Sunshine State Health Plan. Claim Filing Instructions January 2009

Transcription

1 Sunshine State Health Plan laim Filing Instructions January 2009

2 Table of ontents Procedures for laim Submission...3 laims Mailing Instructions...4 laims Filing Deadlines...4 Exceptions...5 laim esubmissions, Adjustments, and Disputes...5 laim Form equirements...6 laim Forms...6 oding of laims...7 MS 1500 (8/05) laim Form Instructions...8 UB-04/MS 1450 (8/05) laim Form Instructions...20 ejections vs. denials...32 Important Steps to a Successful Submission of Paper laims:...34 esubmitted laims...35 Procedures for electronic submission...36 Filing laims Electronically...36 How to Start...36 Specific Data ecord equirements...37 Electronic laim Flow Description & Important General Information...37 Invalid Electronic laim ecord ejections/denials...38 Specific Total arolina Electronic Edit equirements Information...39 Exclusions...40 ommon ejections...40 Electronic Billing Inquiries Electronic emittance Advice (EA)...42 Electronic Fund Transfer (EFT)...43 Appendix ommon ejections for Paper laims ommon auses of Paper laim Processing Denials EOP Denial odes Instructions for Supplemental Information MS 1500 (8/05) Form, Shaded Field 24A-G HIPAA ompliant EDI ejection odes...56 Provider Services Department

3 Paper laim Filing POEDUES FO LAIM SUBMISSION Sunshine State Health Plan hereafter referred to as Sunshine Health, is required by State and Federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary rejections and/or denials. laims will be rejected or denied if not submitted correctly. In general, Sunshine Health follows the MS (enters for Medicare & Medicaid) billing requirements. For questions regarding billing requirements, contact a Sunshine Health Provider Services epresentative at When required data elements are missing or are invalid, claims will be rejected or denied by Sunshine Health for correction and resubmission. laims for billable services provided to Sunshine Health members must be submitted by the provider who performed the services. All claims filed with Sunshine Health are subject to verification procedures. These include but are not limited to verification of the following: All required fields are completed on the MS 1500, UB-04 or EDI electronic claim form. All Diagnosis, Procedure, Modifier, Location (Place of Service), evenue, Type of Admission, and Source of Admission odes are valid for the date of service. All Diagnosis, Procedure, Modifier, and Location (Place of Service) odes are valid for provider type/specialty billing. All Diagnosis, Procedure, and evenue odes are valid for the age and/or sex for the date of the service billed. All Diagnosis odes are to their highest number of digits available (4 th or 5 th digit). Principle Diagnosis billed reflects an allowed Principle Diagnosis as defined in the volume of ID-9 M or ID-9 M update for the date of service billed. Member is eligible for services under Sunshine Health during the time period in which services were provided. Services were provided by a participating provider or if provided by an "out of plan" provider, authorization has been received to provide services to the eligible Provider Services Department

4 Paper laim Filing member (excludes services by an out of plan provider for an emergency medical condition; however authorization requirements apply for poststabilization services). An authorization has been given for services that require prior authorization by Sunshine Health. Medicare coverage or other third party coverage. laims Mailing Instructions Submit claims to Sunshine Health at the following address: Sunshine State Health Plan laim Processing Department P. O. Box 3070 Farmington, MO Administrative claim appeals must be submitted in writing to: Sunshine State Health Plan Attn: Appeals P. O. Box 3000 Farmington, MO Sunshine Health encourages all providers to submit claims electronically. See section on electronic claim filing for more details. laims Filing Deadlines Original claims must be submitted to Sunshine Health within 180 calendar days from the date services were rendered or compensable items were provided. laims received outside of this timeframe will be denied for untimely submission. All requests for claim reconsideration or adjustment must be received within 45 calendar days from the date of notification of payment or denial. Prior processing will be upheld for reconsiderations or adjustments received outside of the 45 day timeframe, unless a qualifying circumstance is offered and appropriate documentation is provided to support the qualifying circumstance. Qualifying circumstances include: atastrophic event that substantially interferes with normal business operations of the provider or damage or destruction of the provider s business office or records by a natural disaster. Pending or retroactive member eligibility. The claim must have been received within 6 months of the eligibility determination date. Mechanical or administrative delays or errors by Sunshine Health or the Florida Agency for Health are Administration (AHA). The member was eligible however the provider was unaware that the member was eligible for services at the time services were rendered. Provider Services Department

5 Paper laim Filing onsideration is granted in this situation only if all of the following conditions are met: o The provider s records document that the member refused or was physically unable to provide their Medicaid card or information. o The provider can substantiate that he continually pursued. reimbursement from the patient until Medicaid eligibility was discovered. o The provider can substantiate that a claim was filed within 180 days of discovering Medicaid Plan eligibility. o No other paid claims filed by the provider prior to the receipt of the claim under review. Exceptions laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 90 days of receipt of the OI (other insurance arrier) disposition. A copy of the EOB must be submitted along with the laim even if the final disposition was a denial. laims billed without a copy of the payment or denial EOB will be denied by Sunshine Health. laim esubmissions, Adjustments, and Disputes If a provider has a question or is not satisfied with the information they have received related to a claim, they should contact a Sunshine Health Provider Services epresentative at When submitting a paper claim for review or reconsideration of the claims disposition, a copy of the EOP must be submitted with the claim, or the claim must clearly be marked as E-SUBMISSION and include the original claim number. Failure to boldly mark the claim as a resubmission and include the claim number (or include the EOP) may result in the claim being denied as a duplicate, or for exceeding the filing limit deadline. Providers may discuss questions with Sunshine Health Provider Services epresentatives regarding amount reimbursed or denial of a particular service; providers may also submit in writing, with all necessary documentation, including the EOP for consideration of additional reimbursement. A response to an approved adjustment will be provided by way of check with an accompanying EOP. All disputed claims will be processed in compliance with the claims payment resolution procedure as described in the Sunshine Health Provider Manual. For an explanation regarding how to request an informal claim payment adjustment or file a complaint, refer to the process described in the Sunshine Health Provider Manual. Provider Services Department

6 Paper laim Filing LAIM FOM EQUIEMENTS laim Forms Sunshine Health only accepts the MS 1500 (8/05) and MS 1450 (UB-04) paper claim forms. Other claim form types will be rejected and returned to the provider. Professional providers and medical suppliers complete the MS 1500 (8/05) form and institutional providers complete the MS 1450 (UB-04) claim form. Sunshine Health does not supply claim forms to providers. Providers should purchase these from a supplier of their choice. All paper claim forms submitted must be completed in black or blue ink. If you have questions regarding what type of form to complete, contact a Sunshine Health Provider Services epresentative at In the instructions for completing the MS 1500 (8/05) and MS 1450 form that follow: Fields that are required without exception are noted with an (equired) in the equired or onditional column. Fields that are dependent upon certain circumstances are noted with a (onditional) in the equired or onditional column and the relevant conditions are explained in the Instructions and omments column. Fields listed as Not equired and do not offer completion information, follow the instructions produced by the National Uniform laim ommittee (NU) for the MS 1500 (8/05) form and the National Uniform Billing ommittee (NUB) Uniform Billing Manual for the UB-04/MS 1450 form. Entries in a field are left justified unless otherwise indicated (i.e. $ harges field 24F). NOTE: Although the following claim filing requirements refer to paper claim forms, the required and conditional claim data requirements listed apply to all claim submissions, regardless of the method of submission (electronic or paper). Provider Services Department

7 Paper laim Filing oding of laims Sunshine Health requires claims to be submitted using codes from the current version of ID-9 M, PT, and HP Level II for the date the service was rendered. laims will be rejected or denied if billed with: Missing, invalid, or deleted codes odes inappropriate for the age or sex of the member An ID-9 M code missing the 4 th or 5 th digit Sunshine Health uses code-auditing software, laimsxten (a McKesson product), to assist in improving accuracy and efficiency in claims processing, payment and reporting, as well as meeting HIPAA compliance regulations. laimsxten will detect, correct, and document coding errors on provider claims prior to payment by analyzing PT, HP, modifier, and place of service codes against rules that have been established by the American Medical Association (AMA), enter for Medicare and Medicaid Services (MS), and the State of Florida. laims billed in a manner that does not adhere to these standard coding conventions will be denied. For more information regarding billing codes, coding, and code auditing and editing refer to your Sunshine Health Provider Manual or contact a Sunshine Health Provider Services epresentative at Provider Services Department

8 Paper laim Filing MS 1500 (8/05) laim Form Instructions equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. NOTE: laims with missing or invalid equired () field information will be rejected or denied. FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 1 1a 2 3 Insurance Program Identification INSUED I.D. NUMBE PATIENT S NAME (Last Name, First Name, Middle Initial) PATIENT S BITH DATE / SEX 4 INSUED S NAME heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Select "D", other. The 10-digit Medicaid identification number on the member s SUNSHINE HEALTH I.D. card. Enter the patient's name as it appears on the member's SUNSHINE HEALTH I.D. card. Do not use nicknames. Enter the patient s 8-digit date of (MM DD YYYY) and mark the appropriate box to indicate the patient s sex/gender. M = male F = female Enter the patient's name as it appears on the member's SUNSHINE HEALTH I.D. card. Not equired Provider Services Department

9 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL PATIENT'S ADDESS Enter the patient's complete address and telephone number including area code on the appropriate line. First line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). 5 (Number, Street, ity, State, Second line In the designated block, Zip code) Telephone enter the city and state. (include area code) Third line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803) ). Note: Patient s Telephone does not exist in the electronic 837 Professional 4010A PATIENT S ELATION TO INSUED INSUED'S ADDESS (Number, Street, ity, State, Zip code) Telephone (include area code) Always mark to indicate self. Enter the patient's complete address and telephone number including area code on the appropriate line. First line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Second line In the designated block, enter the city and state. Third line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)551414). Note: Patient s Telephone does not exist in the electronic 837 Professional 4010A1. Not equired 8 PATIENT STATUS Not equired Provider Services Department

