Keystone First. Claim Filing Instructions

Transcription

1 Keystone First Claim Filing Instructions

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

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

4 Claim Filing Procedures f Claim Submission Keystone First, hereafter referred to as the Plan, is required by State and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in der to ensure timely processing of claims. When required data elements are missing are invalid, claims will be rejected by the Plan f crection and resubmission. Claims f billable and capitated services provided to Plan members must be submitted by the provider who perfmed the services. Claims filed with the Plan are subject to the following procedures: Verification that all required fields are completed on the CMS 1500 UB-04 fms. Verification that all Diagnosis and Procedure Codes are valid f the date of service. Verification f electronic claims against 837 edits at Emdeon Verification of the referral f Specialist non-primary Care Physician claims. IMPORTANT: Rejected claims are defined as claims with invalid required missing data elements, such as the provider tax identification number, member ID number, that are returned to the provider EDI* source without registration in the claim processing system. Rejected claims are not registered in the claim processing system and can be resubmitted as a new claim. Denied claims are registered in the claim processing system but do not meet requirements f payment under Plan guidelines. They should be resubmitted as a crected claim. Denied claims must be re-submitted as crected claims within 365 calendar days from the date of service. Set claim frequency code crectly and send the iginal claim number. Note: These requirements apply to claims submitted on paper electronically. * F me infmation on EDI, review the section titled Electronic Data Interchange (EDI) f Medical and Hospital Claims in this booklet. Verification of member eligibility f services under the Plan during the time period in which services were provided. Verification that the services were provided by a participating provider that the out of plan provider has received authization to provide services to the eligible member. Verification that the provider participated with the Medical Assistance Program at the time of service. Verification that an authization has been given f services that require pri authization by the Plan. Verification of whether there is Medicare coverage any other third party resources and, if so, verification that the Plan is the payer of last rest on all claims submitted to the Plan. 1

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

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

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8 CMS-1500 Fm Requirements Claim Fm Field Requirements The following charts describe the required fields that must be completed f the standard Centers f Medicare and Medicaid Services (CMS) CMS 1500 UB-04 claim fms. If the field is required without exception, an R () is noted in the al box. If completing the field is dependent upon certain circumstances, the requirement is listed as C (al) and the relevant conditions are explained in the Instructions and Comments box. The CMS 1500 claim fm must be completed f all professional medical services, and the UB-04 claim fm must be completed f all facility claims. All claims must be submitted within the required filing deadline of 180 days from the date of service. Although the following examples of claim filing requirements refer to paper claim fms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic paper). Fields (CMS 1500 Claim Fm) CMS-1500 Claim Fm Field # Field Description Instructions and Comments Loop ID Segment N/A Carrier Block 2010BB NM103 N301 N302 N401 N402 N403 1 Insurance Program Identification 1a Insured I.D. Number 2 Patient s Name (Last, First, Middle Initial) Check only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Health Plan s member identification number. If submitting a claim f a newbn that does not have an identification number, enter the mother s ID number. F electronic submissions, ID must be less than 13 alphanumeric characters. Innetwk providers: please omit the three alpha characters preceding the member s ID number on the claim. Out of area providers: please enter the three alpha characters preceding the member s ID number on the claim. Enter the patient s name as it appears on the member s Health Plan I.D. card. If submitting a claim f a newbn that does not have an identification number, enter Baby Girl Baby Boy and last name. 5 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. Notes R 2000B SBR09 Title Claim Filing Indicat in 837P. R 2010BA NM109 Titled Subscriber Primary Identifier In the 837P. R 2010CA 2010BA NM103 NM104 NM105 NM107

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

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

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

12 CMS-1500 Fm Requirements CMS-1500 Claim Fm Field # Field Description 14 Date Of Current Illness Injury, Pregnancy (LMP) Instructions and Comments MMDDYY MMDDYYYY Enter applicable 3-digit qualifier to right of vertical dotted line. Qualifiers include: 431 Onset of Current Symptoms Illness 439 Accident Date 484 Last Menstrual Period (LMP) Use the LMP f pregnancy. Example: Loop ID Segment C 2300 DTP03 Notes 15 Other Date MMDDYY MMDDYYYY Enter applicable 3-digit qualifier between the left-hand set of vertical dotted lines. Qualifiers include: 454 Initial Treatment 304 Latest Visit Consultation 453 Acute Manifestation of a Chronic 439 Accident 455 Last X-Ray 471 Prescription 090 Rept Start (Assumed Care Date) 091 Rept End (Relinquished Care Date) 444 First Visit Consultation Example: C 2300 DTP03 16 Dates Patient Unable To Wk In Current Occupation 17 Name Of Referring Physician Or Other Source if a provider other than the member s primary care physician rendered invoiced services. Enter applicable 2-digit qualifier to left of vertical dotted line. If C 2300 DTP03 Disability Dates Qualifier * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation. R 2310A (Referri ng) 2310D N103 N104 N105 N107

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

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

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

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

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

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

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

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

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

22 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments card. Use a comma space to separate the last and first names. Titles (Mr., Mrs., etc.) should not be repted in this field. Prefix: No space should be left after the prefix of a name e.g. McKendrick. Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. Newbns and Multiple Births: If submitting a claim f a newbn that does not have an identification number, enter Baby Girl Baby Boy and last name. Refer to page 42 f additional newbn billing infmation, including Multiple Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes 19 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

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

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

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

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

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

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

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

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

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

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

33 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments tertiary. 55 Est. Amount Due Enter the estimated amount due (the difference between Total Charges and any deductions such as other coverage). 56 National Provider Identifier Billing Provider 57 A,B,C Other (Billing) Provider Identifier The unique identification number assigned to the provider submitting the bill; NPI is the national provider identifier. if the health care provider is a Covered Entity as defined in HIPAA Regulations. A unique identification number assigned to the provider submitting the bill by the health plan. 58 Insured's Name Infmation refers to the payers listed in field 50. In most cases this will be the patient name. When other coverage is available, the insured is Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 AMT/EAF/ 02 R R 2010A A C C 2010A A 2010B B R R 2010B A 2330A NM1/85/09 REF/EI/02 REF/02=G 2 REF/03 Legacy ID NM1/IL 03/04/05 NM1/IL 03/04/05 Tax ID Only sent if need to determine the Plan ID Use 2010BA is insured is subscriber 30 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

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

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

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

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

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

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

40 UB-04 Fm Requirements UB-04 Claim Fm Field # 74a-e Field Description Instructions and Comments Other Procedure Codes and Dates CPT, HCPCS ICD code is required when a surgical procedure is perfmed. The appropriate ICD codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were perfmed. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X C Outpatient, Bill Types 13X, 23X, 33X 83X C Loop Segment Notes 2300 HIXX-2 HI01-1=BQ pr ABQ Inpatient facility Surgical procedure code is required when a surgical procedure is perfmed. C 75 Unlabeled Field 76 Attending Provider Name and Identifiers Outpatient facility Ambulaty Surgical Center CPT, HCPCS ICD code is required when a surgical procedure is perfmed. Enter the NPI of the physician who has primary C R R 2310A 2310A NM1/71/09 REF02 REF01=0B, 1G/LU 37 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

41 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments NPI#/Qualifier/Oth er ID# 77 Operating Physician Name and Identifiers NPI#/Qualifier/Oth er ID# responsibility f the patient s medical care 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 twodigit qualifier followed by the other ID#. Enter the last name and first name of the Attending Physician. Note: If a qualifier is entered, a secondary ID must be present, and if a secondary ID is present, then a qualifier must be present. Otherwise, the claim will reject. Enter the NPI of the physician who perfmed surgery on the patient in the upper line, and their name in the lower line, last Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes 2310A 2301A C C 2310B 2310B 2310B 2310B NM1/71/03 NM1/71/03 NM1/72/09 NM1/72/03 NM1/72/04 REF/02 (Do not send the Provider s Plan ID) 38 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

42 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments name first. If the operating physician has another unique ID#, enter the appropriate descriptive twodigit qualifier followed by the other ID#. Enter the last name and first name of the Attending Physician. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes Other Provider (Individual) Names and Identifiers NPI#/Qualifier/Oth er ID# when a surgical procedure code is listed. Enter the NPI# of any physician, other than the attending physician, who has responsibility f the patient s medical care 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# R R R R 2310C 2310C 2310C 2310C NM1/ZZ/09 NM1/ZZ/03 NM1/ZZ/04 REF/02 39 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

43 UB-04 Fm Requirements UB-04 Claim Fm Field # Field Description Instructions and Comments 80 Remarks Field Area to capture additional infmation necessary to adjudicate the claim. 81CC,a -d Code-Code Field To rept additional codes related to Fm Locat (overflow) to rept externally maintained codes approved by the NUBC f inclusion in the institutional data set. Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X 83X Loop Segment Notes C C 2300 NTE/ADD/ 01 NTE02 C C NTE01=AD D 40 * (R) fields must be completed on all claims. al (C) fields must be completed if the infmation applies to the situation the services provided. Refer to the NUCC NUBC Reference Manuals f additional infmation.

