective treatment. All providers, including FQH and H must bill Health heck services on the MS1500/837P electronic format Provider Services

73 Appendix Family Planning Submit claims via MS-1500, UB-04 or via 837 Format. Arbor Health Plan members may access family planning services through any family planning clinic or provider without a referral. Some services may require prior authorization. ertain services such as abortion, sterilizations and hysterectomy require the submission of a consent form with the MS 1500 claim form. Members can go to any Arbor Health Plan or Medicaid doctor or clinic for family planning services. Members can choose doctors and clinics not in the Arbor Health Plan network for family planning services. Members do not need a referral for routine family planning services. Some services may need prior authorization. Please call Provider Services with any questions. Arbor Health Plan and Nebraska Medicaid do not cover infertility services for the sole purpose of becoming pregnant. H/FQH Billing and eimbursement All services that are covered by the MO per Nebraska Medicaid should be billed to Arbor Health Plan H/FQH providers must bill encounter services (face to face visit w/ physician or mid-level practitioner to treat acute condition or exacerbation of a chronic condition) on the UB04/837I claim format using revenue code 0521, 0524 or 0525 as appropriate and appropriate PT/HPS codes. Non-encounter (routine/well visits), laboratory and radiology services should be billed on the UB04/837I format using revenue code 0519, 030x or 032x respectively with the appropriate PT HPS codes. EPSDT (Health heck) services must be billed on the MS1500 or 837P electronic format. H/FQH providers will be assigned a Facility Provider ID and a non-facility Group/Practitioner ID(s). All services other than the EPSDT should be billed with the Facility ID number/npi. Home Health are (HH) Provider must bill on UB04 or via 837 electronic format Bill the appropriate revenue code for the homecare service. Eligible revenue codes/procedure code combinations and modifiers can be found below. Providers are required to bill DME codes with appropriate modifiers per the NE DHHS DME Fee Schedule 67 Provider Services

74 Appendix Providers must bill the appropriate modifier in the first position when more than one modifier is billed. Valid Home Health Procedure Modifiers for Nurse and Aide Services: TD = N TE = LPN TG = High omplexity/high Tech UN = Servicing two clients at same time Home Health providers billing for covered DME/Supplies may use the MS1450 or 837I electronic format with revenue code 272 and applicable HPS procedure codes DME service codes which are not priced per the DHHS Practitioner Fee Schedule for Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics, should be submitted with invoice. Immunization VF vaccines for members 18 or under must be billed with vaccine code and appropriate modifier. Vaccines available through the VF program, identified on the fee schedule by presence of an SL modifier. Provider must bill vaccine code with the SL modifier to be reimbursed. VF codes not billed with modifier SL will be denied if member is 0-18 years of age. Immunization codes covered by VF are only reimbursed at the administration fee and are to be billed with an SL modifier to identify administration fee only for members age 0 18 years. Members age 19 or over, immunization fee + administration fee may be reimbursed to the provider and provider should bill both the vaccine code and the administration code. Infusion Therapy Drugs administered by physician or outpatient hospital on the Nebraska Medicaid Fee Schedule will be reimbursed but are subjected to Prior Authorization if billed charge is $250 or greater. Drugs require the provider to also bill the ND and related ND information. Failure to bill the ND required information will result in denial, unless the provider is exempt per NE DHHS. Injectable Drugs Vaccines and radiopharmaceuticals are exempt from ND reporting requirements. All drugs billed are required to be submitted with ND information and may be submitted via MS-1500 or 837 electronic format. efer to ND instructions in Supplemental Information section on page Provider Services

75 Appendix The ND number and the HPS code for drug products are required on both the 837 electronic format and the MS-1500 for reimbursable medications. laims submitted without ND information and a valid HPS code will be denied. Drugs administered by physician or OP hospital on the Nebraska Medical Assistance Program Fee Schedule will be reimbursed but are subjected to Prior Authorization if billed charge is $250 or greater. Drugs require that provider also bill the ND and related ND information. Failure to bill the ND required information will result in denial unless provider is exempt, per NE DHHS. Maternity Visits: Pregnancy diagnosis code must be billed in primary or secondary DX code position When billing for prenatal, delivery, and postpartum care, the provider shall submit a claim at the time of delivery. One charge is submitted covering all: 1. outine prenatal care, 2. vaginal delivery, and 3. postpartum care; or 1. outine prenatal care, 2. cesarean delivery, and 3. postpartum care. When the primary physician does not participate in the total obstetrical care, the partial care (prenatal, delivery, or postpartum care only) may be billed separately from the delivery using the appropriate procedure codes. An explanation for the partial care must be submitted with the appropriate claim form or electronic format (i.e., patient moved, delivered elsewhere, aborted, etc.). Providers shall use one procedure code, i.e., for prenatal care only, but shall provide individual dates of service on the claim. Guidance regarding newborn Medicaid eligibility and enrollment in Arbor Health Plan Newborns are not pre-enrolled before birth Mother/representative (which can be the hospital) must notify AESSNebraska to enroll the newborn. Enrollment can take up to 3 months under normal circumstances Providers should bill fee-for-service for any services separately payable from delivery Arbor Health Plan is not responsible until receipt of an enrollment record for the newborn There is no retroactive eligibility for managed care. If baby is eligible for managed care, effective date is from date of assignment to the managed care program DHHS works with mother and hospital to enroll baby as soon as possible Provider Services