10 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 9 9a 9b 9c 9d 10a, b, c 10d 11 11a 11b OTHE INSUED'S NAME (Last Name, First Name, Middle Initial) *OTHE INSUED S POLIY O GOUP NUMBE OTHE INSUED S BITH DATE / SEX EMPLOYE'S NAME O SHOOL NAME INSUANE PLAN NAME O POGAM NAME IS PTIENT'S ONDITION ELATED TO: ESEVED FO LOAL USE INSUED S POLIY GOUP O FEA NUMBE INSUED S DATE OF BITH / SEX EMPLOYE S NAME O SHOOL NAME efers to someone other than the patient. EQUIED if patient is covered by another insurance plan. Enter the complete name of the insured. NOTE: OB claims that require attached EOBs must be submitted on paper. EQUIED if # 9 is completed. Enter the policy of group number of the other insurance plan. EQUIED if # 9 is completed. Enter the 8- digit date of birth (MM DD YYYY) and mark the appropriate box to indicate sex/gender. M = male F = female for the person listed in box 9. Enter the name of employer or school for the person listed in box 9. Note: Employer s Name or School Name does not exist in the electronic 837 Professional 4010A1. EQUIED if # 9 is completed. Enter the other insured s (name of person listed in box 9) insurance plan or program name. Enter a Yes or No for each category/line (a, b, and c). Do not enter a Yes and No in the same category/line. EQUIED when other insurance is available. Enter the policy, group, or FEA number of the other insurance. Same as field 3. EQUIED if Employment is marked Yes in box 10a. Not equired Provider Services Department

11 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 11c INSUANE PLAN NAME Enter name of the insurance Health Plan or O POGAM NAME program. 11d IS THEE ANOTHE Mark Yes or No. If Yes, complete # 9a-d and HEALTH BENEFIT PLAN #11c. 12 Enter Signature on File, SOF, or the actual legal signature. The provider must have the PATIENT S O member s or legal guardian s signature on file AUTHOIZED PESON S or obtain their legal signature in this box for the SIGNATUE release of information necessary to process equired and/or adjudicate the claim. 13 PATIENT S O AUTHOIZED PESON S SIGNATUE Not equired a 17b DATE OF UENT: ILLNESS (First symptom) O INJUY (AIDENT) O PEGNANY (LMP) IF PATIENT HAS SAME O SIMILA ILLNESS. GIVE FIST DATE DATES PATIENT UNABLE TO WOK IN UENT OUPATION NAME OF EFEING PHYSIIAN O OTHE SOUE ID NUMBE OF EFEING PHYSIIAN NPI NUMBE OF EFEING PHYSIIAN HOSPITALIZATION DATES ELATED TO UENT SEVIES Enter the 6-digit (MM DD YY) or 8-digit (MM DD YYYY) date reflecting the first date of onset for the: Present illness Injury LMP (last menstrual period) if pregnant Enter the name of the referring physician or professional (First name, middle initial, last name, and credentials). equired if 17 is completed. Use ZZ qualifier for Taxonomy code. equired if 17 is completed. If unable to obtain referring NPI, servicing NPI may be used. Not equired Not equired Not equired Provider Services Department

12 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 19 ESEVED FO LOAL USE Not equired 20 OUTSIDE LAB / HAGES Not equired 21 DIAGNOSIS O NATUE OF ILLNESS O INJUY. (ELATE ITEMS 1,2,3, O 4 TO ITEM 24E BY LINE) Enter the diagnosis or condition of the patient using the appropriate release/update of ID-9- M Volume 1 for the date of service. Diagnosis codes submitted must be a valid ID-9 codes for the date of service and carried out to its highest digit 4 th or 5. "E" codes are NOT acceptable as a primary diagnosis. NOTE: laims missing or with invalid diagnosis codes will be denied for payment MEDIAID ESUBMISSION ODE / OIGINAL EF.NO. PIO AUTHOIZATION NUMBE For re-submissions or adjustments, enter the 12-character DN (Document ontrol Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with ESUBMISSION to avoid denials for duplicate submission. NOTE: e-submissions may NOT currently be submitted via EDI. Enter the SUNSHINE HEALTH authorization or referral number. efer to the SUNSHINE HEALTH Provider Manual for information on services requiring referral and/or prior authorization. Not equired Provider Services Department

13 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 24A-J General Information Box 24 contains 6 claim lines. Each claim line is split horizontally into shaded and unshaded areas. Within each un-shaded area of a claim line there are 10 individual fields labeled A-J. Within each shaded area of a claim line there are 4 individual fields labeled 24A-24G, 24H, 24J and 24J. Fields 24A through 24G are a continuous field for the entry of supplemental information. Instructions are provided for shaded and un-shaded fields. The shaded area for a claim line is to accommodate the submission of supplemental information, EPSDT qualifier, Provider Medicaid Number qualifier, and Provider Medicaid Number. Shaded boxes a-g is for line item supplemental information and is a continuous line that accepts up to 61 characters. efer to the instructions listed below and in Appendix 4 for information on how to complete. The un-shaded area of a claim line is for the entry of claim line item detail. 24A-G Shaded SUPPLEMENTAL INFOMATION The shaded top portion of each service claim line is used to report supplemental information for: ND Anesthesia Start/Stop time & duration Unspecified, miscellaneous, or unlisted PT and HP code descriptions. HIB or GTIN number/code. 24A Un-shaded 24B Un-shaded 24 Un-shaded DATE(S) OF SEVIE PLAE OF SEVIE EMG For detailed instructions and qualifiers refer to Appendix 4 of this manual. Enter the date the service listed in 24D was performed (MM DD YY). If there is only one date enter that date in the From field. The To field may be left blank or populated with the From date. If identical services (identical PT/HP code(s)) were performed within a date span, enter the date span in the From and To fields. The count listed in field 24G for the service must correspond with the date span entered. Enter the appropriate 2-digit MS standard place of service (POS) code. A list of current POS codes may be found on the MS website or the following link: Downloads/placeofservice.pdf Enter Y (Yes) or N (No) to indicate if the service was an emergency. Provider Services Department

14 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL Enter the 5-digit PT or HP code and 2- character modifier - if applicable. Only one PT or HP and up to 4 modifiers may be entered per claim line. odes entered must be valid for date of service. Missing or invalid codes will be denied for payment. 24D Un-shaded POEDUES, SEVIES O SUPPLIES PT/HPS MODIFIE Only the first modifier entered is used for pricing the claim. Failure to use modifiers in the correct position or combination with the procedure code, or invalid use of modifiers, will result in a rejected, denied, or incorrectly paid claim. The following national modifiers are recognized as modifiers that will impact the pricing of your claim. 24E Un-shaded 24F Un-shaded 24G Un-shaded 24H Shaded 24H Un-shaded DIAGNOSIS ODE HAGES DAYS O UNITS EPSDT (HUP) Family Planning EPSDT (HUP) Family Planning AA AD FP LL LT NU QK QS QX QY QZ T SB T UE Enter the numeric single digit diagnosis pointer (1,2,3,4) from field 21. List the primary diagnosis for the service provided or performed first followed by any additional or related diagnosis listed in field 21 (using the single digit diagnosis pointer, not the diagnosis code.) Do not use commas between the diagnosis pointer numbers. Diagnosis codes must be valid ID-9 codes for the date of service or the claim will be rejected/denied. Enter the charge amount for the claim line item service billed. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. Enter quantity (days, visits, units). If only one service provided, enter a numeric value of 1. Leave Blank Enter the appropriate qualifier for EPSDT visit Not equired 24I Shaded ID QUALIFIE Use ZZ qualifier for Taxonomy Provider Services Department

15 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL Enter as designated below the Medicaid ID number or taxonomy code. Typical Providers: Enter the Provider taxonomy code or Medicaid Provider ID number that 24Ja Non-NPI POVIDE ID# corresponds to the qualifier entered in 24I Shaded shaded. Use ZZ qualifier for taxonomy code. Atypical Providers: Enter the 6-digit Medicaid Provider ID number. 24Jb Un-shaded NPI POVIDE ID Typical Providers ONLY: Enter the 10- character NPI ID of the provider who rendered services. If the provider is billing as a member of a group, the rendering individual provider s 10-character NPI ID may be entered. 25 FEDEAL TAX I.D. Enter the provider or supplier 9-digit Federal NUMBE SSN/EIN Tax ID number and mark the box labeled EIN. 26 PATIENT S AOUNT NO. Enter the provider's billing account number. Not equired 27 AEPT ASSIGNMENT? Enter an X in the YES box. Submission of a claim for reimbursement of services provided to a Medicaid recipient using Medicaid funds indicates the provider accepts Medicaid assignment. efer to the back of the MS 1500 (12-90) form for the section pertaining to Medicaid Payments. 28 TOTAL HAGES Enter the total charges for all claim line items billed claim lines 24F. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. Provider Services Department

16 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL EQUIED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing SUNSHINE HEALTH. Medicaid programs are always the payers of last resort. 29 AMOUNT PAID Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. EQUIED when #29 is completed. 30 BALANE DUE 31 SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS Enter the balance due (total charges minus the amount of payment received from the primary payer). Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. Note: does not exist in the electronic 837P. EQUIED if the location where services were rendered is different from the billing address listed in field 33. Enter the name and physical location. (P.O. Box # s are not acceptable here.) equired 32 SEVIE FAILITY LOATION INFOMATION First line Enter the business/facility/practice name. Second line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line In the designated block, enter the city and state. Fourth line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Provider Services Department

17 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL Typical Providers ONLY: EQUIED if the location where services were rendered is 32a different from the billing address listed in NPI SEVIES field 33. ENDEED Enter the 10-character NPI ID of the facility where services were rendered. EQUIED if the location where services were rendered is different from the billing address listed in field b OTHE POVIDE ID Typical Providers Enter the 2-character qualifier ZZ followed by the taxonomy code (no spaces). Atypical Providers Enter the 2-character qualifier 1D followed by the 6-character Medicaid Provider ID number (no spaces). Enter the billing provider s complete name, address (include the zip + 4 code), and phone number a BILLING POVIDE INFO & PH # GOUP BILLING NPI First line Enter the business/facility/practice name. Second line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line In the designated block, enter the city and state. Fourth line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)551414). Typical Providers ONLY: EQUIED if the location where services were rendered is different from the billing address listed in field 33. Enter the 10-character NPI ID. Provider Services Department

