HCFA 1500 FORM Instructions for Billing Medical Assistance

Transcription

1 HCFA 1500 FORM Instructions for Billing Medical Assistance You must follow these instructions to complete the HCFA-1500 when billing Medical Assistance. You cannot use Medicare's billing instructions. Do not imprint, type, or write any information on the upper right hand portion of the form. This area is used to stamp the Claim Reference Number which is vital to the processing of your claim. Do not submit a photocopy of your claim to Medical Assistance. Send claims to P.O. Box 8194 on the preprinted envelope (ENV 320). If you do not use the preprinted envelopes, the mailing address is: Office of Medical Assistance Programs, P.O. Box 8194, Harrisburg, PA BLOCK 1 TYPE OF CLAIM (MUST) Place an "X" in the Medicaid block. If this block is not completed or if a block other than Medicaid is checked, your invoice will be returned to you. 1. MEDICARE MEDICAID (Medical Asst) 1. MEDICARE MEDICAID X BLOCK la INSURED'S I.D. NUMBER (MUST) Recipient Number Enter the patient's 10-digit recipient number exactly as it appears on the Pennsylvania ACCESS Card. Do not use the patient's Social Security Number or any other identifier in this block. 1a. INSURED S ID NUMBER BE SURE THAT ELIGIBILITY IS VERIFIED BY ACCESSING THE ELIGIBILITY VERIFICATION SYSTEII (EVS) I EACH TIME A SERVICE IS RENDERED. BLOCK 2 PATIENT'S NAME (OPTIONAL -EXCEPTION: THIS IS A MUST FIELD WHEN BILLING FOR NEWBORNS WITH ELIGIBILITY UNDER THE MOTHER S RECIPIENT NUMBER) Enter the patient's last name, first name and middle initial, if any. The patient's name is not keypunched. The names appearing on the Remittance Advice are taken from the Department's computerized list of recipients. If the 10-digit recipient number you have recorded on the invoice does not match with a number on the Department's file, a blank space will appear on the Remittance Advice, where the patient's name would normally appear. 2. PATIENT S NAME (Last name, First name, Middle Initial JONES, JONATHAN J.

2 - 2 - BLOCK 3 PATIENT'S BIRTHDATE AND SEX (OPTIONAL -EXCEPTION: THIS IS A MUST FIELD WHEN BILLING FOR NEWBORNS WITH TEMPORARY ELIGIBILITY UNDER THE MOTHER'S RECIPIENT NUMBER) Enter the patient's date of birth in Month, day, year (MMDDYY) format. Example: for May 11, Enter an "X" in the appropriate box for male or female. 3. PATIENT S BIRTHDATE MM DD YY SEX M X F NOTE: MEDICAL ASSISTANCE IS THE PAYOR OF LAST RESORT. THE FOLLOWING ITEMS REFER TO ANY RESOURCES OTHER THAN MEDICAL ASSISTANCE: Blocks 4, 7, lla-d, and 13 are to be completed when there is a primary health insurance other than Medical Assistance. Blocks 9a-d are to be completed when there is a secondary health insurance, in addition to the insurance listed in Blocks 4, 7, 11 a-d & 13. BLOCK 4 INSURED'S NAME (MUST, IF APPLICABLE) If the patient has health insurance other than Medical Assistance list the name of the insured here. Enter the name of the insured except when the insured and the patient are the same-then the word "SAME" may be entered. If there is no insurance other than Medical Assistance, this block may be left blank. 4. INSURED'S NAME(Last Name, First Name, Middle Initial) SAME BLOCK 5 PATIENT'S ADDRESS (OPTIONAL) IF YOU SUBMIT LASER PRINTED HCFA-1500 INVOICES, YOU MUST STAMP IN RED, THE WORD "ORIGINAL" EITHER IN THIS BLOCK OR ON THE "SIGNATURE TRANSMITTAL FORM" (MA307) DIRECTLY BELOW THE BLOCK LISTING THE NUMBER OF INVOICE TAPES OR DISKETTES. BLOCK 6 PATIENT S RELATIONSHIP TO INSURED (MUST, IF APPLICABLE) Check the appropriate box for patient s relationship to the insured listed in Block 4. BLOCK 7 INSURED S ADDRESS (MUST, IF APPLICABLE) Enter the insured s address and telephone number except when the address is the same as the patient s-then enter the word SAME. Complete this box only when Block 4 is completed.