76 Appendix Physical/Occupational and Speech Therapies Therapy services may be billed on a UB-04 or MS 1500 claim form or via 837 electronic format. Observation The entire observation visit may not exceed 48 hours duration. Provider should bill no more than 48 hours/units for observation visit. Observation services must be billed in units and populated in the units field When billing for these services, hospitals must include the admission hour and discharge hour in addition to the other required items on the observation claim. An Observation visit should be billed as follows: evenue code 760 or 762 for non-maternity observation. Maternity observation should be billed with revenue code Outpatient Hospital Services Outpatient hospital services should be billed on the UB-04 or 837I electronic format with the following exceptions: Hospital may act as the billing agent for those providing professional services. Any such claims must be submitted on the MS1500 or via 837P electronic format. Hospital Associated Ambulatory Surgical enter (HAAS) that is Medicare participating is reimbursed based on the AS Grouper methodology and services must be billed on the MS1500 or via 837P electronic format. Non-Medicare participating HAAS claims should be billed on the UB04 or via 837I electronic format using type of bill 83x and revenue code 0490 or 0499 as appropriate. All outpatient revenue codes with the following exceptions must be billed with valid PT/HPS codes. Exceptions: pharmacy, supplies and dialysis adiology Services Free Standing radiology centers should bill on MS 1500 or via 837P electronic format using modifier 26. Outpatient hospitals should bill on UB-04 or via 837I electronic format. Outpatient hospitals are paid for technical service only. Outpatient hospitals do not have to bill the T modifier. Payment for the professional component is made according to the Nebraska Medicaid Practitioner Fee Schedule. Surgery Bill on UB-04, or via 837 electronic format Provider Services

77 Appendix Outpatient surgery services should be billed with evenue ode 490 or 499 as appropriate. Free Standing AS and Medicare approved Hospital Associated AS (HAAS) must bill on MS1500/837P format. Non-Medicare approved HAAS must bill on MS1450 (UB04)/837I format using with Bill Type 83X and evenue ode 0490 or 0499 as appropriate. Facility Fee Dental: use PT code with modifier SG. Do not itemize services included in the facility fee. Free Standing AS and Medicare approved Hospital Associated AS (HAAS) must bill on MS1500/837P format using AS approved PT list and SG modifier Non-Medicare approved HAAS must bill on MS1450 (UB04)/837I format using with Bill Type 83X and evenue ode 0490 or 0499 as appropriate. Multiple modifiers - Bilateral secondary procedures should be billed with modifier 50 Swing Bed Services Providers should bill revenue code 011x or 012x as appropriate with revenue code 0022 on MS 1450 or electronic format. Ancillary services, limited to the services listed below should be billed with the defined revenue codes and appropriate PT/HPS codes: Laboratory adiology espiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Audiology ev ode 030x ev ode 032x, 034x or 035x ev ode 041x ev ode 042x ev ode 043x ev ode 044x ev ode 047x Transplants Are not covered by the Arbor Health Plan. Members are disenrolled from the date of the transplant forward. Medical Transplantation Arbor Health Plan is responsible for all covered benefits due members who are being evaluated for medical transplant services up to the date of the transplant or the day that preparatory treatment (chemotherapy or radiation therapy) for stem cell/bone marrow transplants begins. From the date of the approved transplant or preparatory treatment service forward, members are dis-enrolled from Arbor Health Plan and all approved medical services are covered by NE DHHS. Medical transplants subject to these guidelines include the following NE DHHS approved services: heart, liver, kidney, lung, heart/lung, small bowel, and stem cell or bone marrow. orneal transplants are exempt from these guidelines Provider Services