18 Paper laim Filing FIELD# FIELD DESIPTION INSTUTION O OMMENTS EQUIED O ONDITIONAL 33b GOUP BILLING OTHE ID Enter as designated below the Billing Group Medicaid ID number or taxonomy code. Typical Providers: Enter the Provider taxonomy code. Use ZZ qualifier. Atypical Providers: Enter the 6-digit Medicaid Provider ID number. Provider Services Department

19 Paper laim Filing NOTE: equired fields denoted by an **** onditional fields denoted by a **** ********************************** ********************************** ****************************** ** ************** ***************** ********************************* ********************************* ******************************** ********************************** ********************************** ************************************ *********************** ************************************ *********************** ************************ ************************************ ************************************ ************************************ ************************************ ************ ************ **** **** ************************************ **************************************************************************** ********************* ** ** ****** **** ********* ** ** ************* ************* ************************* ** ******************** ******** ************************* ******************************** ************************************* *********** **************** ********** ******************** Provider Services Department

20 Paper laim Filing UB-04/MS 1450 (8/05) laim Form Instructions equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. NOTE: laims with missing or invalid equired () field information will be rejected or denied. Field # Field Description Instructions and omments Line 1: Enter the complete provider name. Line 2: Enter the complete mailing address. 1 (UNLABELED FIELD) Line 3: Enter the ity, State, and zip+4 code (include hyphen) Line 4: Enter the area code and phone number. equired or onditional* 2 (UNLABELED FIELD) Enter the Pay-To Name and Address. Not equired 3a PATIENT ONTOL NO. Enter the facility patient account/control number Not equired 3b MEDIAL EOD NUMBE 4 TYPE OF BILL 5 FED. TAX NO. 6 STATEMENT OVES PEIOD FOM/THOUGH Enter the facility patient medical or health record number. Enter the appropriate 3-digit type of bill (TOB) code as specified by the NUB UB-04 Uniform Billing Manual minus the leading 0 (zero). A leading 0 is not needed. Digits should be reflected as follows: 1 st digit - Indicating the type of facility. 2nd digit - Indicating the type of care 3rd digit - Indicating the billing sequence. Enter the 9-digit number assigned by the federal government for tax reporting purposes. Enter begin and end or admission and discharge dates for the services billed. Inpatient and outpatient observation stays must be billed using the admission date and discharge date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology and dialysis may be billed using a date span. All other outpatient services must be billed using the actual date of service. (MMDDYY) 7 (UNLABELED FIELD) Not Used Not equired Provider Services Department

21 Paper laim Filing 8a Enter the patient s 10-digit Medicaid identification number on the member s SUNSHINE HEALTH I.D. card. Not equired 8 a-b 9 a-e PATIENT NAME PATIENT ADDESS 8b Enter the patient s last name, first name, and middle initial as it appears on the SUNSHINE HEALTH 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. H Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. Enter the patient s complete mailing address of the patient. Line a: Street address Line b: ity Line c: State Line d: ZIP code Line e: ountry ode (NOT EQUIED) Provider Services Department (except line 9e) 10 BITHDATE Enter the patient s date of birth (MMDDYYYY) 11 SEX Enter the patient's sex. Only M or F is accepted. 12 ADMISSION DATE Enter the date of admission for inpatient claims and date of service for outpatient claims. 13 ADMISSION HOU 14 ADMISSION TYPE 15 ADMISSION SOUE Enter the time using 2-digit military time (00-23) for the time of inpatient admission or time of treatment for outpatient services :00 midnight to 12: :00 noon to 12: :00 to 01: :00 to 01: :00 to 02: :00 to 02: :00 to 03: :00 to 03: :00 to 04: :00 to 04: :00 to 05: :00 to 05: :00 to 06: :00 to 06: :00 to 07: :00 to 07: :00 to 08: :00 to 08: :00 to 09: :00 to 09: :00 to 10: :00 to 10: :00 to 11: :00 to 11:59 equired for inpatient admissions (TOB 11X, 118X, 21X, 41X). Enter the 1-digit code indicating the priority of the admission using one of the following codes: 1 Emergency 2 Urgent 3 Elective 4 Newborn Enter the 1-digit code indicating the source of the admission or outpatient service using one of the following codes:

22 Paper laim Filing 1 Physician eferral 2 linic eferral 4 Transfer from a hospital 6 Transfer from another health care facility 7 Emergency oom 8 ourt/law enforcement 9 Information not available Enter the time using 2-digit military time (00-23) for the time of inpatient or outpatient discharge. 16 DISHAGE HOU 00-12:00 midnight to 12: :00 noon to 12: :00 to 01: :00 to 01: :00 to 02: :00 to 02: :00 to 03: :00 to 03: :00 to 04: :00 to 04: :00 to 05: :00 to 05: :00 to 06: :00 to 06: :00 to 07: :00 to 07: :00 to 08: :00 to 08: :00 to 09: :00 to 09: :00 to 10: :00 to 10: :00 to 11: :00 to 11:59 EQUIED for inpatient claims. Enter the 2-digit disposition of the patient as of the through date for the billing period listed in field 6 using one of the following codes: Not equired 17 PATIENT STATUS STATU Description S 01 Discharged to home or self care 02 Transferred to another short-term general hospital 03 Transferred to a SNF 04 Transferred to an IF 05 Transferred to another type of institution 06 Discharged home to care of home health 07 Left against medical advice 08 Discharged home under the care of a Home IV provider 20 Expired 30 Still patient or expected to return for outpatient services 31 Still patient SNF administrative days 32 Still patient IF administrative days 62 Discharged/Transferred to an IF, distinct rehabilitation unit of a hospital 65 Discharged/Transferred to a psychiatric hospital or distinct psychiatric unit of a hospital Provider Services Department

23 Paper laim Filing EQUIED when applicable. ondition codes are used to identify conditions relating to the bill that may affect payer processing ONDITION ODES Each field (18-24) allows entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. 29 AIDENT STATE Not equired 30 (UNLABELED FIELD) Not Used Not equired Occurrence ode: EQUIED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing a-b OUENE ODE and OUENE DATE Each field (31-34a) allows entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. Occurrence Date: EQUIED when applicable or when a corresponding Occurrence ode is present on the same line (31a-34a). Enter the date for the associated occurrence code in MMDDYYYY format a-b OUENE SPAN ODE and OUENE DATE Occurrence Span ode: EQUIED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). Provider Services Department

24 Paper laim Filing For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. 37 (UNLABELED FIELD) Occurrence Span Date: EQUIED when applicable or when a corresponding Occurrence Span code is present on the same line (35a-36a). Enter the date for the associated occurrence code in MMDDYYYY format. EQUIED for re-submissions or adjustments. Enter the 12-character DN (Document ontrol Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with ESUBMISSION to avoid denials for duplicate submission. NOTE: e-submissions may NOT currently be submitted via EDI. 38 ESPONSIBLE PATY NAME AND ADDESS Not equired ode: EQUIED when applicable. Value codes are used to identify events relating to the bill that may affect payer processing. Each field (39-41) allows entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes) a-d VALUE ODES ODES and AMOUNTS Up to 12 codes can be entered. All a fields must be completed before using b fields, all b fields before using c fields, and all c fields before using d fields. For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. Amount: EQUIED when applicable or when a Value ode is entered. Enter the dollar amount for the associated value code. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. Provider Services Department

25 Paper laim Filing General Information Fields Line Line Line Line 23 Service Line Detail EV D The following UB-04 fields 42-47: Have a total of 22 service lines for claim detail information. Fields 42, 43, 45, 47, 48 include separate instructions for the completion of lines 1-22 and line 23. Enter the appropriate 4 digit revenue codes itemizing accommodations, services, and items furnished to the patient. efer to the NUB UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Enter accommodation revenue codes first followed by ancillary revenue codes. Enter codes in ascending numerical value. ev D Enter 0001 for total charges. DESIPTION PAGE OF Enter a brief description that corresponds to the revenue code entered in the service line of field 42. Enter the number of pages. Indicate the page sequence in the PAGE field and the total number of pages in the OF field. If only one claim form is submitted enter a 1 in both fields (i.e. PAGE 1 OF 1 ). EQUIED for outpatient claims when an appropriate PT/HPS code exists for the service line revenue code billed. The field allows up to 9 characters. Only one PT/HP and up to two modifiers are accepted. When entering a PT/HPS with a modifier(s) do not use a spaces, commas, dashes or the like between the PT/HP and modifier(s) 44 HPS/ATES efer to the NUB UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. The following revenue codes/revenue code ranges must always have an accompanying PT/HP. 45 Line Line 23 SEVIE DATE EATION DATE 46 SEVIE UNITS 47 Line Line Line EQUIED on all outpatient claims. Enter the date of service for each service line billed. (MMDDYY) Enter the date the bill was created or prepared for submission on all pages submitted. (MMDDYY) Enter the number of units, days, or visits for the service. A value of at least 1 must be entered. TOTAL HAGES Enter the total charge for each service line. TOTALS Enter the total charges for all service lines. NON-OVEED HAGES Enter the non-covered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts. Provider Services Department

26 Paper laim Filing 48 Line 23 TOTALS Enter the total non-covered charges for all service lines. 49 (UNLABELED FIELD) Not Used Not equired 50 A- 51 A- 52 A- PAYE HEALTH PLAN IDENTIFIATION NUMBE EL. INFO 53 ASG. BEN. 54 PIO PAYMENTS Enter the name for each Payer reimbursement is being sought in the order of the Payer liability. Line A refers to the primary payer; B, secondary; and, tertiary. EQUIED for each line (A, B, ) completed in field 50. elease of Information ertification Indicator. Enter Y (yes) or N (no). Providers are expected to have necessary release information on file. It is expected that all released invoices contain "Y. Enter Y" (yes) or "N" (no) to indicate a signed form is on file authorizing payment by the payer directly to the provider for services. Enter the amount received from the primary payer on the appropriate line when Medicaid/ SUNSHINE HEALTH is listed as secondary or tertiary. Not equired 55 EST. AMOUNT DUE Not equired 56 NATIONAL POVIDE IDENTIFIE or POVIDE ID equired: Enter provider s 10-character NPI ID. 57 OTHE POVIDE ID 58 INSUED'S NAME 59 PATIENT ELATIONSHIP Enter the qualifier 1D followed by your 6-digit Medicaid Provider ID number. For each line (A, B, ) completed in field 50, enter the name of the person who carries the insurance for the patient. In most cases this will be the patient s name. Enter the name as last name, first name, middle initial. Not equired Not equired Provider Services Department