3 - 3 - BLOCK 8 PATIENT STATUS (OPTIONAL) BLOCK 9 OTHER INSURED'S NAME (MUST, IF APPLICABLE) If the patient has another health insurance secondary to that listed in Block 11, enter the last name, first name, and middle initial of the insured if it is different from the patient's name that is shown in Block 2. Otherwise, enter the word "SAME." If you have determined that the patient has Medical Assistance coverage only, and no other insurance, leave this field blank. BLOCK 9a OTHER INSURED'S POLICY OR GROUP NUMBER (MUST, IF APPLICABLE) This block is used to identify a secondary insurance other than Medical Assist- tance, and the primary insurance listed in 11a-d. Enter the policy number and the group number of any secondary insurance that is available. Only use Blocks 9a-d, if you have completed Blocks lla-d and a secondary policy is available. (For example, the patient may have both Blue Cross and Aetna benefits available.) BLOCK 9b OTHER INSURED'S DATE OF BIRTH (MUST, IF APPLICABLE) Enter the other insured's date of birth in month, day, year (MMDDYY) format and enter an "X" in the appropriate box for the other insured's sex. BLOCK 9c EMPLOYER'S NAME OR SCHOOL NAME (MUST, IF APPLICABLE) BLOCK 9d INSURANCE PLAN NAME OR PROGRAM NAME (MUST, IF APPLICABLE) Enter the other insured's insurance plan name or program name. BLOCK 10a-c IS PATIENT'S CONDITION RELATED TO: (MUST, IF APPLICABLE) Enter an "X" in the appropriate "YES" or "NO" block to indicate whether the patient's condition is related to employment, auto accident, or other accident (i.e., liability suit) as it applies to one or more of the services described in Block 24d. For auto accidents, enter the state's 2-digit postal code in which the accident occurred in the PLACE (state) block (e.g., IN for Indiana). BLOCK 10d RESERVED FOR LOCAL USE (OPTIONAL) Policyholder's Social Security Number Enter the nine-digit social security number of the policyholder if the policy- holder is not the recipient.

4 - 4 - BLOCK 11 INSURED'S POLICY GROUP OR FECA NUMBER (MUST, IF APPLICABLE) Enter the Policy number and the Group Number of the primary insurance other than Medical Assistance. BLOCK 11a INSURED'S DATE OF BIRTH (MUST, IF APPLICABLE) Enter the insured's birth date in month, day, year (MMDDYY) format and the insured's sex if different from Block 3. BLOCK 11b EMPLOYER'S NAME OR SCHOOL NAME (MUST, IF APPLICABLE) Enter the employer's name, if applicable. BLOCK 11c INSURANCE PLAN NAME OR PROGRAM NAME (MUST, IF APPLICABLE) (Primary Insurance Name and Address) List the name and address of the primary insurance listed in Block 11. BLOCK 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? (MUST, IF APPLICABLE) If the patient has another resource available to pay for the service, bill the other resource before billing Medical Assistance. IF THERE IS MORE THAN ONE RESOURCE AVAILABLE PLACE AN "X" IN "YES" AND COMPLETE BLOCKS 9a THRU 9d. BLOCK 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE AND DATE (MUST) Recipient's Signature and Date ALL INVOICES MUST HAVE EITHER THE RECIPIENT'S SIGNATURE OR THE VORDS "SIGNATURE EXCEPTION" APPEARING IN THIS ITEM. The purpose of the recipient's signature is to certify that the recipient received the service from the provider indicated on the invoice and that the person listed on the Pennsylvania ACCESS Card is the individual who received the service provided. The following May sign his or her name on behalf of the recipient: 1. a parent 2. a legal guardian 3. a relative 4. a friend NOTE: THE PROVIDER OR AN EMPLOYEE OF THE PROVIDER DOES NOT QUALIFY AS AN AGENT OF THE RECIPIENT.