44 Special Instructions Special Instructions and Examples f CMS 1500, UB-04 and EDI Claims Submissions I. Supplemental Infmation A. CMS 1500 Paper Claims Field 24: Imptant Note: All unspecified Procedure HCPCS codes require a narrative description be repted in the shaded ption of field 24. The shaded area of lines 1 through 6 allow f the entry of 61 characters from the beginning of 24A to the end of 24G. The following are types of supplemental infmation that can be entered in the shaded lines of Item Number 24 ( 2410/LIN and CTP segments when submitting via 837): Anesthesia duration in hours and/ minutes with start and end times Narrative description of unspecified codes National Drug Codes (NDC) f drugs Vend Product Number Health Industry Business Communications Council (HIBCC) Product Number Health Care Unifm Code Council Global Trade Item Number (GTIN) fmerly Universal Product Code (UPC) f products Contract rate The following qualifiers are to be used when repting these services. 7 Anesthesia infmation ZZ Narrative description of unspecified code (all miscellaneous fields require this section be repted) N4 National Drug Codes VP Vend Product Number Health Industry Business Communications Council (HIBCC) OZ Product Number Health Care Unifm Code Council Global Trade Item Number (GTIN) CTR Contract rate To enter supplemental infmation, begin at 24A by entering the qualifier and then the infmation. Do not enter a space between the qualifier and the number/code/infmation. Do not enter hyphens spaces within the number/code. Me than one supplemental item can be repted in the shaded lines of Item Number 24. Enter the first qualifier and number/code/infmation at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/infmation. B. EDI Field 24D (Professional) Details pertaining to EPSDT, Anesthesia Minutes, and crected claims may be sent in Notes (NTE) Remarks (NSF fmat). Details sent in NTE that will be included in claim processing: Please include L1, L2, etc. to show line numbers related to the details. Please include these letters AFTER those specified below: o EPSDT claims need to begin with the letters EPSDT followed by the specific code as per DHS instructions o Anesthesia Minutes need to begin with the letters ANES followed by the specific times o Crected claims need to begin with the letters RPC followed by the details of the iginal claim (as per contract instructions) o DME Claims requiring specific instructions should begin with DME followed by specific details C. EDI Field 33b (Professional) Field 33b Other ID# - Professional: 2310B loop, REF01=G2, REF02+ Plan s Provider Netwk Number. Less than 13 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 claims 41

45 Special Instructions 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 Claim statement date Loop 2300, DTP*434 Field 51 Health Plan ID the number used by the health plan to identify itself. Keystone First s Health Plan EDI Payer ID# is E. EDI Repting DME DME Claims requiring specific instructions should begin with DME followed by specific details. Example: NTE*ADD*DME AEROSOL MASK, USED W/DME NEBULIZER F. Repting NDC on CMS-1500 and UB-04 and EDI 1. NDC on CMS 1500 NDC should be entered in the shaded sections of item 24A through 24G. To enter NDC infmation, begin at 24A by entering the qualifier N4 and then the 11 digit NDC infmation. o Do not enter a space between the qualifier and the 11 digit NDC number. o o Enter the 11 digit NDC number in the fmat (no hyphens). Do not use f a compound medication, bill each drug as a separate line item with its appropriate NDC Enter the drug name and strength Enter the NDC quantity unit qualifier o F2 International Unit o GR Gram o ML Milliliter o UN Unit Enter the NDC quantity o Do not use a space between the NDC quantity unit qualifier and the NDC quantity o Note: The NDC quantity is frequently different than the HCPC code quantity Example of entering the identifier N4 and the NDC number on the CMS 1500 claim fm: N4 qualifier NDC Quantity 11 digit NDC NDC Unit Qualifier 2. NDC on UB-04 NDC should be entered in Fm Locat 43 in the Revenue Description Field. Rept the N4 qualifier in the first two (2) positions, left-justified. o Do not enter spaces o Enter the 11 character NDC number in the fmat (no hyphens). o Do not use f a compound medication, bill each drug as a separate line item with its appropriate NDC Immediately following the last digit of the NDC (no delimiter), enter the Unit of Measurement Qualifier. 42

46 Special Instructions o o o o F2 International Unit GR Gram ML Milliliter UN Unit Immediately following the Unit of Measure Qualifier, enter the unit quantity with a floating decimal f fractional units limited to 3 digits (to the right of the decimal). o Any unused spaces f 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 NDC via EDI The NDC is used to rept prescribed drugs and biologics when required by government regulation, as deemed by the provider to enhance claim repting/adjudication processes EDI claims with NDC info should be repted in the LIN segment of Loop ID This segment is used to specify billing/repting f drugs provided that may be part of the service(s) described in SV1. Please consult your EDI vend if not submitting in X12 fmat f details on where to submit the NDC number to meet this specification. When LIN02 equals N4, LIN03 contains the NDC number. This number should be 11 digits sent in the fmat with no hyphens. Submit one occurrence of the LIN segment per claim line. Claims requiring multiple NDC s sent at claim line level should be submitted using CMS-1500 UB-04 paper claim. When submitting NDC in the LIN segment, the CTP segment is requested. This segment is to be submitted with the Unit of Measure and the Quantity. When submitting this segment, CTP03, Pricing; CTP04, Quantity; and CTP05, Unit of Measure are required. 43

47 Special Instructions II. Provider Preventable s Payment Policy and Instructions f Submission of POA Indicats f Primary and Secondary Diagnoses Effective July 1, 2012 Keystone First modified its payment policy with respect to Provider Preventable s (PPC) to comply with the Patient Protection and Affdable Care Act of 2010 (ACA). The ACA defines PPCs to include two distinct categies: Health Care Acquired s; and Other Provider-Preventable s. It is Keystone First s policy to deny payment f PPCs. Health Care Acquired s (HCAC) apply to Medicaid inpatient hospital settings only. An HCAC is defined as condition occurring in any inpatient hospital setting, identified currently in the future, as a hospital-acquired condition by the Secretary of Health and Human Services under Section 1886(d)(4)(D) of the Social Security Act. HCACs presently include the full list of Medicare s hospital acquired conditions, except f DVT/PE following total knee hip replacement in pediatric and obstetric patients. Other Provider-Preventable s (OPPC) is me broadly defined to include inpatient and outpatient settings. An OPPC is a condition occurring in any health care setting that: (i) is identified in the Commonwealth of Pennsylvania State Medicaid Plan; (ii) has been found by the Commonwealth to be reasonably preventable through application of procedures suppted by evidence-based guidelines; (iii) has a negative consequence f the Member; (iv) can be discovered through an audit; and (v) includes, at a minimum, three existing Medicare National Coverage Determinations f OPPCs (surgery on the wrong patient, wrong surgery on a patient and wrong site surgery). F a list of PPCs f which Keystone First will not provide reimbursement, please refer to the Appendix of this Manual. Submitting Claims Involving a PPC In addition to broadening the definition of PPCs, the ACA requires pays to make pre-payment adjustments. That is, a PPC must be repted by the Provider at the time a claim is submitted. There are some circumstances under which a PPC adjustment will not be taken, will be lessened. F example: o No payment reduction will be imposed if the condition defined as a PPC f a particular patient existed pri to the initiation of treatment f that patient by the Provider. Please refer to the Repting a Present on Admission section f details. o Reductions in Provider payment may be limited to the extent that the identified PPC would otherwise result in an increase in payment; and Keystone First can reasonably isolate f nonpayment the ption of the payment directly related to treatment f, and related to the PPC. Practitioner/Dental Providers If a PPC occurs, Providers must rept the condition through the claims submission process. Note that this is required even if the Provider does not intend to submit a claim f reimbursement f the services. The requirement applies to Providers submitting claims on the CMS P fms, as well as and dental Providers billing via ADA claim fm 837D fmats. F professional service claims, please use the following claim type and fmat: Claim Type: Rept a PPC by billing the procedure of the service perfmed with the applicable modifier: PA (surgery, wrong body part); PB (Surgery, wrong patient) PC (wrong site surgery) in 24D of the CMS 1500 claim fm. Dental Providers must rept a PPC on the paper ADA claim fm using modifier PA, PB PC on the claim line, rept modifiers PA, PB PC in the remarks section claim note of a dental claim fm. 44