27 Paper laim Filing 60 INSUED S UNIQUE ID EQUIED: Enter the patient's Insurance/Medicaid ID exactly as it appears on the patient's ID card. Enter the Insurance /Medicaid ID in the order of liability listed in field GOUP NAME Not equired 62 INSUANE GOUP NO. Not equired TEATMENT AUTHOIZATION ODES DOUMENT ONTOL NUMBE Enter the 12-character Document ontrol Number (DN) of the paid SUNSHINE HEALTH claim when submitting a replacement or void on the corresponding A, B, line reflecting SUNSHINE HEALTH from field 50. Applies to claim submitted with a Type of Bill (field 4) Frequency of 7 (eplacement of Prior laim) or Type of Bill Frequency of 8 (Void/ancel of Prior laim). Not equired 65 EMPLOYE NAME Not equired 66 DX Not equired 67 PINIPAL DIAGNOSIS ODE Enter the principal/primary diagnosis or condition (the condition established after study that is chiefly responsible for causing the visit) using the appropriate release/update of ID-9-M Volume 1& 3 for the date of service. Diagnosis codes submitted must be a valid ID-9 codes for the date of service and carried out to its highest digit 4 th or 5. "E" and most V codes are NOT acceptable as a primary diagnosis. NOTE: laims missing or with invalid diagnosis codes will be denied for payment. Provider Services Department

28 Paper laim Filing Enter additional diagnosis or conditions that coexist at the time of admission or that develop subsequent to the admission and have an effect on the treatment or care received using the appropriate release/update of ID-9- M Volume 1& 3 for the date of service. 67 A-Q OTHE DIAGNOSIS ODE Diagnosis codes submitted must be a valid ID-9 codes for the date of service and carried out to its highest digit 4 th or 5. "E" and most V codes are NOT acceptable as a primary diagnosis. NOTE: laims with incomplete or invalid diagnosis codes will be denied for payment. 68 (UNLABELED) Not Used Not equired Enter the diagnosis or condition provided at the time of admission as stated by the physician using the appropriate release/update of ID-9-M Volume 1& 3 for the date of service. 69 ADMITTING DIAGNOSIS ODE Diagnosis codes submitted must be a valid ID-9 codes for the date of service and carried out to its highest digit 4 th or 5. "E" codes and most V are NOT acceptable as a primary diagnosis. NOTE: laims missing or with invalid diagnosis codes will be denied for payment. Enter the ID-9-M code that reflects the patient s reason for visit at the time of outpatient registration. 70a requires entry, 70b-70c are conditional. 70 a,b,c PATIENT EASON ODE Diagnosis codes submitted must be a valid ID-9 codes for the date of service and carried out to its highest digit 4 th or 5. "E" codes and most V are NOT acceptable as a primary diagnosis. NOTE: laims missing or with invalid diagnosis codes will be denied for payment. 71 PPS / DG ODE Not equired 72 EXTENAL AUSE Not equired a,b,c ODE 73 (UNLABELED) Not equired EQUIED on inpatient claims when a procedure is performed during the date span of the bill. 74 PINIPAL POEDUE ODE / DATE ODE: Enter the ID-9 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2 nd or 3 rd digits of code. It is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). EQUIED for EDI Submissions. Provider Services Department

29 Paper laim Filing EQUIED on inpatient claims when a procedure is performed during the date span of the bill. 74 a-e OTHE POEDUE ODE DATE ODE: Enter the ID-9 procedure code(s) that identify significant a procedure(s) performed other than the principal/primary procedure. Up to 5 ID-9 procedure codes may be entered. Do not enter the decimal between the 2 nd or 3 rd digits of code. It is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). 75 (UNLABELED) Not equired Enter the NPI and Name of the physician in charge of the patient care: NPI: Enter the attending physician 10-character NPI ID. Taxonomy ode: Enter valid taxonomy code 76 ATTENDING PHYSIIAN QUAL: Enter one of the following qualifier and ID number 0B State License # 1G Provider UPIN G2 Provider ommercial # ZZ Taxonomy ode LAST: Enter the attending physician s last name FIST: Enter the attending physician s first name. EQUIED when a surgical procedure is performed: NPI: Enter the operating physician 10-character NPI ID. Taxonomy ode: Enter valid taxonomy code 77 OPEATING PHYSIIAN QUAL: Enter one of the following qualifier and ID number 0B State License # 1G Provider UPIN G2 Provider ommercial # ZZ Taxonomy ode LAST: Enter the operating physician s last name 78 & 79 OTHE PHYSIIAN FIST: Enter the operating physician s first name. Enter the Provider Type qualifier, NPI, and Name of the physician in charge of the patient care: (Blank Field): Enter one of the following Provider Type Qualifiers: DN eferring Provider ZZ Other Operating MD 82 endering Provider NPI: Enter the other physician 10-character NPI ID. QUAL: Enter one of the following qualifier and ID number 0B State License # 1G Provider UPIN G2 Provider ommercial # Provider Services Department

30 Paper laim Filing LAST: Enter the other physician s last name. FIST: Enter the other physician s first name. 80 EMAKS Not equired 81 A: Taxonomy of billing provider. Use ZZ qualifier Provider Services Department

31 Paper laim Filing NOTE: equired fields denoted by an **** onditional *********************** ********************** ** ************* ***** *************************************** ****************************** ****************************** * ******** ******* * **** *** * ******************************* * ****** ****** ****** ****** ***** ***** * *************** * ******** * ******* * ******* **************************************** ********** ******** ******* *** *** *** ****** ******** ******* ************* ******************** * * ************* ************************* ***************** ************************ ********************************************************************* ******* ****** ********** ********* ************* ************ ************* ************** ********** ********** ********* ************* ************ ************* ************** ********** ********** ********************* ************** ********* ********** ********** ********* ******* ************** ********** Provider Services Department

32 Paper laim Filing EJETIONS VS. DENIALS All paper claims sent to the laims Office must first pass specific edits prior to acceptance. laim records that do not pass these edits are invalid and will be rejected or denied. A EJETION is defined as an unclean claim that contains invalid or missing data elements required for acceptance of the claim into the claim processing system. These data elements are identified in the MS 1500 (8/05) and MS 1450 (UB-04) Instructions with an (equired), such as a missing provider tax identification number or a provider tax identification number that cannot be not identified in the claim processing system. A list of common upfront rejections can be found listed below and a more comprehensive list with explanations can be located in Appendix 1. If all edits pass and the claim is accepted, it will then be entered into the system for processing. A DENIAL is defined as a claim that has passed edits and entered into the system, however has been billed with invalid or inappropriate information causing the claim to deny. An EOP (Explanation of Payment) will be sent that includes the denial reason. Please see page34 for tips on resubmission of denied claims. A list of common delays and denials can be found listed below and a more comprehensive list with explanations can be located in Appendix 2. ommon auses of Upfront ejections Unreadable Information. Information within the claim form cannot be read. The ink is faded, too light, or too bold (bleeding into other characters), the font is too small, or hand written information is not legible. Incorrect Form Type the form is not a form accepted by Sunshine Health or not allowed for the provider type. Provider Services Department

33 Paper laim Filing Member DOB (date of birth) is missing. Member Name or ID number is missing. Provider Name, TIN, or NPI number is missing. DOS - The DOS (date of service) on the claim is not prior to receipt of claim (future date of service). DATES A date or dates are missing from required fields. Example: "Statement From" UB-04 & Service From" 1500 (8/05). "To Date" before "From Date". TOB - Invalid TOB (Type of Bill) entered. Diagnosis ode is missing, invalid, or incomplete. Service Line Detail - No service line detail submitted. DOS (date of service) entered is prior to the member s effective date. Admission Type is missing (Inpatient laims UB-04/MS 1450). Patient Status is missing (when Inpatient laims UB-04/MS 1450). Occurrence ode/date is missing or invalid. EV ode (revenue code) is missing or invalid. PT/Procedure ode is missing or invalid. ommon auses of laim Processing Delays and Denials Billed harges are missing or incomplete. Wrong Form Type - The paper claim form submitted is not on a "ed" dropout O form. Diagnosis ode is missing the 4th or 5th digit. Procedure or Modifier odes entered are invalid or missing. DG code is missing or invalid. EOBs (Explanation of Benefits) from the Primary insurer is missing or incomplete. Provider Services Department

34 Paper laim Filing EPSDT information is missing or incomplete. Member ID is invalid. Newborn laim information is invalid. Place of Service ode is invalid. Provider TIN and NPI/Medicaid do not match. evenue ode is invalid. Dates of Service span do not match the listed Days/Units. Signature is missing. Tax Identification Number (TIN) is invalid. Third Party Liability (TPL) information is missing or incomplete. Important Steps to a Successful Submission of Paper laims: 1. omplete all required fields on the MS 1500 or UB-04 forms. 2. Ensure all Diagnosis, Procedure, Modifier, and Location (Place of Service), Type of Admission, and Source of Admission odes are valid for the date of service. 3. Ensure all diagnosis and procedure codes are appropriate for the age and sex of the member. 4. Ensure all diagnosis codes are coded to their highest number of digits available (fourth and fifth digit). 5. Ensure member is eligible for services under Sunshine Health during the time period in which services were provided. 6. Ensure that services were provided by a participating provider or that the out of plan provider has received authorization to provide services to the eligible member. 7. Ensure an authorization has been given for services that require prior authorization by Sunshine Health. 8. laim forms submitted without ed dropout O forms may cause unnecessary delays to processing. Provider Services Department