5 - 5 - There are some situations in which the provider is not required to obtain the recipient's signature. Those situations are: 1. When billing for inpatient hospital, short procedure unit, nursing home and emergency room services provided by an independent physician. 2. When billing for services which are paid in part by another third party, such as Medicare or Blue Shield. 3. When billing for services provided to a recipient who is unable to sign because of a physical condition. 4. When billing for services provided to a recipient who is physically absent, such as laboratory services, reading an X-ray or reading an EEG. 5. When resubmitting an invoice which was previously rejected. 6. When billing on computer generated (pin-fed) invoices. In all of the above situations, you must print the words "Signature Exception" on the recipient's signature line of the invoice. NOTE: FOR MACHlNE PRINTED CONTINUOUS PIN-FED INVOICES OR MAGNETIC TAPE BILLING, PLEASE REPER TO THE BILLING INFORIIATION SECTION OF YOUR PROVIDER HANDBOOK FOR SPECIAL INSTRUCTIONS CONCERNING OBTAINING RECIPIENT SIGNATURES ON AN ENCOUNTER FORM (MA-9I). A COPY OF THE MA-9I IS LOCATED IN THE HANDBOOK. YOU CANNOT ORDER THE MA-9I; YOU MUST MAKE COPIES FOR YOUR USE. FOR AUTOMATED BILLERS, A SIGNATURE ON AN ENCOUNTER FORM IS REQUIRED IN ALL SITUATIONS WHEN A SIGNATURE IS REQUIRED ON AN INVOICE. BLOCK 13 BLOCK 14 INSURED OR AUTHORIZED PERSON'S SIGNATURE (OPTIONAL) DATE OF CURRENT ILLNESS (OPTIONAL) Enter the date of current illness (first symptom), injury (accident), or pregnancy in month, day, year (MMDDYY) format. BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS (OPTIONAL) If the patient had the same or similar illness, list the date of the first onset of the illness. Item 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION (OPTIONAL) Enter the "FROM" and "TO" date only if the patient is unable to work due to the current illness or injury. This block is only important for Workers' Compensation cases. It may be left blank for other situations.

6 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE (MUST OR MUST, IF APPLICABLE) Enter the name and degree of the referring/supervising/attending practitioner or prescriber as described below: 1. For provider types 05, 08, 09, 10, 11(0P), 12(0P), 16, 19, 20, 21, 23, 28, 29, , 37, and 43; the name of the referring, supervising or prescribing practitioner is a MUST. 2. For provider types , , 18, 31, , and 50; the name of the referring, supervising or prescribing practitioner is a MUST IF APPLICABLE. 3. For provider type 26. the name and degree of the professional rendering treatment is a MUST. 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Frank Henderson, M.D. BLOCK 17a I.D. NUMBER OF REFERRING PHYSICIAN (MUST OR MUST, IF APPLICABLE) If you have completed Block 17, completion of this block is a MUST. To complete this block, use the referring practitioner's or prescriber's license number. This number contains a prefix consisting of two alpha characters, the certification number composed of six digits, and a one letter suffix. 1. Enter the complete license number of the practitioner noted in Block For provider type 18, enter the license number, if available, of the practitioner noted in Block For provider type 26, when a physician treated the patient, enter the license number of the physician, noted in Block 17. If another professional renders treatment leave this item blank. 4. For provider types 28, 29, and 33; enter the seven-digit Medical Assistance identification number of the practitioner Doted in Block 17. If an out-of-state practitioner or prescriber orders a service, use the following format for their license number: Characters 1-2 Enter the State abbreviation 3-8 Enter six numeral 9's 9 Enter an "X"