48 Special Instructions Claim Fmat: Rept the E diagnosis codes, such as E876.5, E876.6 E876.7 in field 21 [and/] field 24E of the CMS 1500 claim fm. Inpatient/Outpatient Facilities Providers submitting claims f facility fees must rept a PPC via the claim submission process. Note that this repting is required even if the Provider does not intend to submit a claim f reimbursement of the services. This requirement applies to Providers who bill inpatient outpatient services via UB I fmats. F Inpatient facilities When a PPC is not present on admission (POA) but is repted as a diagnosis associated with the hospitalization, the payment to the hospital will be reduced to reflect that the condition was hospital-acquired. When submitting a claim which includes treatment as a result of a PPC, facility providers are to include the appropriate ICD-9 diagnosis codes, including applicable external cause of injury E codes on the claim in field 67 A Q. Examples of ICD-9 and E diagnosis codes include: Wrong surgery on crect patient E876.5; Surgery on the wrong patient, E876.6; Surgery on wrong site E876.7 If, during an acute care hospitalization, a PPC causes the death of a patient, the claim should reflect the Patient Status Code 20 Expired. F per-diem percent of charge based hospital contracts, claims including a PPC must be submitted via paper claim with the patient s medical recd. These claims will be reviewed against the medical recd and payment adjusted accdingly. Claims with PPC will be denied if the medical recd is not submitted concurrent with the claim. All infmation, including the patient s medical recd and paper claim should be sent to: Medical Claim Review c/o Keystone First Health Plan PO Box 7304 London, KY F DRG-based hospital contracts, claims with a PPC will be adjudicated systematically, and payment will be adjusted based on exclusion of the PPC DRG. Facilities need not submit copies of medical recds f PPCs associated with this payment type. F Outpatient Providers Outpatient facility providers submitting a claim that includes treatment required because of a PPC must include the appropriate ICD-9 diagnosis codes, including applicable external cause of injury E codes on the claim in field 67 A Q. Examples of ICD-9 and E diagnosis codes include: Wrong surgery on crect patient E876.5; Surgery on the wrong patient, E876.6; and Surgery on wrong site E

49 Special Instructions UB I Valid POA indicats are as follows, blanks are not acceptable: Y = Yes = present at the time of inpatient admission N = No = not present at the time of inpatient admission U = Unknown = documentation is insufficient to determine if condition was present at time of inpatient admission W = Clinically Undetermined = provider is unable to clinically determine whether condition was present at time of inpatient admission not null value = Exempt from POA repting A. Repting POA on the UB-04 Claim Fm Fields 67 A Q: Valid primary and secondary diagnosis codes (up to 5 digits), are to be placed in the unshaded ption of 67 A Q, followed by the applicable POA indicat (1 character) in the shaded ption of 67 A Q. Sample UB-04 populated with primary and secondary diagnosis codes, and POA indicats: FL 67 Primary FL 67 FL 67 A - Q Diagnosis Code POA Secondary Diagnosis Codes 66 DX Y 25001A N B U V1581 C W D I J K L M 69 Admit DX 70 Patient Reason DX B. Repting POA in Electronic 837I Fmat a b C 71 PPS CODE FL 67 A Q POA Provider is to submit their POA data via the K3 segment on all 837I claims, (004010X096A1), f Pennsylvania. Although this segment can repeat, Plan requires provider submit POA data on a single K3 Segment. No additional K3 segments with the letters POA will be validated. K301 must contain POA as the first three characters the POA data will not be picked up. K3*POA~ K3 Segment must only contain details pertaining to the Principal and Other Diagnosis found in the HI segment with qualifiers BK f Principal and BF f Other Diagnosis pri to the ending Z ( X). The POA indicat f the BN External Cause of Injury on the K3 segment with POA is entered following the ending Z ( X). This is required by Emdeon f Medicare Claims as well. No POA Indicat is to be sent f the BJ/ZZ Admitting Diagnosis Data. Following the letters POA in the K3 Segment is to be only those identified on the Medicare Bulletin. 1, Y, N, U, W are valid, with ending characters of X Z and ECode indicat. Example: 1st claim: 1 Principal and 2 Other Diagnosis K3*POAYNUZ~ 2nd Claim: 1 Principal and 3 Other Diagnosis and an ECode K3*POAYYNIZY~ 46

50 Special Instructions Common Causes of Claim Processing Delays, Rejections Denials Authization Referral Number Invalid Missing A valid authization number must be included on the claim fm f all services requiring pri authization referral from an assigned Primary Care Physician (PCP). Attending Physician ID Missing Invalid Inpatient claims must include the name of the physician who has primary responsibility f the patient's medical care treatment, and the medical license number on the appropriate lines in field number 82 (Attending Physician ID) of the UB-04 (CMS 1450) claim fm. A valid medical license number is fmatted as 2 alpha, 6 numeric, and 1 alpha character (AANNNNNNA) OR 2 alpha and 6 numeric characters (AANNNNNN). Billed Charges Missing Incomplete A billed charge amount must be included f each service/procedure/supply on the claim fm. Diagnosis Code Missing Digits Precise coding sequences must be used in der to accurately complete processing. Review the ICD-9-CM ICD-10 manual f the appropriate categies, subcategies, and extensions. After October 1, 2015, three-digit categy codes are required at a minimum. Refer to the coding manuals to determine when additional alpha numeric digits are required. Use X as a place holder where fewer than seven digits are required. Submit the crect ICD qualifier to match the ICD code being submitted. Diagnosis, Procedure Modifier Codes Invalid Missing Coding from the most current coding manuals (ICD-9-CM, CPT HCPCS) is required in der to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. DRG Codes Missing Invalid Hospitals contracted f payment based on DRG codes must include this infmation on the claim fm. EOBs (Explanation of Benefits) from Primary Insurers Missing Incomplete A copy of the EOB from all third party insurers must be submitted with the iginal claim fm. Include pages with run dates, coding explanations and messages. Payment from the previous payer may be submitted on the 837I 837P. Besides the infmation supplied in this document, the line item details may be sent in the SVD segment. Include the adjudication date at the other payer in the DTP, qualifier 573. COB pertains to the other payer found in 2330B. F COB, the plan is consider the payer of last rest. Imptant: Include all primary and secondary diagnosis codes on the claim. All primary and secondary diagnosis codes must have a cresponding POA indicat. Imptant: Missing invalid data elements incomplete claim fms will cause claim processing delays, inaccurate payments, rejections denials. Imptant: Regardless of whether reimbursement is expected, the billed amount of the service must be documented on the claim. Missing charges will result in rejections denials. Imptant: All billed codes must be complete and valid f the time period in which the service is rendered. Incomplete, discontinued, invalid codes will result in claim rejections denials. Imptant: State level HCPCS coding takes precedence over national level codes unless otherwise specified in individual provider contracts. Imptant: The services billed on the claim fm 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. Imptant: EPSDT services may be submitted electronically on paper. 47