35 Paper laim Filing esubmitted laims All requests for reconsideration or adjustments must be received within 45 calendar days from the date of notification of payment or denial. Paper claims submitted for review or reconsideration, must be clearly and boldly marked with E-SUBMISSION and/or OETED LAIM, and must include the original claim number, or a copy of the EOP. Failure to do this could allow a claim to deny as a duplicate or deny for non-timely filing Provider Services Department

36 Electronic Data Interchange (EDI) POEDUES FO ELETONI SUBMISSION 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 healthcare 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 rework (adjustments). eceipt of clearinghouse reports as proof of claim receipt. This 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. laims that are not submitted correctly or containing the allowed field data will be rejected and/or denied. Filing laims Electronically How to Start First you will need specific hardware/software requirements. There are many different products that can be used to bill electronically. As long as you have the capability to send EDI claims, whether through direct submission to the clearinghouse or through another clearinghouse/vender, you can submit claims electronically. Provider Services Department

37 Electronic Data Interchange (EDI) Second, the provider needs to contact their vendor and confirm the vendor will transmit the claims to one of the clearinghouses used by Sunshine Health. Third, the provider should confirm with vendor the accurate location of the Sunshine Health Provider ID number. Last, the provider needs to verify with Sunshine Health that their provider record is set up to allow EDI claim submission. Questions regarding electronically submitted claims should be directed to Ext At times, a voice mail will have to be left on the EDI line. You should receive a return call with 24 hours. The companion guides and clearinghouse options are on the Sunshine Health website at 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. Specific Data ecord equirements laims transmitted electronically must contain all the same data elements identified within the laim Filing section of this booklet. Please contact the clearinghouses or vendor you intend to use and ask if they require additional data record requirements. The companion guide is located on Sunshine Health website at Electronic laim Flow Description & Important General Information In order to send claims electronically to Sunshine Health, all EDI claims must first be forwarded to one of Sunshine Health clearinghouses. This can be completed via a direct submission to a clearinghouse or through another EDI clearinghouse or vendor to one of Sunshine Health clearinghouses. Once the clearinghouse receives the transmitted claims, they are validated against their proprietary specifications and Plan specific requirements. laims not meeting the requirements are immediately rejected and sent back to the sender via a clearinghouse error report. It is very important you review this error report daily to identify any claims that were not transmitted to Sunshine Health. Provider Services Department

38 Electronic Data Interchange (EDI) The name of this report can vary based upon the provider s contract with their intermediate EDI vendor or clearinghouse. Accepted claims are passed to Sunshine Health, and the clearinghouse returns an acceptance report to the sender immediately. laims forwarded to Sunshine Health by a clearinghouse are validated against provider and member eligibility records. laims that do not meet provider and/or member eligibility requirements are rejected and sent back on a daily basis to the clearinghouse. The clearinghouse in turn forwards the rejection back to its trading partner (the intermediate EDI vendor or provider). It is very important you review this report daily. The report shows rejected claims and these claims need to be reviewed and corrected timely. laims passing eligibility requirements are then passed to the claim processing queues. Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from the clearinghouse or other contracted EDI software vendors, must be reviewed and validated against transmittal records daily. Since the clearinghouse returns acceptance reports directly to the sender, submitted claims not accepted by the clearinghouse are not transmitted to Sunshine Health. If you would like assistance in resolving submission issues reflected on either the acceptance or claim status reports, please contact your clearinghouse or vendor customer service department. ejected electronic claims may be resubmitted electronically once the error has been corrected. Invalid Electronic laim ecord ejections/denials All claim records sent to Sunshine Health must first pass the clearinghouse proprietary 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 by Sunshine Health. In these cases, the claim must be corrected and re-submitted within the required filing deadline of 180 calendar days from the date of service. It is important that you review the acceptance or claim status reports received from the clearinghouse or your EDI software vendor in order to identify and re-submit these claims accurately. Provider Services Department

39 Electronic Data Interchange (EDI) Specific Sunshine State Health Plan Electronic Edit equirements Information Institutional laims - 837I v4010 Edits Provider s identifying number should be submitted in the ANSI X12, X096a, 837I in loops: AA (billing Provider) The following information is needed: NM108 qualifier is XX NM109 is Provider NPI. The 1st EF segment should be EF01 Qualifier EI, EF02 Employer Identification number. The 2nd EF segment should be EF01 Qualifier 1D, EF02 Provider Medicaid number. The 3 rd EF segment should be EF01 Qualifier G2, EF02 Sunshine Health provider number. Professional laims - 837P v4010 Edits The provider s identifying number should be submitted in the ANSI X12, X098a, 837P in loops: B (endering Provider) AA (Billing Provider) If any of these loops are used, the following information is needed in the segments below. NM108 qualifier is XX NM109 is Provider NPI. The 1st EF segment should be EF01 Qualifier EI, EF02 Employer Identification number. The 2nd EF segment should be EF01 Qualifier 1D, EF02 Provider Medicaid number. The 3 rd EF segment should be EF01Qualifer G2, EF02 Sunshine Health provider number. Adjusted EDI laims LM05-3 equired 6 or 7. Provider Services Department

40 Electronic Data Interchange (EDI) IN 2300 Loop/EF segment is F8; ef 02 must input original claim number assigned. Failure to include the original claim number will result in rejection of the adjustment (error code 76) Exclusions ertain claims are excluded from electronic billing. Excluded laim ategories At this time, these claim records must be submitted on paper. These exclusions apply to inpatient and outpatient claim types. Excluded laim ategories laim records requiring supportive documentation or attachments such as OB claims with a primary insurer s EOB laim records billing with miscellaneous codes laim records for medical, administrative or claim appeals laim requiring documentation of the receipt of an informed consent form laim for services that are reimbursed based on purchase price (e.g. custom DME, prosthetics) laim for services requiring clinical review (e.g. complicated or unusual procedure) laim for services needing documentation and requiring ertificate of Medical Necessity- oxygen, motorized wheelchairs NOTE: Provider identification number validation is not performed at the clearinghouse level. The clearinghouse will reject claims for provider information only if the provider number fields are empty. ommon ejections learinghouse laim records with missing or invalid required fields laims submitted without any provider numbers laims submitted without member numbers Provider Services Department

41 Electronic Data Interchange (EDI) Sunshine Health (EDI Edits within the laim System) laims received with invalid provider numbers check to ensure the TIN and NPI are correct. laims received with invalid member numbers check the member number to ensure number was input correctly on file. Electronic Billing Inquiries Please direct inquiries as follows: Action ontact If you would like to transmit claims ontact one of the clearinghouses for electronically SUNSHINE HEALTH. If you have a general EDI question ontact EDI Support at Ext If you have questions about specific ontact your clearinghouse technical claims transmissions or acceptance support area laim Status reports If you have questions about your laim Status (receipt or completion dates) If you have questions about claims that are reported on the emittance Advice ontact EDI Support at Ext ontact Provider laim Services at If you would like to update provider, payee, UPIN, Tax ID number or payment address information For questions about changing or verifying provider information Notify Provider Services in writing at: Sunshine State Health Plan Provider Services 400 Sawgrass orporate Pkwy Suite 100 Sunrise, FL Or By Fax: By Telephone: Provider Services Department

42 Electronic Data Interchange (EDI) IMPOTANT STEPS TO A SUESSFUL SUBMISSION OF EDI LAIMS: 1. Select clearinghouse to utilize. 2. ontact the clearinghouse to inform them you wish to submit electronic claims to Sunshine Health. 3. Inquire with the clearinghouse what data records are required. 4. Verify with Provider elations at Sunshine Health that the provider is set up in the Sunshine Health system before submitting EDI claims. 5. You will receive two reports from the clearinghouse. ALWAYS review these reports daily. The first report will be a report showing the claims that were accepted by the clearinghouse and are being transmitted to Sunshine Health and those claims not meeting the clearinghouse requirements. The second report will be a claim status report showing claims accepted and rejected by Sunshine Health. ALWAYS review the acceptance and claim status reports for rejected claims. If rejections are noted correct and resubmit. 6. MOST importantly, all claims must be submitted with providers identifying numbers. See the MS 1500 (8/05) and UB claim form instructions and claim forms for details. 835 Electronic emittance Advice (EA) Sunshine Health will have the option for providers to receive an 835 electronic remittance advice transaction. The EA will be received from the clearinghouse the provider utilizes for 837 files. Payer EA enrollment form is on the same form as the request for Electronic Fund Transfer (EFT) registration form. Providers should be prepared to supply the following information during the setup phase: EDI/Vendor and Submitter ID Group/Facility Name ontact Name, Phone Number, and Address Provider Services Department

43 Electronic Data Interchange (EDI) Address Tax ID Payee ID Electronic Fund Transfer (EFT) Sunshine Health has the option for providers to receive payment through an electronic fund transfer instead of a paper check. The provider is required to complete an EFT form. This form can be obtained by calling the Sunshine Health Provider elations Department or from the Sunshine Health website at This form also has a place to request an EA. The set up process for EFT and EA is approximately three weeks. Once you begin receiving an EA you will also receive a paper copy remittance advice for 60 days. After 60 days, the provider will only receive the electronic remittance advice. Provider Services Department

44 APPENDIX Appendix: APPENDIX 1. OMMON EJETIONS FO PAPE LAIMS 2. OMMON AUSES OF PAPE LAIM POESSING DENIAL 3. EOP DENIAL ODES 4. INSTUTIONS FO SUPPLEMENTAL INFOMATION MS-1500 (8/05) FOM, SHADED FIELD 24A-G 5. HIPAA OMPLIANT EDI EJETION ODES Provider Services Department

45 APPENDIX Appendix 1 OMMON EJETIONS FO PAPE LAIMS Admission Type missing (when Inpatient). PT/Procedure ode missing or invalid. DATES Dates missing from required fields. Example: Statement From UB-04 & Service From 1500 (8/05). To Date before From Date. Diagnosis ode missing or invalid. DOS on claim is not prior to receipt of claim (future date of services). DOS prior to effective date. Incorrect Form Type laim not submitted on approved MS 1500 (8/05) for professional medical services or the UB-04 for all facility claims. Invalid TOB Invalid type of bill. Member DOB missing Member DOB is missing from the claim. Member Name or Id Number missing or invalid from the claim. No detail service line submitted. Occurrence ode/date missing or invalid. Patient Status missing (when Inpatient). Provider Name, TIN, or NPI number missing from claim. EV ode missing or invalid. Unreadable laim date is unreadable due to either too light (insufficient toner), dot-matrix printers, or too small font to allow for clear electronic imaging of claim. 8/05. Provider Services Department