7 - 7-17A. I.D NUMBER OF REFERRING PHYSICIAN NY999999X \BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES (MUST, IF APPLICABLE) If the patient was hospitalized in an inpatient setting, provide the admission date and discharge date in six-digit format. Enter a zero to the left of all one-digit numbers. For example, if the patient was hospitalized on March 23, 1994, and discharged on March 25, 1994, enter: Date Admitted (mmddyy) Date Discharged (mmddyy) From (To) INTERMITTENT BILLS POR INPATIENT VISITS MAY BE SUBMITTED. IN THIS CASE, ENTER SIX ZEROS POR THE DISCHARGE DATE. POR EXAMPLE: Date Admitted (mmddyy) Date Discharged (mmddyy) From (To) WHEN SUBMITTING A FINAL BILL FOR THE REMAINING INPATIENT VISITS, THE ACTUAL ADMISSION AND DISCHARGE DATES MUST BE ENTERED IN THE APPROPRIATE BLOCKS. NOTE: For inpatient services, consultants, radiologists. and anesthesiologists may bill for their services before the patient is discharged. In this instance, enter six zeros for the discharge date. BLOCK 19 RESERVED POR LOCAL USE (MUST, IF APPLICABLE) This block will be used for the number of attachments and the attachment types. Enter the number of attachments with a single digit followed by a slash and up to tour two-digit attachment codes. Number of Attachments (MUST, IF APPLICABLE) With the exception of Medicare claims and claims for which you received payment from more than one insurer, the Department does not require that you attach insurance statements to the invoice. However, the number of statements on file is required. It you have two attachments, list the number of attachments followed by a slash and the two attachment codes appropriate to your claim. You may list up to four 2-digit attachment codes. 19. RESERVED FOR LOCAL USE 2/05, 11 (# OF ATTACHMENTS/LIST OF ATTACHMENT CODES)

8 - 8 - NOTE: Claims fro abortions, hysterectomies, sterilizations, and newborns (when billing under the mother's recipient number) must be submitted on hard copy invoices and must include copies of the appropriate attachments. Attachment Code (MUST, IF AFPLICABLE) If you have indicated that a statement(s} is attached or on file, enter the appropriate code(s) for the statements. (See example above.) 01 - Prior Authorization on File *03 - Abortion Physician Certification (MA3) (Federal Requirement) *04 - Sterilization Patient Consent Form (MA 31) (Federal Requirement) **05 - Medicare EOMB (Attached) *06 - Hysterectomy Acknowledgement Form (MA 30) (Federal Requirement) 07 - SSA 1453 on File 08 - Termination of Medical Necessity Letter 09 - Medicare Denial On File 10 - Third Party Payment Statement on File 11 - Third Party Denial on File *12 - Restricted Recipient Referral Form *13 - Medical Documentation for Hysterectomy 14 - Program Exception 15 - Medicare Benefits Exhausted 16 - Patient Pay Applied to Previous Claim ***26 - Newborn (Instructions are listed below for information that you must list on "Remarks Sheet"). ***99 - Remarks (Instructions are listed below for more detailed information on "Remarks Sheet"). *Attachments must be submitted with invoice **If you receive payment from Medicare and you are billing for a Medicare deductible or coinsurance amount, place Attachment Code 05 in Block 19 and attach the BOMB to invoice. Do not show any amount in Block 24K. See Block 24K #3, for additional information on Medicare billing. ***REMARKS SHEET (MUST, IF APPLICABLE) Whenever your invoice requires remarks, place attachment code 99 in Block 19 to indicate that remarks are attached to your invoice. The Remarks Sheet should be an 8 1/2" x 11" sheet of white paper paperclipped to your invoice. Do not staple. You must place your MAID provider number and the recipient's number on the Remarks Sheet. This will clearly identify the remarks with your claim in the event they become separated. The following information lists the instances that would require you to use a Remarks Sheet:

9 Explanation of Unusual Circumstances or Conditions The Remarks Sheet is used if space is needed to explain unusual circumstances or conditions relative to services reported on the invoice or as required in any other section of the billing instructions. 2. Newborn Claims When billing for newborns who do not have a recipient number, be sure to enter Attachment Code 26 with Attachment Code 99 in Block 19. On the Remarks Sheet, list your provider number and the mother's recipient number, the mother's name, her date of birth, and her Social Security Number. 3. Ambulance Transportation In order for ambulance transportation to be considered medically necessary, one or more of the conditions listed in Chapter 1245, Section (1) of the Ambulance Transportation regulations must be documented in the Remarks Section. (See Section III -Policies, for Chapter Ambulance Transportation Regulations.) 4. Qualified Small Business Disclaimer The Remarks Sheet must be used for the qualified small business disclaimer. BLOCK 20 OUTSIDE LAB? (LEAVE BLANK) BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (MUST, OR MUST IF APPLICABLE) 1. Primary ICD-9-CM Diagnosis Code (MUST) The Department requires the most specific diagnosis code which most accurately describes the condition for which the service is being rendered. The only time a three-digit code is acceptable is when there is no subheader number beneath the three-digit header; for example, diagnosis code 193 (malignant neoplasm of thyroid gland) has no subheader. The majority of diagnosis codes are four-digits. However, when a symbol appears in front of the diagnosis code, a fifth digit is required. These valid digits are found with each code. Enter the most specific three-, four-, or five-digit ICD-9-CM code to identify the primary diagnosis, symptoms or conditions of the patient. You may report up to four codes, but you must report at least one code. 21. DIAGNOSIS/NATURE OF ILLNESS (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24 E BY LINE) 1. XXX XX YYY YY 4.