51 Special Instructions EPSDT Infmation Missing Incomplete Keystone First requires EPSDT screening claims to be submitted by mail using the CMS 1500 Federal claim fm, the Universal Billing fm (UB- 04), electronically using the HIPAA compliant 837 Professional Claims (837P) transaction the Institutional Claims (837I) transaction. External Cause of Injury Codes External Cause of Injury E diagnosis codes should not be billed as primary and/ admitting diagnosis. Include applicable POA Indicats with ECI codes. Future Claim Dates Claims submitted f Medical Supplies Services with future claim dates will be denied, f example, a claim submitted on October 1 st f bandages that are delivered f October 1 st through October 31 st will deny f all days except October 1 st. Handwritten Claims (See Illegible Claim Infmation) Highlighted Claim Fields (See Illegible Claim Infmation) Illegible Claim Infmation Infmation on the claim fm must be legible in der to avoid delays inaccuracies in processing. Review billing processes to ensure that fms are typed printed in black ink, that no fields are highlighted (this causes infmation to darken when scanned filmed), and that spacing and alignment are appropriate. Handwritten infmation often causes delays inaccuracies due to reduced clarity. Incomplete Fms All required infmation must be included on the claim fms in der to ensure prompt and accurate processing. Member Name Missing The name of the member must be present on the claim fm and must match the infmation on file with the Plan. Member Plan Identification Number Missing Invalid The Plan s assigned identification number must be included on the claim fm electronic claim submitted f payment. Member Date of Birth does not match Member ID Submitted a newbn claim submitted with the mother s ID number will be pended f manual processing causing delay in prompt payment. Imptant: Submitting the iginal copy of the claim fm will assist in assuring claim infmation is legible. Imptant: The individual provider name and NPI number as opposed to the group NPI number must be indicated on the claim fm. Imptant: Do not highlight any infmation on the claim fm accompanying documentation. Highlighted infmation will become illegible when scanned filmed. Imptant: Do not attach notes to the face of the claim. This will obscure infmation on the claim fm may become separated from the claim pri to scanning. Imptant: Although the newbn claim is submitted under the mother s ID, the claim must be processed under the baby s ID. The claim will not be paid until the state confirms eligibility and enrollment in the plan. Imptant: The claim f baby must include the baby s date of birth as opposed to the mother s date of birth. Imptant: On claims f twins other multiple births, indicate the birth der in the patient name field e.g. Baby Girl Smith A, Baby Girl Smith B, etc. Imptant: 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. Newbn Claim Infmation Missing Invalid Always include the first and last name of the mother and baby on the claim fm. If the baby has not been named, insert Baby Girl Baby Boy in front of the mother s last name as the baby s first name. Verify that the appropriate last name is recded f the mother and baby. 48

52 Special Instructions Payer Other Insurer Infmation Missing Incomplete Include the name, address and policy number f all insurers covering the Plan member. Place of Service Code Missing Invalid A valid and appropriate two digit numeric code must be included on the claim fm. Refer to CMS 1500 coding manuals f a complete list of place of service codes. Provider Name Missing The name of the provider of service must be present on the claim fm and must match the service provider name and TIN on file with the Plan. Provider NPI number Missing Invalid The individual NPI and group NPI numbers f the service provider must be included on the claim fm. Revenue Codes Missing Invalid Facility claims must include a valid four-digit numeric revenue code. Refer to UB-04 coding manuals f a complete list of revenue codes. Spanning Dates of Service Do Not Match the Listed Days/Units Span-dating is only allowed f identical services provided on consecutive dates of service. Always enter the cresponding number of consecutive days in the days/unit field. Signature Missing The signature of the practitioner provider of service must be present on the claim fm and must match the service provider name, NPI and TIN on file with the Plan. Tax Identification Number (TIN) Missing Invalid - The Tax I. D. number must be present and must match the service provider name and payment entity (vend) on file with the Plan. Third Party Liability (TPL) Infmation Missing Incomplete Any infmation indicating a wk related illness/injury, no fault, other liability condition must be included on the claim fm. Additionally, a copy of the primary insurer s explanation of benefits (EOB) applicable documentation must be fwarded along with the claim fm. Type of Bill A code indicating the specific type of bill (e.g., hospital inpatient, outpatient, replacements, voids, etc.). The first digit is a leading zero. Do not include the leading zero on electronic claims. Adjusted claims may be sent via paper EDI. Imptant: The individual service provider name and NPI number must be indicated on all claims, including claims from outpatient clinics. Using only the group NPI billing entity name and number will result in rejections, denials, inaccurate payments. Imptant: When the provider facility has me than one NPI number, use the NPI number that matches the services submitted on the claim fm. Imprecise use of NPI number s results in inaccurate payments denials. Imptant: 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 rept from the EDI software vend each day. Imptant: Claims without the provider signature will be rejected. The provider is responsible f re-submitting these claims within 180 calendar days from the date of service. Imptant: Claims without a tax identification number (TIN) will be rejected. The provider is responsible f re-submitting these claims within 180 calendar days from the date of service. Imptant: Any changes in a participating provider s name, address, NPI number, tax identification number(s) must be repted to the Plan immediately. Contact your Provider Account Executive to assist in updating the Plan s recds. Electronic Data Interchange (EDI) f Medical and Hospital Claims Electronic Data Interchange (EDI) allows faster, me efficient and cost-effective claim submission f providers. EDI, perfmed in accdance with nationally recognized standards, suppts the health care industry s effts to reduce administrative costs. 49

53 Electronic Data Interchange (EDI) The benefits of billing electronically include: Reduction of overhead and administrative costs. EDI eliminates the need f paper claim submission. It has also been proven to reduce claim re-wk (adjustments). Receipt of clearinghouse repts makes it easier to track the status of claims. Faster transaction time f 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 fm. By the time a claim is successfully received electronically, infmation needed f processing is present. This reduces the chance of data entry errs that occur when completing paper claim fms. All the same requirements f paper claim filing apply to electronic claim filing. Imptant: Please allow f nmal processing time befe resubmitting the claim either through EDI paper claim. This will reduce the possibility of your claim being rejected as a duplicate claim. Imptant: In der to verify satisfacty receipt and acceptance of submitted recds, please review both the Emdeon Acceptance rept, and the R059 Plan Claim Status Rept. Refer to the Claim Filing section f general claim submission guidelines. Quicker claim completion. Claims that do not need additional investigation are generally processed quicker. Repts have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. 50

54 Electronic Data Interchange (EDI) ELECTRONIC CLAIMS SUBMISSION (EDI) The following sections describe the procedures f electronic submission f hospital and medical claims. Included are a high level description of claims and rept process flows, infmation on unique electronic billing requirements, and various electronic submission exclusions. 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 to Emdeon, whether through direct submission through another clearinghouse/vend, you can submit claims electronically. Contracting with Emdeon and Other Electronic Vends 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 Suppt Line at You may also choose to contract with another EDI clearinghouse vend who already has Emdeon capabilities. Imptant: Contact EDI Technical Suppt at: (prompt #4) Or by at [email protected] Imptant: Providers using Emdeon other clearinghouses and vends are responsible f arranging to have rejection repts fwarded to the appropriate billing open receivable departments. Imptant: The Payer ID f Keystone First is NOTE: Plan payer specific edits are described in Exhibit 99 at Emdeon. Contacting the EDI Technical Suppt Group Providers interested in sending claims electronically may contact the EDI Technical Suppt Group f infmation and assistance in beginning electronic submissions. When ready to proceed: Read over the instructions within this booklet carefully, with special attention to the infmation on exclusions, limitations, and especially, the rejection notification repts. Contact your EDI software vend and/ Emdeon to infm them you wish to initiate electronic submissions to the Plan. Be prepared to infm the vend of the Plan s electronic payer identification number. Imptant: Emdeon is the largest clearinghouse f EDI Healthcare transactions in the wld. It has the capability to accept electronic data from numerous providers in several standardized EDI fmats and then fwards accepted infmation to carriers in an agreed upon fmat. 51