46 APPENDIX Appendix 2 OMMON AUSES OF PAPE LAIM POESSING DENIALS Billed harges Missing or Incomplete A billed charge amount must be included for each service/procedure/supply on the claim form. laims not submitted on ed dropout O forms laim forms submitted without red dropout may cause unnecessary delays to processing. Diagnosis ode Missing 4th or 5th Digit Precise coding sequences must be used in order to accurately complete processing. eview the ID-9-M manual for the 4th and 5th digit diagnosis. DG odes Missing or Invalid Hospitals contracted for payment based on DG codes should include this information on the claim form. 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. Include pages with run dates, coding explanations and messages. EPSDT (HUP) Information Missing or Incomplete HUP information should be billed in accordance with the Florida policies and procedures. Age appropriate assessments, lab tests, x-rays and other required elements of the HUP visit are all inclusive in the practice rate and should not be billed separately. Medically necessary elective tests and procedures are billable. The referral code must be used when billing a screening. Member ID Invalid The member Medicaid ID does not match Name or DOB submitted. Newborn laim Information Invalid Newborns must be billed separately from the mother. If the baby has not been named, insert Girl or Boy in front of the mother s last name as the baby s first name. Verify that the appropriate last name is recorded for the mother and baby. Provider Services Department

47 APPENDIX Place of Service ode 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. Procedure or Modifier odes Invalid or Missing- oding from the most current coding manuals (PT or HPS) or appropriate unique coding is required in order to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. Provider TIN and NPI/Medicaid Do Not Match The submitted NPI or Medicaid ID do not match Provider s Tax ID number. evenue odes Missing or Invalid Facility claims must include a valid threedigit numeric revenue code. efer to UB-92 coding manual for a complete list of revenue codes. Spanning Dates of Service Do Not Match the Listed Days/Units Spandating 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. Signature Missing The signature of the provider of service must be present on the claim form and must match the service provider name and TIN on file with Sunshine Health. Tax Identification Number (TIN) Missing or Invalid- The Tax I. D. number must be present and must match the service provider name and payment entity (vendor) on file with Sunshine Health. 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. Provider Services Department

48 APPENDIX Appendix 3 EOP DENIAL ODES DENIAL ODE DENIAL DESIPTION 07 DENY: THE POEDUE ODE IS INONSISTENT WITH THE PATIENT'S SEX 09 DENY: THE DIAGNOSIS IS INONSISTENT WITH THE PATIENT'S AGE 0A 0 0 DENY: NOT EIMBUSABLE - BILL UNDE AMBULANE MEDIAID ID 1999 ODE DELETED IN 2000, PLEASE EBILL WITH OET ODE DENY: SEVIE NOT ON HMO ADIOLOGY SHEDULE-INELIGIBLE FO EIMBUSEMENT 10 DENY: THE DIAGNOSIS IS INONSISTENT WITH THE PATIENT'S SEX 14 DENY: THE DATE OF BITH FOLLOWS THE DATE OF SEVIE 16 DENY: EVENUE ODE NOT EIMBUSABLE - PT/HPS ODE EQUIED 17 DENY: EQUESTED INFOMATION WAS NOT POVIDED 18 DENY: DUPLIATE LAIM/SEVIE 19 DENY: WOK ELATED INJUY AND THE LIABILITY OF WOKE'S OMP AIE 1 1K 1L MEDIAL/HOSPITAL DETAIL EOD ANELLED DENY: PT O DX ODE IS NOT VALID FO AGE OF PATIENT DENY: VISIT & PEVEN ODES AE NOT PAYABLE ON SAME DOS W/O DOUMENTATION 20 DENY: THIS INJUY IS OVEED BY THE LIABILITY AIE 21 DENY: LAIM THE ESPONSIBLITY OF THE NO-FAULT AIE 22 DENY: THIS AE IS OVEED BY A OODINATION OF BENEFITS AIE 23 DENY: HAGES HAVE BEEN PAID BY ANOTHE PATY-OB 24 DENY: HAGES OVEED UNDE APITATION 25 DENY: YOU STOP LOSS DEDUTIBLE HAS NOT BEEN MET 26 DENY: EXPENSES INUED PIO TO OVEAGE 27 DENY: EXPENSES INUED AFTE OVEAGE WAS TEMINATED 28 DENY: OVEAGE NOT IN EFFET WHEN SEVIE POVIDED 29 DENY: THE TIME LIMIT FO FILING HAS EXPIED 2L DENY: NO AUTH OBTAINED FO LOATION BILLED/SUBMITTED 34 DENY: INSUED HAS NO OVEAGE FO NEWBONS 35 DENY: BENEFIT MAXIMUM HAS BEEN EAHED 37 DENY: BALANE DOES NOT EXEED DEDUTIBLE 38 DENY: SEVIES NOT POVIDED O AUTHOIZED BY OU POVIDES 39 DENIED AT THE TIME OF AUTHOIZATION EQUEST 3D 3L 3P DENY: NON-SPEIFI DIAGNOSIS- EQUIES 4TH DIGIT PLEASE ESUBMIT DENY: BENEFIT IS LIMITED TO 4 IN A 90 DAY PEIOD DENY: PAID UNDE SETTLEMENT 40 DENY: HAGES DO NOT MEET QUALIFIATIONS FO EMEGENY AE OUT OF AEA 46 DENY: THIS SEVIE IS NOT OVEED 47 DENY: THIS DIAGNOSIS IS NOT OVEED 48 DENY: THIS POEDUE IS NOT OVEED 49 DENY: THESE AE NONOVEED SEVIES BEAUSE THIS IS A OUTINE EXAM 4D DENY: NON-SPEIFI DIAGNOSIS- EQUIES 5TH DIGIT PLEASE ESUBMIT Provider Services Department

49 APPENDIX 4E DENY: 2004 PT ODES NOT AEPTABLE FO SEVIE DATES PIO TO 4/01/04 50 DENY:NOT A MO OVEED BENEFIT 52 DENY: POVIDE NOT ONTATED FO THIS MEMBE'S GOUP 55 DENY: THIS ITEM AVAILABLE FO PUHASE ONLY 57 DENY: ODE WAS DENIED BY ODE AUDITING SOFTWAE 58 DENY: ODE EPLAED BASED ON ODE AUDITING SOFTWAE EOMMENDATION 5L DENY: BENEFIT LIMIT FO SEVIES WITHOUT AN AUTHOIZATION HAS BEEN MET 6L EOB INOMPLETE-PLEASE ESUBMIT WITH EASON OF OTHE INSUANE DENIAL 7N DENY: SEVIE IS NOT PAYABLE ONUETLY WITH VISION EXAM AS BILLED 81 OIGINAL ODE WAS EPLAED BY HP ODEEVIEW SOFTWAE 83 ODE IS DENIED BY HP ODEEVIEW SOFTWAE 86 DENY: THIS IS NOT A VALID MODIFIE FO THIS ODE 8T DENY: SEVIE INLUDED IN DELIVEY PAYMENT 96 DENY: SEVIE AN NOT BE OMBINED WITH OTHE SEVIE ON SAME DAY 97 PAYMENT IS INLUDED IN ALLOWANE FO BASI SEVIE 98 DENY: POEDUE INVALID FO YEA WHIH SEVIE WAS ENDEED 99 DENY:MIS/UNLISTED ODES AN NOT BE POESSED W/O DESIPTION/EPOT 9 DENY: SEND OMPLETE MEDIAL EODS FOM DOS 1/97 TO PESENT 9E DENY: ODE EPLAED BASED ON ODE AUDITING SOFTWAE EOMMENDATION 9H DENY: ODE QUESTIONED BY ODE AUDIT SOFTWAE-DENIED AFTE MEDIAL EVIEW 9I INFOMATION EQUESTED WAS NOT EEIVED WITHIN THE TIME FAME SPEIFIED 9K LAIM ANNOT BE POESSED WITHOUT PATHOLOGY EPOT 9L DENY: PO MUST BE BILLED WITH OMMEIAL AMBULATOY SV BASE ATE 9M DENY: THIS PT ODE IS INVALID WHEN BILLED WITH THIS DIAGNOSIS 9N LAIM ANNOT BE POESSED WITHOUT OPEATIVE EPOT A1 DENY: AUTHOIZATION NOT ON FILE A8 DENY: NO AUTHOIZATION ON FILE AA DENY: UNAUTHOIZED SEVIE: BILL PATIENT AB DENY: UNAUTHOIZED ADMISSION PE INPATIENT EVIEW A DENY: UNAUTHOIZED SEVIE - DO NOT BILL PATIENT AD DENY: UNAUTHOIZED ADMISSION. DO NOT BILL PATIENT. (INPATIENT EVIEW) AE DENY: HOSPITAL ONFINEMENT EASED PE MED EVIEW AF DENY: ONUENT AE ENDEED BY SAME SPEIALTY PHYSIIAN AG DENY: SEVIE DOES NOT MEET EMEGENY ITEIA, BILL PATIENT AH DENY:PE MEDIAL EVIEW PATIENT NOT HOSPITALIZED AT TIME OF SEVIE AK DENY: UNTIL HOSPITAL ALLS IN ADMISSION A DENY: NON-MEMBE LAB - BILL EFEING POVIDE AS DENY: BASED ON EVIEW OF MED E - PLP EMEGENY DEFINITION NOT MET AT APNTA MONITOS WEE NOT PUHASED AV PLEASE EMIT MEDIAL EODS FO ONSIDEATION OF ADDITIONAL PAYMENTS AW DENY: ESUBMIT WITH ANESTHESIA SEVIE TO EEIVE EIMBUSEMENT FO PO BD DENY: BENEFIT IS NOT OVEED BY HMO BG DENY: TYPE OF BILL MISSING O INOET ON LAIM, PLEASE E-SUBMIT BI DENY: LAIM ANNOT BE POESSED WITHOUT AN ITEMIZED BILL BO DENY:NOT PAYABLE-ANOTHE POIVDE/FAILTY BILLED FO OMPLETE SEVIE BS DENY: INVALID DATES OF SEVIE PLEASE E-SUBMIT BZ DENY: PLEASE ESUBMIT WITH OESPONDING E & M ODE FO PAYMENT 2 PT HAS BEEN EBUNDLED AODING TO LAIM AUDIT Provider Services Department