10 To bill for radiological services, electrocardiograms or electroencephalograms and the diagnosis is not furnished, enter XRY 11. To bill for laboratory services and the diagnosis is not furnished, enter LAB Secondary ICD-9-CH Diagnosis Code (MUST, IF APPLICABLE) If there is a secondary diagnosis present, enter the appropriate ICD-9-CM Diagnosis Code to identify it. 3. Tertiary Diagnosis Codes (MUST, IF APPLICABLE) 4. Fourth Diagnosis Code (MUST, IF APPLICABLE) NOTE: The three-volume set of ICD-9-CM Diagnosis Codes may be obtained from: Superintendent of Documents U.S. Government Printing Office Department 33 Washington, D.C Volumes 1 and 2 of the ICD-9-CM Diagnosis Codes may be obtained from: ICD-9CM Third Edition mvolumes 1 and 2 P.O Box Pittsburgh, PA ICD-9-CM P.O. Box 971 AAnn Arbor, MI BLOCK 22 MEDICAID RESUBMISSION (MUST, IF APPLICABLE) 1. Resubmission of Rejected Claim Code When resubmitting a rejected claim, enter the first two digits of the Remittance Advice Number of the original rejected claim. Original Reference Number When resubmitting a rejected claim, enter the Claim Reference Number (CRN) of the original rejected claim. Code/Original Reference Number 26 / Submission of Claim Adjustment (MUST, IF APPLICABLE) Code

11 When submitting a claim adjustment, enter ADJ in the "Code" block. Original Reference Number Complete this item with the 10-digit claim reference number and 2-digit line number of your last approved claim. From the Remittance Advice, enter the Claim Reference Number assigned to the invoice. The Claim Reference Number is found in the second column from the left on the Remittance Advice. The line number is found in the third column from the left on the Remittance Advice. Code / Original Reference Number ADJ / TO ADJUST A PREVIOUSLY PAID CLAIM ADJUSTMENT, THE CLAIM REFERENCE NUMBER AND THE LINE NUMBER OF THE LAST APPROVED ADJUSTMENT FOR THE SERVICE MUST BE ENTERED IN THIS BLOCK. CLAIM ADJUSTMENTS ARE MADE ONLY TO CORRECT CLAIMS THAT HAVE APPEARED AS APPROVED ON YOUR REMITTANCE ADVICE. YOU MUST SUBMIT A NEW INVOICE TO CORRECT A REJECTED CLAIM, OR FOR A CLAIM THAT HAS NEVER APPEARED ON A REMITTANCE ADVICE. The Claim Adjustment CAN be used: The Claim Adjustment CANNOT Be used: 1. To correct an overpaid or under paid claim. 2. To remove a payment which was paid under the wrong recipient number. 3. To remove a payment if the claim was submitted in error or if an unanticipated payment is received from another resource. 4. To correct the patient history file with regard to copay (Visit Code 11). 1. To correct more than one claim line. A separate HCFA-1500 must be submitted for each claim line. 2. To correct a rejected claim. 3. To correct a pended claim. 4. To correct a claim that never appeared on a Remittance Advice. 5. To correct a recipient number or a provider number. It is not necessary to submit claim adjustments to the Department for amounts less than one dollar. NOTE: TO RETURN MONEY PAID UNDER AN INCORRECT RECIPIENT NUMBER, A CLAIM ADJUSTMENT MUST BE SUBMITTED FOR EACH PAID CLAIM LINE. ENTER THREE (3) ZEROS IN THE $ CHARGES BLOCK (BLOCK F) OF THE HCFA IN ADDITION, A NEW HCFA-1500 MUST THEN BE SUBMITTED USING THE PATIENT'S CORRECT 10-DIGIT RECIPIENT NUMBER.