55 Electronic Data Interchange (EDI) Specific Data Recd Requirements Claims transmitted electronically must contain all the same data elements identified within the Claim Filing section of this booklet. Emdeon any other EDI clearinghouse vend may require additional data recd requirements. Electronic Claim Flow Description In der to send claims electronically to the Plan, all EDI claims must first be fwarded to Emdeon. This can be completed via a direct submission through another EDI clearinghouse vend. Once Emdeon receives the transmitted claims, the claim is validated f HIPAA compliance and the Plan s Payer Edits as described in Exhibit 99 at Emdeon. Claims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon err rept. The name of this rept can vary based upon the provider s contract with their intermediate EDI vend Emdeon. Accepted claims are passed to the Plan, and Emdeon returns an acceptance rept to the sender immediately. Claims fwarded to the Plan by Emdeon are immediately validated against provider and member eligibility recds. Claims that do not meet this requirement are rejected and sent back to Emdeon, which also fwards this rejection to its trading partner the intermediate EDI vend provider. Claims passing eligibility requirements are then passed to the claim processing queues. Claims are not considered as received under timely filing guidelines if rejected f missing invalid provider member data. Providers are responsible f verification of EDI claims receipts. Acknowledgements f accepted rejected claims received from Emdeon other contracted EDI software vends, must be reviewed and validated against transmittal recds daily. Since Emdeon returns acceptance repts directly to the sender, submitted claims not accepted by Emdeon are not transmitted to the Plan. Imptant: Rejected electronic claims may be resubmitted electronically once the err has been crected. Imptant: Emdeon will produce an Acceptance rept * and a R059 Plan Claim Status Rept** f its trading partner whether that is the EDI vend provider. Providers using Emdeon other clearinghouses and vends are responsible f arranging to have these repts fwarded to the appropriate billing open receivable departments. * An Acceptance rept verifies acceptance of each claim at Emdeon. ** A R059 Plan Claim Status Rept is a list of claims that passed Emdeon s validation edits. However, when the claims were submitted to the Plan, they encountered provider member eligibility edits. Imptant: Claims are not considered as received under timely filing guidelines if rejected f missing invalid provider member data. Timely filing Note: Your claims must be received by the EDI vend by 9:00 P.M. in der to be transmitted to the Plan the next business day. Imptant: Contact Emdeon Provider Suppt Line at Imptant: Claims submitted can only be verified using the Accept and/ Reject Repts. Contact your EDI software vend Emdeon to verify you receive the repts necessary to obtain this infmation. Imptant: When you receive the Rejection rept from Emdeon your EDI vend, the plan does not receive a recd of the rejected claim. If you would like assistance in resolving submission issues reflected on either the Acceptance R059 Plan Claim Status repts, contact the Emdeon Provider Suppt Line at If you need assistance in resolving submission issues identified on the R059 Plan Claim Status rept, contact the EDI Technical Suppt Hotline at (prompt #4) by at [email protected] 52

56 Electronic Data Interchange (EDI) Invalid Electronic Claim Recd Rejections/Denials All claim recds sent to the Plan must first pass Emdeon HIPAA edits and Plan specific edits pri to acceptance. Claim recds 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 crected and re-submitted within the required filing deadline of 180 calendar days from the date of service. It is imptant that you review the Acceptance R059 Plan Claim Status repts received from Emdeon your EDI software vend in der to identify and re-submit these claims accurately. Plan Specific Electronic Edit Requirements The Plan currently has two specific edits f 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. Exclusions Certain claims are excluded from electronic billing. These exclusions fall into two groups and apply to inpatient and outpatient claim types. Excluded Claim Categies. At this time, these claim recds must be submitted on paper Claim recds f medical, administrative claim appeals Excluded Provider Categies. Claims issued on behalf of the following providers must be submitted on paper. Providers not transmitting through Emdeon providers sending to Vends that are not transmitting (through Emdeon) NCPDP Claims Pharmacy (through Emdeon) Imptant: Requests f adjustments may be submitted by telephone to: Provider Claim Services (Select the prompt f the crect Plan, and then, select the crect prompt f claim issues.) If you prefer to write, please be sure to stamp each claim submitted crected resubmission and address the letter to: Claims Processing Department Keystone First P.O. Box 7115 London, KY Outpatient medical appeals must be submitted in writing to: Provider Appeals Department Keystone First PO Box 7316 London, KY Inpatient medical appeals must be submitted in writing to: Provider Appeals Department Keystone First PO Box 7307 London, KY Refer to the Provider Manual the Provider Center online at f complete instructions on submitting administrative medical appeals. Submit written disputes to: Practitioner Dispute Keystone First Airpt Business Center 200 Stevens Drive Philadelphia, PA

57 Electronic Data Interchange (EDI) Common Rejections Invalid Electronic Claim Recds Common Rejections from Emdeon Claims with missing invalid batch level recds Claim recds with missing invalid required fields Claim recds with invalid (unlisted, discontinued, etc.) codes (CPT-4, HCPCS, ICD-9, etc.) Claims without provider numbers Claims without member numbers Claims in which the date of birth submitted does not match the member ID. Invalid Electronic Claim Recds Common Rejections from the Plan (EDI Edits within the Claim System) Claims received with invalid provider numbers Claims received with invalid member numbers Claims received with invalid member date of birth Resubmitted Professional Crected Claims Providers using electronic data interchange (EDI) can submit professional crected claims* electronically rather than via paper to Keystone First. * A crected claim is defined as a resubmission of a claim with a specific change that you have made, such as changes to CPT codes, diagnosis codes billed amounts. It is not a request to review the processing of a claim. Your EDI clearinghouse vend needs to: Use 6 f adjustment of pri claims 7 f replacement of a pri claim utilizing bill type in loop 2300, CLM05-03 (837P) Include the iginal claim number in segment REF01=F8 and REF02=the iginal claim number; no dashes spaces Do include the plan s claim number in der to submit your claim with the 6 7 Do use this indicat f claims that were previously processed (approved denied) Do not use this indicat f claims that contained errs and were not processed (rejected upfront) Do not submit crected claims electronically and via paper at the same time o F me infmation, please contact the EDI Hotline at edi.keystonefirstpa.com o Providers using our NaviNet ptal, ( can view their crected claims faster than available with paper submission processing. Imptant: Claims iginally rejected f missing invalid data elements must be crected and resubmitted within 180 calendar days from the date of service. Rejected claims are not registered as received in the claim processing system. (Refer to the definitions of rejected and denied claims on page 1.) Imptant: Befe resubmitting claims, check the status of your submitted claims online at Imptant: Crected Professional Claims may be sent in on paper via CMS 1500 via EDI. If sending paper, please stamp each claim submitted crected resubmission and send all crected resubmitted claims to: Claims Processing Department Keystone First PO Box 7115 London, KY Imptant: Crected Institutional and Professional claims can be resubmitted electronically using the appropriate bill type to indicate that it is a crected claim. Contact the Emdeon Provider Suppt Line at: Contact EDI Technical Suppt at: Imptant: Provider NPI number validation is not perfmed at Emdeon. Emdeon will reject claims f provider NPI only if the provider number fields are empty. Imptant: The Plan s Provider ID is recommended as follows: 837P Loop 2310B, REF*G2[PIN] 837I Loop 2310A, REF*G2 [PIN] 54

58 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) f 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 rept, but are unable to locate your claim via NaviNet, it is possible that your claim is in review by Keystone First. 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 infmation sent on the claim in der to have your claim processed effectively. 55

59 Electronic Billing Inquiries Please direct inquiries as follows: Action If you would like to transmit claims electronically If you have general EDI questions If you have questions about specific claims transmissions acceptance and R059 - Claim Status repts If you have questions about your R059 Plan Claim Status (receipt completion dates) If you have questions about claims that are repted on the Remittance Advice. If you need to know your provider NPI number If you would like to update provider, payee, NPI, UPIN, tax ID number payment address infmation F questions about changing verifying provider infmation If you would like infmation on the 835 Remittance Advice: Check the status of your claim: Sign up f NaviNet Contact Contact Emdeon Provider Suppt Line at: Contact EDI Technical Suppt at: by at:edi.keystonefirstpa.com Contact your EDI Software Vend call the Emdeon Provider Suppt Line at Contact Provider Claim Services at f claim inquiries. Contact Provider Claim Services at f claim inquiries. Contact Provider Services at: Notify Provider Netwk Management in writing at: Keystone First 200 Stevens Drive Philadelphia, PA Or by fax at: Contact your EDI Vend Review the status of your submitted claims on NaviNet at NaviNet Customer Service:

60 Tips f Accurate Diagnosis Coding: How to Minimize Retrospective Chart Review What is the Risk Sce Adjustment Model? The Department of Human Services (DHS) utilizes medical encounter data supplied by Keystone First to evaluate disease severity and risk of increased medical expenditures. DHS employs the Chronic Illness and Disability Payment System (CDPS), a diagnostic classification system, to suppt health-based capitation payments to Keystone First. Accurate payments from DHS help us ensure that providers are reimbursed appropriately f services provided to our members. We must obtain health status documentation from the diagnoses contained in claims data. Why are retrospective chart reviews necessary? Although Keystone First captures infmation through claims data, certain diagnosis infmation is commonly contained in medical recds but is not repted via claim submission. Complete and accurate diagnosis coding will minimize the need f retrospective chart reviews. What is the significance of the ICD-9-CM Diagnosis code? International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) codes are identified as 3 to 5 digit codes used to describe the clinical reason f a patient s treatment and a description of the patient s medical condition diagnosis (rather than the service perfmed). Chronic diseases treated on an ongoing basis may be coded and repted as many times as the patient receives treatment and care f the condition(s). Do not code conditions that were previously treated and no longer exist. However, histy codes (V10-19) may be used as secondary codes if the histical condition family histy has an impact on current care influences treatment. Per the ICD-9-CM Official Guidelines f Coding and Repting (October, 1, 2010), providers must code all documented conditions that were present at time of the encounter/visit, and require affect patient care treatment management. Have you coded f all chronic conditions f the member? Examples of disease conditions that should always be considered and included on the submission of the claim if they coexist at the time of the visit: Amputation status Diabetes mellitus Multiple sclerosis Bipolar disder Dialysis status Paraplegia Cerebal vascular disease Drug/alcohol psychosis Quadriplegia COPD Drug/alcohol dependence Renal failure Chronic renal failure HIV/AIDS Schizophrenia Congestive heart failure Hypertension Simple chronic bronchitis CAD Lung, other severe cancers Tums and other cancers Depression Metastic cancer, acute leukemia (Prostate, breast, etc.) What are your responsibilities? Physicians must accurately rept the ICD-9-CM diagnosis codes to the highest level of specificity. F example, a diabetic with neuropathy should be repted with the following primary and secondary codes: o Diabetes with neurological manifestations and f diabetic polyneuropathy Accurate coding can be easily accomplished by keeping accurate and complete medical recd documentation. 57

61 Documentation Guidelines Repted diagnoses must be suppted with medical recd documentation. Acceptable documentation is clear; concise, consistent, complete, and legible. Physician Documentation Tips First list the ICD-9CM code f the diagnosis, condition, problem other reason f the encounter visit shown in the medical recd to be chiefly responsible f the services provided. Adhere to proper methods f appending (late entries) crecting inaccurate data entries, such as lab radiology results. Strike through, initial, and date. Do not obliterate. Use only standard abbreviations. Identify patient and date on each page of the recd. Ensure physician signature and credentials are on each date of service documented. Update physician superbills annually to reflect updated ICD-9CM coding changes, and the addition of new ICD-9CM codes. Physician Communication Tips When used, the SOAP note fmat can assist both the physician and recd reviewer/coder in identifying key documentation elements. SOAP stands f: Subjective: How the patients describe their problems illnesses. Objective: Data obtained from examinations, lab results, vital signs, etc. Assessment: Listing of the patient s current condition and status of all chronic conditions. Reflects how the objective data relate to the patient s acute problem. Plan: Next steps in diagnosing problem further, prescriptions, consultation referrals, patient education, and recommended time to return f follow-up. 58

62 Appendix Supplemental Infmation Ambulance Anesthesia Audiology Chiropractic Care Dialysis Durable Medical Equipment (DME) EPSDT Supplemental Billing Infmation Fact Carve Out Family Planning Home Health Care (HHC) Infusion Therapy Injectable Drugs Maternity Multiple Surgical Reduction Payment Policy Physical/Occupational and Speech Therapies Termination of Pregnancy ICD-10 Infmation Most Common Claims Errs 59

63 Appendix Ambulance Ground and Air Ambulance Services are billed on CMS Fmat When billing f Procedure Codes A0425 A0429 and A0433 A0434 f Ambulance Transptation services, the provider must also enter a valid 2-digit modifier at the end of the associated 5-digit Procedure Code. Different modifiers may be used f the same Procedure Code. Providers must bill the transpt codes with the appropriate destination modifier. Mileage must also be billed with the ambulance transpt code and be billed with the appropriate transpt codes. Providers who submit transpt codes without a destination modifier will be denied f invalid/missing modifier. Providers who bill mileage alone will be denied f invalid/inappropriate billing. Mileage when billed will only be paid when billed in conjunction with a PAID transpt code. A second trip is reimbursed if the recipient is transferred from first hospital to another hospital on same day in der to receive appropriate treatment. Second trip must be billed with a (HH) destination modifier. F 837 claims, all ambulance details are required. Ambulance Transpt infmation; Ambulance Certification; pick-up and drop-off locations Procedure Code Modifiers: The following procedure code modifiers are required with all transpt procedure codes. The first place alpha code represents the igin and the second place alpha code represents the client's destination. Codes may be used in any combination unless otherwise noted. D - Diagnostic therapeutic site (other than physician's office hospital) E - Residential, domiciliary custodial facility (other than skilled nursing facility) G - Hospital-based dialysis facility (hospital hospital-related) H - Hospital I - Site of transfer (e.g., airpt helicopter pad) between modes of ambulance transpt J - Non hospital-based dialysis facility N - Skilled nursing facility P - Physician's office (includes HMO non-hospital facility, clinic, etc.) R - Residence S - Scene of accident acute event X - (DESTINATION CODE ONLY) Intermediate stop at physician's office enroute to the hospital (includes HMO non-hospital facility, clinic, etc.) Anesthesia Procedure codes in the Anesthesia section of the Current Procedural Terminology manual are to be used to bill f surgical anesthesia procedures. Anesthesia claims must be submitted using anesthesia (ASA) procedure codes only (base plus time units); All services must be billed in minutes; 15 minute time increments will be used to determine payment. Audiology Audiology services must be billed on a CMS 1500 claim fm via 837P. 60

64 Appendix Chemotherapy Services may be billed electronically via 837 electronic fmat via paper on a CMS 1500 UB-04. Providers are to use the appropriate chemotherapy administration procedure code in addition to the J-code f the chemotherapeutic agent. If a significant separately identifiable Evaluation and Management service is perfmed, the appropriate E/M procedure code may also be repted. Chiropractic Care Claims f chiropractic services are billed on a CMS 1500 via 837 electronic fmat. First visit does not require a referral pri authization. Subsequent visits require pri authization. Must bill appropriate CPT code and modifiers. Dialysis Reimbursement f dialysis services must be billed using the UB-04 claim fm via 837I electronic fmat. Keystone First's Claims Department will automatically adjudicate Claims f payment f cumulative monthly amounts of erythropoietin equal to less than 50,000 units. Dialysis centers and/ physicians will be required to submit documentation to the Keystone First Specialty Drug Program to establish the medical necessity of cumulative monthly doses of erythropoietin greater than 50,000 units. With the exception of facilities contracted at a case rate f Epogen, units over these amounts require Pri Authization and will be denied if they are billed without an authization. Once a specific dose is authized, it will be approved f up to three months. Epogen must be repted with revenue code 634 and revenue code 635. Durable Medical Equipment Services are billed on a CMS 1500 claim fm An NU modifier is used f all purchases An RR modifier is required f all rentals Repair codes on the DME Fee Schedule require the submission of procedure code K0739 Codes that require pri authization are noted on the Keystone First DME fee schedule. Refer to the Provider Manual f authization rules and guidelines Program Exceptions - codes K0868 through K0891 will be reviewed on a case by case basis. Benefit Exceptions items/services not listed on the Keystone First DME fee schedule will be reviewed on an individual basis based on coverage, benefit guidelines, and medical necessity Miscellaneous codes will not be used if an appropriate code is on the Keystone First DME fee schedule 61