50 APPENDIX 6 8 B H N S Y D1 D3 D8 DD DJ DL DN DQ DS DT DW DX DY DZ EB E ED EQ EY FD FP FQ FZ G1 G8 GA GB G GE GL GM GS H1 H3 H8 H9 HG HK HL HP PT HAS BEEN EPLAED AODING TO LAIM AUDIT PT HAS BEEN DENIED AODING TO LAIM AUDIT AUTHOIZATION IS ANELLED -EO IN ENTY DENY: ONTINUITY OF AE,BILL PEVIOUS INSUANE AIE FOWADED TO OU APPED HIOPATI POVIDE DENY: NOTPAYABLE/ANESTHESIOLOGIST BILLED FO OMPLETE SEVIES DENY: PATIENT IN HILD POTETIVE SEVIES DENY: SEV PEVIOUSLY DENIED/ SUBMIT WITTEN APPEAL FO EONSIDEATION DENY: SEVIE INLUDED IN E.. VISIT DENY: EXEEDS ESTABLISHED ONTATED EIMBUSEMENT - DO NOT BILL PT. DENY: SEVIES INLUDED IN THE DG PAYMENT DENY: SIGNED ONSENT FOM HAS NOT BEEN EEIVED DENY:INAPPOPIATE ODE BILLED,OET & ESUBMIT DENY: EBILL USING A PHAMAY LAIM FO THIS SEVIE DENY: POEDUES INLUDED IN FINAL ESTOATION DENY: MEMBE UNDE 21 YS OF AGE WHEN SIGNING ONSENT FOM DENY: DUPLIATE SUBMISSION-OIGINAL LAIM STILL IN PEND STATUS DENY: PLEASE FOWAD TO THE DENTAL VENDO FO POESSING. DENY: INAPPOPIATE DIAGNOSIS BILLED, OET AND ESUBMIT DIAGNOSIS BILLED IS INVALID, PLEASE ESUBMIT WITH OET ODE. DENY: APPEAL DENIED DENY: SEVIE HAS EXEEDED THE AUTHOIZED LIMIT DENY: DENIED BY MEDIAL SEVIES DIAGNOSIS ANNOT BE USED AS PIMAY DIAGNOSIS, PLEASE ESUBMIT DENY - PLEASE ESUBMIT EPSDT SEVIES UNDE POVIDE'S EPSDT ID NUMBE DENY: DIAGNOSIS DOES NOT SUPPOT E/M BILLED DIAGNOSIS IS NOT OVEED, BILL STATE ENTITY DENY: ESUBMIT LAIM TO FIST DENT FO PAYMENT DENY: LAIMS DENIED FO POVIDE FAUD. DENY: ESUBMIT LAIM UNDE FQH/H LINI MEDIAID NUMBE DENY: DOUMENTATION DOES NOT EFLET ALL OMPONENTS OF BILLED E/M DENY: POEDUE UNDE THIS POGAM IS NOT OVEED FO THE MEMBE'S AGE DENY: ONE LAIM ALLOWED FO TYPE OF SEVIE DUING 6 MTH PEIOD DENY: POEDUE NOT OVEED FO THE MEMBE'S AGE DENY: GLOBAL ODE IS INVALID PE STATE GUIDELINES DENY:PE ST. GUIDELINES DELIVEY MUST BE BILLED SEPAATE FOM VISITS DENY: GLOBAL ODE IS INVALID PE STATE GUIDELINES SEVIE OVEED UNDE GLOBAL FEE AGEEMENT DENY: ESUBMIT W/ MEDIAID# OF INDIVIDUAL SEVIING POVIDE IN BOX 24K DENY: DATE OF SV ON LAIM IS GEATE THAN EEIVED DATE,PLEASE ESUBMIT DENY: POVIDE MUST USE HP/PT FO OET PIING DENY: INLUDED IN AS FEE DENY: HOMEGOWN POEDUE ODES AE NOT VALID FO THIS DOS DENY: HOMEGOWN MODIFIES AE NOT VALID FO THIS DOS DENY: GOUP PATIE DOES NOT MATH AUTH DATES ON MEDIAL DETAIL DO NOT MATH DENY: LAIM AND AUTH LOATIONS DO NOT MATH DENY: LAIM AND AUTH SEVIE POVIDE NOT MATHING Provider Services Department

51 APPENDIX HQ HS HT HU HW I1 I2 I3 I4 I5 I6 I9 IB ID IE IG IK IL IM IN IV IW K4 K8 KK L0 L5 L6 LO L LY M5 MA MD MF MG MH MO MP MQ MY MZ N5 NA N ND NP N DENY: EDI LAIM MUST BE SUBMITTED IN HAD OPY W/ONSENT FOM ATTAHED DENY: LAIM AND AUTH POVIDE SPEIALTY NOT MATHING DENY: LAIM AND AUTH TEATMENT TYPE NOT MATHING DENY: LAIM TYPE DOES NOT MATH LAIM TYPE ON THE AUTHOIZATION DENY: PAYMENT INLUDED IN THE HIGHE INTENSITY ODE BILLED OTHE INSUANE EOB SUBMITTED DOES NOT MATH BILLED, PLEASE ESUBMIT DENY: POEDUE IS ONLY PAYABLE FO INPATIENT LOATION DENY: ID-9 POEDUE ODE EQUIES A 3D DIGIT DENY: ID-9 POEDUE ODE EQUIES A 4TH DIGIT DENY: NON-OVEED ID-9 POEDUE, SEVIE DENIED DENY: DIAGNOSIS O PT/HPS/ID-9 PO ODE INVALID FO DATE OF SEVIE DENY: DIAGNOSIS IS AN INVALID O DELETED ID9 ODE DENY: POEDUE ONLY OVEED WITH DIAGNOSIS OF DIABETI FOOT DISEASE DENY: NO W-9 FOM ON FILE PT NOT EIMBUSED SEPAATELY. INLUDED AS PAT OF INLUSIVE POEDUE DENY: INVALID O MISSING DISHAGE STATUS, PLEASE E-SUBMIT DENY: 2ND EM NOT PAYABLE W/O MODIFIE 25 & MED EODS, PLEASE ESUBMIT VEIFY THE OET LOATION ODE FO SEVIE BILLED AND ESUBMIT DENY: ESUBMIT WITH MODIFIE SPEIFIED BY STATE FO POPE PAYMENT DENY: OGINIAL PT BILLED WAS AN INVALID ODE.PLEASE E-BILL. DENY: INVALID/DELETED/MISSING PT ODE DENY: OIGINAL HPS BILLED WAS AN INVALID ODE. PLEASE EBILL DENY: MEMBE IS NOT THE ESPONSIBILITY OF SUNSHINE HEALTH DENY: SEVIES INLUDED IN GLOBAL SETTLEMENT AGEEMENT DENY:K ODES AE NOT BILLABLE-USE APPOPIATE HPS ODES PLEASE ESUBMIT WITH THE PIMAY MEDIAE EXPLANATION OF BENEFITS DENY: NO ESPONSE TO LETTE EGADING OTHE HEALTH INSUANE DENY: BILL PIMAY INSUE 1ST. ESUBMIT WITH EOB. DENY: PT & LOATION AE NOT OMPATIBLE, PLEASE ESUBMIT. DENY: WHEN PIME INS.EIEVES INFO-ESUBMIT TO SEONDAY INS. DENY: PLEASE ESUBMIT WITH INVOIE FO PAYMENT DENY: IMMUNIZATION ADMINISTATION INLUDED IN INJETION FEE MEDIAID# MISSING O NOT ON FILE, PLEASE OET AND ESUBMIT DENY:SEVIES PEVIOUSLY DENIED BY OU MENTAL HEALTH POVIDE DENY: INAPPOPIATE MEDIAID# SUBMITTED FO SV POVIDE,PLEASE ESUBMIT DENY: SIGNATUE MISSING FOM BOX 31, PLEASE ESUBMIT DENY: PLEASE SUBMIT TO MENTAL HEALTH PLAN FO POESSING MODIFIE BILLED IS NOT VALID, PLEASE ESUBMIT WITH OET ODE. DENY: PLEASE ESUBMIT TO THE MEDIAL PLAN FO ONSIDEATION DENY: MEMBE NAME/NUMBE/DATE OF BITH DO NOT MATH,PLEASE ESUBMIT DENY: MEMBE'S PP IS APITATED - SEVIE NOT EIMBUSABLE TO OTHE PPS DENY: PLEASE ESUBMIT WITH POVIDES MEDIAID ID NUMBE. DENY: NAME OF DUG, ND NUMBE AND QUANTITY IS EQUIED TO POESS LAIM OTHE INS. DENIED - OOP POVIDE/NOT AUTHOIZED - SEVIES NOT PAYABLE DENY:TUBAL WAS PEFOMED BEFOE THE 30 DAY WAITING PEIOD DENY: THIS IS A DELETED ODE AT THE TIME OF SEVIE DENY: AUTHOIZATION EQUESTED FO NON-PLAN POVIDE DENY: THIS SEVIE IS NOT OVEED FO NON-EGISTEED EIPIENTS Provider Services Department