12 BLOCK 23 PRIOR AUTHORIZATION NUMBER (or Place of Service Review/Admission Certification Number) (MUST, IF APPLICABLE) Refer to the appropriate appendix in your provider handbook for information regarding Centralized Prior Authorization. If a prior authorization number is required, enter the number in item 23. For provider types 01, 04, and 08, refer to the appropriate appendix in your handbook or Medical Assistance Bulletin for information regarding place of service review/admission certificiation. If a place of service review/admission certification number is required, enter that number in item 23. BLOCK 24A DATE(S) OF SERVICE (MUST, OR MUST IF APPLICABLE) From ) (MUST, IF APFLICABLE) If the same service was provided on consecutive days, enter the first day of service here. Use a six-digit format for all dates. If you are billing for a service that was provided on one day only, you are permitted to complete either the "From" or the "To" date. Note to Medical Suppliers: When billing for equipment rentals, use only one date-ofservice in either the From or the "To" dates of service block. Block 24G "Units" will always be "1". To ( ) (MUST) The "To" date will indicate the last consecutive day the same service was provided. Use a six-digit format for all dates. NOTE: CONSECUTIVE SERVICE DATES ARE THOSE CONTIGUOUS CALENDAR DAYS DURING WHICH THE SAME SERVICE WAS PROVIDED. IF DATES ARE NOT CONSECUTIVE, SEPARATE CLAIM LINES MUST BE USED. For example, if the same service was provided on March 26 and March 27, 1994, enter: From To If the service was provided on March 23, 1994 only, you may complete either the "From" or "To" block. BLOCK 24B PLACE OF SERVICE (MUST) Enter the appropriate code to identify where the service was performed.

13 For ambulance transportation, enter the appropriate code to indicate where the recipient was transported. 01 Office 10 Psychiatric Partial Hospital 02 Patient s Home ization Facility 03 Inpatient Hospital 11 Community 04 Renal Dialysis Center/ Facility 12 Ambulatory Surgical Center or 05 Outpatient Hospital Hospital Short Procedure Unit 06 Independent Laboratory 14 Emergency Room 15 Mental Retardation Center 07 Hospital Special Treatment Room 16 Freestanding Inpatient Hospice 08 Nursing Facility 09 Independent Clinic For example, if the service was provided in an emergency room, enter: Place of Ser. 14 NOTE: Place of Service 05 (Outpatient Hospital) is only valid for physicians when the following Types of Service are used: 80 Medical Diagnostic Both Components AY Medical Diagnostic Professional Components 50 Radiation Therapy - Both Components 51 - Radiation Therapy - Professional Components 53 Nuclear Medicine - Both Components 58 Nuclear Medicine Professional Components 54 Diagnostic Radiology Both Components 57 Diagnostic Radiology Professional Component 89 Laboratory Professional Component 25 Surgical Diagnostic Injection/Introduction Procedures Only BLOCK 24C TYPE OF SERVICE (MUST) Enter the proper code for the procedure identified in item 24D. For example, if the type of service for the service performed was surgical, enter: Type of Service 20 The types of service you are eligible to use are listed on your Provider Notice Information. You will be paid only for those types of service. If you wish to bill for a type of service not listed on your Provider Notice Information, you must contact the Department in writing and request that the additional types of service be added to your file before you submit an invoice.