65 Appendix EPSDT Supplemental Billing Infmation EPSDT Billing Guidelines CMS 1500, UB-04 Electronic 837 Fmat EPSDT Billing Guidelines f Paper Electronic 837 Claim Submissions Providers billing f complete Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screens may bill using the CMS 1500 UB-04 paper claim fms electronically, using the 837 fmat. Providers choosing to bill f complete EPSDT screens, including immunizations, on the CMS 1500 UB- 04 claim fm the 837 electronic fmats must: Use Z76.1, Z76.2, Z Z as the primary diagnosis code Accurate payment of EPSDT claims will be determined solely by the presence of EPSDT modifiers to identify an EPSDT Claim. Failure to append EPSDT modifiers will cause claims to be processed as non-epsdt related encounters Use one of the individual age-appropriate procedure codes outlined on the most current EPSDT Periodicity Schedule (listed below), as well as any other EPSDT related service, e.g., immunizations, etc. Use EPSDT Modifiers as appropriate: EP - Complete Screen; 52 - Incomplete Screen; 90 - Outpatient Lab; U1 - Autism. o Use U1 modifier in conjunction with CPT code f Autism screening o CPT code without a U1 modifier is to be used f a Developmental screening Age Appropriate Evaluation and Management Codes (As listed on the current EPSDT Periodicity Schedule and Coding Matrix) Newbn Care: Newbn Care (during the admission) Newbn (same day discharge) New Patient: Established Patient: Age < 1 yr Age < 1 yr Age 1-4 yrs Age 1-4 yrs Age 5-11 yrs Age 5-11 yrs Age yrs Age yrs Age yrs Age yrs Billing example: New Patient EPSDT screening f a 1 month old. The diagnosis and procedure code f this service would be: Z76.2 (Primary Diagnosis) 99381EP (E&M Code with Complete modifier) * Enter charges. Value entered must be greater than zero ($0.00) including capitated services. Please consult the EPSDT Program Periodicity Schedule and Coding Matrix, as well as the Recommended Childhood Immunization Schedule f screening timeframes and the services required to bill f a complete EPSDT screen. (Both are available in a printable PDF fmat online at the Provider Center at 62

66 Appendix Completing the CMS 1500 UB-04 Claim Fm The following blocks must be completed when submitting a CMS 1500 UB-04 claim fm f a complete EPSDT screen: EPSDT Referral Codes (when a referral is necessary, use the listed codes in the example below to indicate the type of referral made) Diagnosis Nature of Illness Injury Procedures, Services Supplies CPT/HCPCS Modifier EPSDT/Family Planning UB- CMS Item Description C/R d Reserved f Local Use EPSDT Referrals Enter the applicable 2-character EPSDT Referral Code f referrals made needed as a result of the screen. YD Dental *( f ages 3 and over) C* YO Other YV Vision YH Hearing YB Behavial YM Medical C C C C C 18 N/A Codes Enter the Code A1 EPSDT R Diagnosis Nature When billing f EPSDT screening services, R of Illness Injury diagnosis code Z76.1, Z76.2, Z Z (Routine Infant Child Health Check) must be used in the primary field (21.1) of this block. Additional diagnosis codes should be entered in fields 21.2, 21.3, An appropriate diagnosis code must be included f each referral. Immunization V-Codes are not required. 42 N/A Revenue code Enter Revenue Code 510 R 44 24D Procedures, Services Supplies CPT/HCPCS Modifier Populate the first claim line with the age appropriate E & M codes along with the EP modifier when submitting a complete EPSDT visit, as well as any other EPSDT related services, R N/A 24H EPSDT/Family Planning e.g., immunizations Enter Visit Code 03 when providing EPSDT screening services. Key: Block Code Provides the block number as it appears on the claim. C al must be completed if the infmation applies to the situation the service provided. R must be completed f all EPSDT claims. R 63

67 Appendix *Dental Referral In completing a dental referral, providers should advise the child s parent guardian that a dental exam is required accding to the periodicity schedule. The provider should complete and fax the EPSDT Dental Referral notification fm (available under Fms on Provider Center of contact Keystone First Member Services at while the member is in the office, within four (4) business days to notify them that the child is due f a dental referral as part of a complete EPSDT screen. Either method of notification fulfills the provider s requirement to refer the member to a dental home. Either method of notification fulfills the requirement f the provider to refer the member to a dental home*. Keystone First Member Services will then codinate with the member and their family to locate a participating dentist and arrange an appointment f the child. Documentation of the dental referral should be recded in the child's medical recd and on the claim fm by utilizing the appropriate EPSDT dental referral code. Dental Referral: Use the EPSDT modifier EP (Complete Screen) when the process outlined above has been followed. Enter the EPSDT referral code YD (dental referral) in field 10d on the CMS 1500 claim fm, field 37 on the UB-04 fm. When the dental referral has not occurred, submit the claim with the EPSDT modifier 52 (Incomplete Screen). *Payment f a complete screen is determined by the presence of both the EP modifier and YD referral code. Imptant: Failure to follow these billing guidelines may result in rejected electronic claims and/ non-payment of completed EPSDT screenings. Fact Drug Carve-Out Note: These instructions are only applicable f in-patient facilities f which fact are a carve-out in their Keystone First contract. Submit clinical infmation f Fact via secure to [email protected] The request is reviewed by hemophilia Nurse Case Manager who has thirty (30) days from receipt of complete infmation to review the case. Questions regarding status should be directed to Nurse Case Manager at Upon Nurse Case Manager approval and authization, an approval notice is sent to the Attending Physician, Member and Hospital contact. Upon Case Manager recommendation of denial, the case is sent to a Medical Direct f review. o o o After review of the request and the Medical Direct concurs with the denial recommendation, a denial notice is sent to the Attending Physician, Member and Hospital Contact. Any appeal should follow the instructions and process that are provided on the denial letter. After review, if the Medical Direct decides to approve and authizes the request, an approval notice is sent to the Attending Physician, Member and Hospital Contact. 64

68 Appendix Family Planning Members are covered f Family Planning Services without a referral Pri Authization from Keystone First. Members may self-refer f routine Family Planning Services and may go to any physician clinic, including physicians and clinics not in the Keystone First Netwk. Members that have questions need help locating a Family Planning Services provider can be referred to Member Services at Sterilization Sterilization is defined as any medical procedure, treatment operation f the purpose of rendering an individual permanently incapable of reproducing. A Member seeking sterilization must voluntarily give infmed consent on the Department of Human Services s Sterilization Consent Fm (MA 31 fm) Home Health Care (HHC) Provider must bill on CMS 1500, UB04, 837 electronic fmat (whichever fmat is designated in their Keystone First contract). When billing on a UB04, bill the appropriate revenue code f the homecare service. Providers are required to bill DME codes with appropriate modifiers per the Keystone First DME Fee Schedule Bill the appropriate and valid HCPCS that cresponds with the NDC Providers must bill the appropriate modifier in the first position when me than one modifier is billed. Refer to NDC instructions on page 35. Infusion Therapy Drugs administered by physician outpatient hospital require pri authization. Drugs require the provider to also bill the NDC and related NDC infmation. Failure to bill the NDC required infmation will result in denial. Injectable Drugs Vaccines and radiopharmaceuticals are exempt from NDC repting requirements. All drugs billed are required to be submitted with NDC infmation and may be submitted via CMS electronic fmat. Refer to NDC instructions in Supplemental Infmation section on pages The NDC number and a valid HCPCS code f drug products are required on both the 837 electronic fmat and the CMS-1500 f reimbursable medications. F 837I claims, submit only one NDC per line; Emdeon only considers the first NDC on a claim line. Maternity Bill an appropriate office visit code with a pregnancy diagnosis in addition to T1001-U9. Last menstrual period (LMP) is a required field to be submitted on all claim types (refer to the Keystone First Claims Filing Instructions f further details). The completed ONAF fm must be faxed to Bright Start ( ) within seven calendar days of the date of the prenatal visit as indicated on the fm. ONAF fms not meeting the seven calendar day submission requirement will not be reimbursed f T1001-U9. 65