52 APPENDIX NS SEVIE NOT OVEED WHEN OBTAINED FOM A POVIDE NON PA IN MHS NETWOK NT DENY:POVIDE NOT ONTATED FO THIS SEVIE-DO NOT BILL PATIENT NV DENY: STEILIZATION ONSENT FOM IS NOT VALID O IS MISSING INFOMATION NX DENY: INVALID O NO TAX ID NUMBE SUBMITTED ON LAIM, PLEASE ESUBMIT OX DENY: ODE IS ONSIDEED AN INTEGAL OMPONENT OF THE E/M ODE BILLED P0 DENY:LAB BILLED NOT PAYABLE TO PATHOLOGIST-NO DIET MD WOK/INVOLVEMENT PF DENY: POFESSIONAL FEE MUST BE BILLED ON HFA FOM PO DENY: LINIIAL LAB/X AY NOT PAYABLE TO PATHOLOGISTS QD TAX ID SUBMITTED IS INOET FO DATE OF SEVIE. PLEASE ESUBMIT DENY: EQUIED EFEAL ODE FO HEALTH HEK VISIT INVALID O MISSING D DENY: EVENUE ODE AND DIAGNOSIS AE NOT OMPATIBLE. PLEASE ESUBMIT. E DENY: ENTAL BENEFIT EXHAUSTED - AFTE 10 ENTALS ONSIDEED PUHASED I BABY'S ASSIGNED ID NUMBE IS NEEDED FO LAIM POESSING J DENY: EVENUE ODES NOT BILLED ON THE UB92, PLEASE E-SUBMIT M DENY: MODIFIE EQUIED FO PAYMENT OF SEVIE - ESUBMIT W/MODIFIE P EOUP DUE TO PAYMENT BEYOND 90 DAYS DENY: EOVEY OOM INLUDED IN AS ATE S DENY: BILL ADDESS DOES NOT MATH SYSTEM-ESUBMIT WITH OET BILL ADD X DENY: PLEASE SUBMIT TO THE PHAMAY VENDO FO POESSING. SD DENY: EDENTIALING WAS NOT APPOVED - ALL SEVIES AE DENIED SQ DENY: NOT EIMBUSEABLE TO THIS POVIDE - BILL DIALYSIS ENTE SU DENY: VISIT IS INLUDED IN SUGEY SW DENY: SEVIES BILLED BY AN E MD - SPE 93 WHEN BILLED W/ MODIFIE 26 T4 DENY:POVIDE NOT ONTATED FO SEVIE-DO NOT BILL PATIENT T5 DENY: PLEASE ESUBMIT TANPOTATION LAIMS TO MEDOMPLY TB DENY: TUBAL NOT PEFOMED IN THE 180 DAY TIME FAME TF DENY: PT/HPS ODES NOT AEPTABLE FO SEVIE DATES PIO TO NEW YEA TH DENY:PHYSIAL MEDIINE IS NOT OVEED IN PHYSIIAN'S OFFIE TI E.. PHYS PAID TIAGE, ANILLAY SEVIES NOT PAYABLE TM TO OMPLETE POESSING, WE NEED THE TIME UNITS, PLEASE ESUBMIT. T DENY: PAYABLE WITH TEATMENT OOM O STAND ALONE SEVIE ONLY TS TEMPEATUE GADIENT STUDIES AE NOT OVEED FO THIS DIAGNOSIS TU DENY: SUBMIT TO TANSPOTATION VENDO FO POESSING TX MEDIAID# POVIDED NOT ON FILE, PLEASE OET AND ESUBMIT U1 LAIM ANNOT BE POESSED WITHOUT MEDIAL EODS U4 DENY:UPON EVIEW OF EODS-NO INDIATION OF PHYS SEVIES U5 DENY:UNLISTED / UNSPEIFI ODE -E-BILL MOE SPEIFI ODE UD DENY: NO EOD OF INPATIENT HOSPITAL STAY UI DENY:PE EVIEW NO EOD OF INPT STAY,SEND DISHAGE SUMMAY US UNLISTED ODE - INELIGIBLE FO ONSIDEATION, PLEASE OET & ESUBMIT. UU DENY: ANTEPATUM/POST PATUM NOT PAYABLE INPT UZ DENY: SEVIES BILLED ON INOET FOM, PLEASE EBILL ON A UB92 V1 DENY: SEVIE IS INLUDED IN THE DELIVEY PAYMENT V3 MED EODS EEIVED FO WONG DATE OF SEVIE V4 MED EODS EEIVED NOT LEGIBLE V5 MED EODS EEIVED FO WONG PATIENT V6 MED EODS WITHOUT LEGIBLE PATIENT NAME AND/O DOS V8 MED EODS EEIVED WITHOUT DOS Provider Services Department

53 APPENDIX VA VOID ADJUSTMENT V DENY - PLEASE ESUBMIT AODING TO VAINES FO HILDEN GUIDELINES VG DENY: VALID DG ODE EQUIED VS DENY: PLEASE SUBMIT TO THE VISION VENDO FO POESSING. W0 DENY: TANSPLANT LAIM SUBMIT TO IGNA LIFESOUE FO EPIING W6 DENY: TANSPLANT LAIM SUBMIT TO INTELINK FO EPIING X5 DENY: NO SIGNATUE ON ONSENT FOM X6 DENY: SEVIES AE UNDE EVIEW XA DENY: PLP NOT MET - DENIAL UPHELD ON EONSIDEATION XE EVENUE/POEDUE ODE BILLED FO THE DIAGNOSIS SUBMITTED IS NOT OVEED XG DENY: ED EONSIDEATION - ONTAT ATE WAS PAID XI DENY: ED EONSIDEATION NOT EEIVED TIMELY XJ DENY: NO INFO POVIDED FO ED PAYMENT EONSIDEATION - PLEASE ESUBMIT XL DENY: ED APPEAL - ONTAT ATE WAS PAID XM DENY: ED APPEAL NOT EEIVED TIMELY XN DENY - ED EONSIDEATION - PLP NOT MET XX OVEAGE NOT IN EFFET ON DATE OF SEVIE - BILL THE STATE YU DENY: MEDIAID AND TIN NUMBES ON FILE DO NOT MATH Z4 DENY: ESUBMIT WITH DOUMENTATION THAT VALIDATES MEDIAL NEESSITY Z DENY: POEDUE IS INAPPOPIATE FO POVIDE SPEIALTY ZD SUBMIT ED EODS & EOP W/IN 30 DAYS FO PESENTING SYMPTOM ASSESS ZU DENY: POEDUE IS ONLY VALID AFTE 01/01/1999 ZY DENY: ALL E HAGES PENDING UNTIL FUTHE NOTIE Provider Services Department

54 APPENDIX Appendix 4 INSTUTIONS FO SUPPLEMENTAL INFOMATION MS-1500 (8/05) FOM, SHADED FIELD 24A-G The following types of supplemental information are accepted in a shaded claim line of the MS 1500 (8/05) form field 24A-G: Anesthesia duration in hours and/or minutes with begin (start) and end times Narrative description of unspecified/miscellaneous/unlisted 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 T ZZ N4 OZ VP ontract rate Narrative description of unspecified/miscellaneous/unlisted codes National Drug odes (ND) The following qualifiers are to be used when reporting ND units: F2 International Unit G Gram ML Milliliter UN Unit Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN) Vendor Product Number- Health Industry Business ommunications ouncil (HIB) Labeling Standard 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 supplemental information. Do not enter hyphens or spaces within the ND, HIB, or GTIN number/code. Provider Services Department

55 APPENDIX When reporting a service that does not have a qualifier, enter two blank spaces before entering the information. More than one supplemental item can be reported in a single shaded claim line IF the information is related to the un-shaded claim line item it is entered on. When entering more than one supplemental item, enter the first qualifier at the start of 24A followed by the number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the ND, HIB, or GTIN number/code. After the entry of the first supplemental item, enter three blank spaces and then the next qualifier and number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the ND, HIB, or GTIN number/code. Examples: Anesthesia Unlisted, Non-specific, or Miscellaneous PT or HP ode ND Vendor Product Number- HIB Product Number Health are Uniform ode ouncil GTIN No qualifier - More Than One Supplemental Item Provider Services Department

56 APPENDIX Appendix 5 HIPAA ompliant EDI ejection odes These codes are the standard national rejection codes for EDI submissions. All errors indicated for the code must be corrected before the claim is resubmitted. Please see Sunshine Health s list of common EDI rejections to determine specific actions you may need to take to correct your claims submission. 01 Invalid Member Date of Birth 02 Invalid Member 06 Invalid Provider 07 Invalid Member Date of Birth; and Invalid Provider 08 Invalid Member; and Invalid Provider 09 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 12 Prv not valid at DOS 13 Invalid Mbr DOB; Prv not valid at DOS 14 Invalid Mbr; Prv not valid at DOS 15 Mbr not valid at DOS; Invalid Prv 16 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv 17 Invalid Diag 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 21 Mbr not valid at DOS; Prv not valid at DOS 22 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS 23 Invalid Prv; Invalid Diag 24 Invalid Mbr DOB; Invalid Prv; Invalid Diag 25 Invalid Mbr; Invalid Prv; Invalid Diag 26 Mbr not valid at DOS; Invalid Diag 27 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag 29 Prv not valid at DOS; Invalid Diag 30 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag 31 Invalid Mbr; Prv not valid at DOS; Invalid Diag 32 Mbr not valid at DOS; Prv not valid; Invalid Diag 33 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc Provider Services Department

57 APPENDIX 43 Mbr not valid at DOS; Invalid Proc 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 52 Invalid Mbr DOB; Invalid Diag; Invalid Proc 53 Invalid Mbr; Invalid Diag; Invalid Proc 55 Mbr not valid at DOS; Prv not valid at DOS; Invalid Proc 57 Invalid Prv; Invalid Diag; Invalid Proc 58 Invalid Mbr DOB; Invalid Prv; Invalid Diag; Invalid Proc 59 Invalid Mbr; Invalid Prv; Invalid Diag; Invalid Proc 60 Mbr not valid at DOS; Invalid Diag; Invalid Proc 61 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag; Invalid Proc 63 Prv not valid at DOS; Invalid Diag; Invalid Proc 64 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag; Invalid Proc 65 Invalid Mbr; Prv not valid at DOS; Invalid Diag; Invalid Proc 66 Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 67 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 72 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 73 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 74 ejected. Dates of service prior to xx-xx-xxxx 75 Invalid Units of Service 76 Original laim number required Provider Services Department