14 The type(s) of service which may be applicable to you are as follows: AE -Surgical Supplies AF -Drug and Alcohol AG -Methadone Maintenance AH -Partial Hospitalization AJ -EPSDT Screening (Excludes Treatment) AK -Home Health Care AL -Pharmaceutical Services AM -Orthotics AP -Renal Dialysis Services AR -Family Planning Services AS -Provider Mileage AT -Burial AU -Audiology Services AX -Comprehensive Health AT -Medical Diagnostic -Professional Component AZ -Medical Diagnostic -Technical Component DC -Medicare Deductible/Coinsurance EI -Early Intervention ES -EPSDT FP -HB+ Foundation Provider HB -Healthy Beginnings Plus OT -Occupational Therapy PS -Psychological Service PT -Physical Therapy SS -Social Service ST -Speech Therapy 9A -Ambulance Services 9B -Blood/Blood Products 9P -Purchase -Durable Medical Equipment 9R -Rental -Durable Medical Equipment 9S -Prosthetic Devices 10 -Assistant Surgeon 20 -Surgical 25 -Surgical Diagnostic 27 -ASC/SPU Support Component for day surgery 30 -Obstetrical 40 -Anesthesia 50 -Radiation Therapy -Both Components 51 -Radiation Therapy -Professional Component RT -Radiation Therapy -Technical Component 53 -Nuclear Medicine -Both Components 54 -Diagnostic Radiology -Both Components RD -Diagnostic Radiology -Technical Component 57 -Diagnostic Radiology -Professional Component RN -Nuclear Medicine -Technical Coaponent 58 -Nuclear Medicine -Professional Component 60 -Medical 70 -Psychiatric 80 -Medical Diagnostic -Both Components 86 -Laboratory -Both Components

15 LT -Laboratory -Technical Component 89 -Laboratory -Professional Component 90 -Consultation Remember that in order to bill for any of the above types of service, they must be contained on your Provider Notice Information. If you want to bill for a type of service that is not on your Provider Notice Information. Please contact the Department regarding the necessary enrollment change. NOTE: Physicians who wish to be reimbursed for dispensing Medications to recipients or for EPSDT screening must make special enrollment arrangements with the Department (see the Provider Notice Information Form Section of your Handbook). The Medical Assistance Program Fee Schedule contains all the procedures covered by the Medical Assistance Program. There are several columns on each page relating to each procedure code. The first column denotes the type of service. BLOCK 24D PROCEDURES, SERVICES OR SUPPLIES (MUST OR MUST, IP APPLICABLE) HCPCS Procedure Code (MUST) The Medical Assistance Program Fee Schedule contains all the procedures covered by the Medical Assistance Program. There are several columns on each page relating to each procedure code. The first column denotes the type of service. The second column indicates the procedure code. The corresponding terminology for the procedure code along with applicable modifiers and other payment limitations are found in the third column. For surgical and obstetrical procedures, the fourth column indicates the number of days during the postoperative and postpartum periods during which no additional payment will be made for any follow up visits. This column may also contain additional limitations for payments. The final column indicates the Medical Assistance fee for the service and any appropriate indicators. Enter the code for the procedure performed. Only those codes listed in the Medical Assistance Program Fee Schedule are covered by the Medical Assistance Program. (See Section III -Policies, Medical Assistance Program Fee Schedule.) For example, if the procedure was a simple repair of a recent two inch wound to the leg, enter: HCPCS Modifier (MUST, IF APPLICABLE) 1. If a modifier is associated with the procedure performed, enter the Modifier after the procedure code; a second modifier, if applicable, also may be entered. 2. All ambulance services must have a modifier. Modifiers applicable to ambulance services are as follows:

16 RH Home to Hospital HR Hospital to Home HE Hospital to Long Term Care Facility HH Discharge / Transfer from one Hospital to another RE Home to Long Term Care Facility ER Long Term Care Facility to Home DC Patient s Residence to Renal Dialysis Center EH Long Term Care Facility to Hospital SH Scene of Emergency to Hospital SC Scene of Emergency to Clinic SR Scene of Emergency to Rural Health Clinic VC Other DH Renal Dialysis Center to Patient s Residence 3. Bilateral procedures which require a modifier are indicated in the Medical Assistance program Fee Schedule. Modifiers applicable to bilateral procedures are as follows: RT Right Side of Body LT Left Side of Body 50 Bilateral 4. If you obtain prior authorization for a service and a modifier was assigned to that procedure code, you must bill using the assigned modifier. Refer to Medical Assistance Program Fee Schedule for a complete list of modifiers. For example, the service rendered was an ambulance trip from a scene of an accident to a hospital, enter: Modifier SH BLOCK 24E DIAGNOSIS CODE (MUST) Enter the diagnosis reference number as shown in Block 21 to correlate the diagnosis code to the respective procedure or service performed. If the service was provided for the primary diagnosis listed, enter a 1. If the service was provided for the secondary diagnosis 2, enter a 2, etc. E Diagnosis Code 1