69 Appendix The prenatal outreach bonus (99429) is eligible when the initial visit is within the first trimester and billed in conjunction with a pregnancy diagnosis and an appropriate office visit code. Refer to the updated Bright Start fee schedule at f complete details. Multiple Surgical Reduction Payment Policy Keystone First adheres to the following payment procedure: When two me surgical inpatient outpatient procedures are perfmed by the same practitioner on the same day, the practitioner will be reimbursed at 100% f the highest allowable payment f one procedure and 25% f the second highest paying procedure, with no payment f additional procedures. When two me surgical procedures are perfmed and anesthesia is provided by the same anesthesiologist during the same period of hospitalization, the anesthesiologist will be reimbursed at 100% f the highest allowable payment f one procedure and 25% f the second highest paying procedure, with no payment f additional procedures. When two me surgical procedures are perfmed during the same surgical event, and anesthesia is provided by the same anesthesiologist, the anesthesiologist should bill f the highest billable anesthesia procedure code. All anesthesia time must be allotted to that single anesthesia procedure code. No payment will be made f additional anesthesia procedures provided during that surgical event, with the exception of codes 01967, and Physical/Occupational and Speech Therapies Members are entitled to 24 physical, 24 occupational, and 24 speech therapy outpatient visits within a calendar year. A referral from the Member's PCP is required f the initial visit to the therapist. Initial visits are not considered part of the 24 visits. Once the Member exceeds the 24 visits of physical, occupational, and/ speech therapy, an authization is required to continue services. Therapy services may be billed on a UB-04 CMS 1500 claim fm via 837 electronic fmat. Termination of Pregnancy First and second trimester terminations of pregnancy require pri authization and are covered in the following two circumstances: 1. The member s life is endangered if she were to carry the pregnancy to term; 2. The pregnancy is the result of an act of rape incest. o Submit the physician s certification on the Pennsylvania Department of Human Services s Physician s Certification f an Abtion (MA 3 fm). The fm must be completed in accdance with the instructions and must accompany the claims f reimbursement. All claims and certification fms will be retained by Keystone First. If the Member is under the age of 18, a Recipient Statement Fm (MA368) must be completed and submitted. o Submit the Pennsylvania Department of Human Services s Physician s Certification f an Abtion (MA3) and the Pennsylvania Department of Human Services s Recipient Statement Fm (MA 368 MA 369) with the claim f reimbursement. The Physician s Certification f an Abtion and Recipient Statement Fm must be submitted in accdance with the instructions on the certification/fm. The claim fm, Physician s Certification f an Abtion, and Recipient Statement Fm will be retained by Keystone First. 66

70 Appendix Submit claims and all appropriate fms to: Keystone First P.O. Box 7115 London, KY ICD-10 Infmation Overview Keystone First has adopted the Centers f Medicare & Medicaid (CMS) Claims Processing Guidelines f the International Classification of Diseases, 10th Edition (ICD-10), in accdance with CMS requirements--currently scheduled f October 1, F dates of service on after the October 1, 2015 deadline, claims must be submitted using ICD-10 diagnosis codes. Claims submitted with a date of service pri to October 1, 2015 must be submitted using ICD-9 diagnosis codes. Claims Splitting Claims that have a span of dates of service cannot have both ICD-9 diagnosis codes and ICD-10 diagnosis codes submitted on the same claim. The claim must be split into two claims: One claim with ICD-9 diagnosis codes f services provided befe October 1, One claim with ICD-10 diagnosis codes f services provided on after October 1, ICD-10 Rules Type of Service Begins Ends Pri-Authization Claim Inpatient Inpatient with known discharge date Inpatient with unknown discharge date Outpatient Long-Term Outpatient Admission on after 10/1/15 Admission befe 10/1/15 Admission befe 10/1/15 Services on after 10/1/15 Services begin befe 10/1/15 Discharge on after 10/1/15 Known discharge on after 10/1/15 Unknown at the time of admission but discharge is on after 10/1/15 Not Applicable Services end on after 10/1/15 Pri Authizations must be requested with ICD-10 codes Pri Authizations must be requested with ICD-10 codes Pri Authizations must be requested with ICD-9 codes. Pri- Authization would be valid f entire admission. Pri Authizations must be requested with ICD-10 codes Pri Authizations requested in ICD-9 will be valid f services on after 10/1/15. Claim f services on after 10/1/15 must be billed with ICD- 10 The code set used on the claim will depend on the discharge date, entire claim must be ICD-10 in this case The code set used on the claim will depend on the discharge date, entire claim must be ICD-10 in this case Claim must have ICD-10 codes The claims f these services must be separated and submitted with the crect code type based on the date of services. Claims with both ICD-9 and ICD-10 codes (mixed claims) will not be permitted. 67

71 Appendix Additional Resources CMS has published guidance on potential claims issues when ICD-9 codes are effective f that ption of the services rendered on September 30, 2015, and earlier, and when ICD-10 codes are effective f that ption of the services rendered on October 1, 2015, and later. To become familiar with the types of services affected by claims splitting pri to the October 1, 2015 implementation date, please visit the following link: MLN/MLNMattersArticles/downloads/SE1325.pdf.CMS s Road to 10 online resource ( ) can help smaller practices build action plans as well as provide common codes and resources f primary care and specialty physicians. Most Common Claims Errs Field # CMS-1500 (02/12) Field/Data Element "Reject Statement" (Reject Criteria) Effective April 1, Patient s Name 3 Patient s Birth Date 3 Patient s Birth Sex 4 Insured s Name 5 Patient s Address( number, street, city, state, zip) phone 6 Patient Relationship to Insured 7 21 Insured's Address( number, street, city, state, zip) phone Infmation related to Diagnosis/Nature of Illness/Injury 24 Supplemental Infmation 24A Date of Service "Member name is missing illegible." (If first and/ last name are missing illegible, the claim will be rejected.) "Member date of birth (DOB) is missing." (If missing month and/ day and/ year, the claim will be rejected.) "Member's sex is required." (If no box is checked, the claim will be rejected.) "Insured s name missing illegible." (If first and/ last name is missing illegible, the claim will be rejected.) "Patient address is missing." (If street number and/ street name and/ city and/ state and/ zip are missing, the claim will be rejected.) "Patient relationship to insured is required." (If none of the four boxes are selected, the claim will be rejected.) "Insured s address is missing." (If street number and/ street name and/ city and/ state and/ zip are missing, the claim will be rejected.) "Diagnosis code is missing illegible." (The claim will be rejected.) "National Drug Code (NDC) data is missing/incomplete/invalid." (The claim will be rejected if NDC data is missing incomplete, has an invalid unit/basis of measurement.) Date of service (DOS) is missing illegible." (The claim will be rejected if both the From and To DOS are missing. If both From and To DOS are illegible, the claim will be rejected. If only the From To DOS is billed, the other DOS will be populated with the DOS that is present.) 24B Place of Service "Place of service is missing illegible." (Claim will be rejected.) 24D Procedure, Services Supplies "Procedure code is missing illegible." (Claim will 68

72 Appendix Field # CMS-1500 (02/12) Field/Data Element "Reject Statement" (Reject Criteria) Effective April 1, 2015 be rejected.) 24E 24F 24G 24J Diagnosis Pointer Line item charge amount Days/Units Rendering Provider identification 26 Patient Account/Control Number 27 Assignment Number 28 Total Claim Charge Amount Signature of physician supplier including degrees credentials Billing Provider Infmation and Phone number 33 Billing Provider Infmation and Phone number "Diagnosis (DX) pointer is required on line [lines 1-6]. (F each service line with a From DOS, at least one diagnosis pointer is required. If the DX pointer is missing, the claim will be rejected.) "Line item charge amount is missing on line [lines 1-6]. (If a value greater than equal to zero is not present on each valid service line, claim will be rejected.) "Days/units are required on line [lines 1-6]. (F each line with a From DOS, days/units are required. If a numeric value is not present on each valid service line, claim will be rejected.) "National provider identifier (NPI) of the servicing/rendering provider is missing, illegible." (If NPI is missing illegible, claim will be rejected.) "Patient Account/Control number is missing illegible" (If missing illegible, claim will reject) "Assignment acceptance must be indicated on the claim." (If "Yes" "No" is not checked, the claim will be rejected.) "Total charge amount is required." (If a value greater than equal to zero is not present, the claim will be rejected.) "Provider name is missing illegible." (If the provider name, including degrees credentials, and date is missing illegible, the claim will be rejected.) "Billing provider name and/ address is missing incomplete." (If the name and/ street number and/ street name and/ city and/ state and/ zip are missing, the claim will be rejected.) "Field 33 of the CMS1500 claim fm requires the provider s physical service address." (If a PO Box is present, the claim will be rejected.) 69

73 Appendix NOTES 70