78 Appendix Transplant evaluation services require prior-authorization by Arbor Health Plan. Provider (PP or Transplant Surgeon) is requested to contact Arbor Health Plan Utilization Management to obtain authorization for transplant evaluation. Evaluation approval will be based on review of previous medical history. Once the evaluation has been completed, Arbor Health Plan requires the following information from the Transplant Surgeon, which will be submitted to NE DHHS to initiate the prior-authorization for actual transplant procedures and disenrollment from the managed care program: a. Member s name, ID#, Date of birth (including application to Medicare, if available); and b. Name and location of the transplant center to be utilized( including the facility s current patient selection criteria for transplant centers not previously approved) c. Physician letters: 2 letters from 2 separate transplant team physician on the facility s transplant team who have independently evaluated the member. LOMN must include: medical indications, contraindications and treatment plan d. Psychosocial evaluations and plans: to include treatment plan for pre-transplant support and for supportive services post transplant. Must include social work evaluation and complete psychosocial assessment and treatment plan completed by licensed mental health practitioner, as well as medical plan of support and follow up e. Additional supportive information specific to the type of transplant The DHHS transplant review team will review all information submitted for determination of prior authorization. The Department will send a written verification of approval or denial of the request to the transplant facility within fifteen (15) working days. The Department reserves the right to request additional information regarding the facility, transplant team, or the client's medical and psychosocial status. In an emergency situation that requires transplantation before Departmental approval of the transplant can be obtained, documentation verifying the emergency situation must be submitted along with the other required information for prior authorization of payment coverage. Prior authorization for payment coverage must be obtained prior to submitting the claim. The hospital performing the transplant procedure is advised to contact NE DHHS to assure receipt of priorauthorization for the transplant and any post-transplant services before services are rendered in the absence of written notification from DHHS. Note: Behavioral Health services are not covered by Arbor Health Plan but members who are being evaluated for transplant remain covered by the Nebraska DHHS Behavioral Health Managed are contractor during the evaluation period. Providers rendering transplant evaluation services, including all physician/practitioner visits or outpatient facility services should claim these services to Arbor Health Plan using the appropriate claim format: professional services or the services of independent facility providers should be claimed on the MS 1500 or ANSI X12 837P format; outpatient hospital facility services should be claimed on the MS 1450 or ANSI X12 837I format Any specific billing instructions as previously defined in this manual remain applicable. Tribal linic Services Most office visit services performed at tribal clinics are to be billed as encounter visits and paid at an encounter rate established by MS Provider Services

79 Appendix The HPS code used to bill the encounter is T1015 SE. Procedure code modifier SE is required for this service. Procedure code T1015 SE must be billed on the first line of the Form MS Actual procedure codes for services rendered during the encounter are to be billed on subsequent claim lines. Only the encounter line will be paid. (For example, Line 1 is T1015 SE, line 2 is (or EP if HEALTH HEK (EPSDT), line 3 is 71070, and line 4 is 81000). harges must be the usual and customary charges. Services rendered outside the office setting, office services that do not meet the criteria for the encounter, are to be billed on the Form MS-1500 using the appropriate HPS codes and will be paid according to the Nebraska Practitioner Fee Schedule. Examples of non-encounter services are, but not limited to: Inpatient and outpatient (including E) hospital visits, home and nursing facility visits, home health visit, durable medical equipment, pharmacy, ambulance, brief visit with nurse for blood pressure check, telehealth or telephone consultations. Providers do not need to obtain prior-authorization before rendering non-emergent encounter services to American Indian tribal members. This applies whether or not the tribal member is assigned to another primary care provider. Tribal Hospital-Based Facility Services Billing equirements: The hospital-based facility shall submit all claims for payment for services to Medicaid clients on Form MS-1450 or the standard electronic Health are laim using Bill Type 013x and evenue ode 510 to report encounter services using HPS code T1015SE. Institutional transaction (AS X12N 837). Non-hospital-based providers shall use the appropriate claim form or electronic format Tribal Inpatient ehabilitation Services Inpatient ehabilitation Services, for general acute care hospital providers with ehabilitation beds/units, will be reimbursed on a per diem basis, even to those facilities routinely reimbursed using DG Methodology for all other services. These facilities should bill revenue code 0118, 0128, 0138, 0148, or 0158 as appropriate to receive reimbursement at the per diem rate for these services. ehabilitation hospitals providing ehabilitation Special Needs services and ehabilitation Ventilation Assistance Unit (VAU) services should bill as follows: Special Needs Services: Bill Type , evenue ode 0169 VAU Services: Bill Type , evenue ode Note: Transfer from an acute to rehabilitation setting either between facilities or within the same facility is considered a new admission and requires a separate authorization and separate bill Provider Services

80 Electronic Billing Inquiries Electronic Billing Inquiries Please direct inquiries as follows: Action ontact If you would like to transmit claims electronically If you have general EDI questions If you have questions about specific claims transmissions or acceptance and laim Status reports If you have questions about your 059 Plan laim Status (receipt or completion dates) If you have questions about claims that are reported on the emittance Advice. If you need to know your provider NPI number If you would like to update provider, payee, NPI, UPIN, tax ID number or payment address information For questions about changing or verifying provider information If you would like information on the 835 emittance Advice heck the status of your claim Sign up for NaviNet ontact Emdeon at: ontact Arbor Health Plan EDI Technical Support at: or by at: [email protected] ontact your EDI Software Vendor or call the Emdeon Provider Support Line at ontact Provider laim Services at ontact Provider laim Services at for claim inquiries. ontact Provider Services at: Notify Provider Network Management in writing at: Arbor Health Plan Omaha Tower 2120 South 72 nd St. 10 th Floor Omaha, NE Or by fax at: Or by telephone at: ontact your EDI Vendor or call Emdeon at eview the status of your submitted claims on NaviNet at: NaviNet ustomer Service: Sign up for Electronic Funds Transfer ontact Emdeon at , Option Provider Services

81 75 NOTES

82 76 NOTES