17 BLOCK 24F $ CHARGES (HUST) Enter your usual charge to the self-paying public for the service{s) provided. For example, if your usual charge for one office visit is $20.00, enter: Charges If you are billing for multiple units of service, be sure to multiply your usual charge by the Dumber of units billed. NOTE: Rural Health Clinics and Federally Qualified Health Centers are to enter their all-inclusive Medicare rate. BLOCK 24G DAYS OR UNITS (MUST) Enter the number of times the service was performed on the same or consecutive days of service. For example, if the same service was provided on October 26 and 27, 1993, enter: Units of Service 2 If the service was provided on October 23, 1993, only, enter: Units of Service 1 If the service rendered was 24 abdominal pads; enter: Units of Service 24 BLOCK 24H EPSDT/FAMILY PLANNING (MUST, If Applicable) Visit Codes Enter the appropriate visit code as it applies to this claim line. If none of the following codes apply, leave this item blank. 09 -Service rendered to a pregnant woman or related to a delivery 10 -Service rendered to a resident of a medical facility as defined in 11O1.63(b)(2)(iii). 11 -Copayment was not paid by the recipient. The Department will still deduct copay from invoice.

18 BLOCK 241 EMG (HUST, IF APPLICABLE) If the service provided was on an emergency basis, enter the number 1. If the service provided was urgent, enter the number 2. If these codes do not apply, leave this field blank. I EMG 1 BLOCK 24J COB (Coordination of Benefits) (MUST, IF APPLICABLE) Resource Code This block is a one-digit field. If the patient has another resource available to pay for the service, bill the other resource before billing Medical Assistance. Information on Third Party Resources is generally provided by the Eligibility Verificiation System (EVS). Also, ask the patient if he/she has any medical resources not listed on EVS. If there is more than one resource available, enter the resource code of the primary insurance. If none of the following apply, leave this block blank. 1 -Medicare Part B 2 -Blue Cross J -Blue Shield 4 -Champus 6 -Medicare Part A 7 -Other 8 -Worker's Compensation/Casualty Insurance For example, if the patient has private insurance, such as Prudential, Aetna, etc., and it covers the service provided, enter: COB 7 Important: When you list a resource code in this block, you will proceed as follows: 1. If the other resource denied the claim, place the appropriate attachment code in Block If the other resource made payment on the claim, place the appropriate attachment code in Block 19 and place the amount paid by that insurer in Block K.

19 If Medicare denied or if Medicare benefits were exhausted, place the appropriate attachment code in Block If Medicare approved the claim, place attachment code 05 in Block 19 and attach the BOKB to the claim. BLOCK 24K RESERVED FOR LOCAL USE Other Insurance Paid (MUST, IF APPLICABLE) This block is only for other insurance payments excluding Medicare. If you received payment from Medicare, do not complete this block. Refer to Number 3 below. Do not use this block for provider or payee identification numbers. 1. Enter the portion of the bill that was paid by another insurance company in the this block. Do not enter the amount paid by Medicare in this block. Also, maintain on file a copy of that company's Explanation of Benefits. NOTE: MEDICAL ASSISTANCE IS CONSIDERED THE PAYOR OF LAST RESORT. ALL OTHER COVERAGE MUST BE EXHAUSTED BEFORE BILLING MA. THE MA PROGRAM IS ONLY RESPONSIBLE FOR PAYMENT OF THE UNSATISFIED PORTION OF THE BILL UP TO THE MAXIMUM ALLOWABLE MEDICAL ASSISTANCE FEE FOR THE SERVICE. For example, if the patient's insurance company paid $40.00 for the service provided, enter: Reserved for Local Use If payment was received from more than one resource other than Medicare, place the total of both resources in Block K. 3. To ensure the proper use of the patient's Medicare resources, providers are required to bill Medicare first for procedures when they are provided to persons eligible for Medicare Part B. Approved Medicare claims will then be automatically "crossed-over" to Medical Assistance. Whenever Medicare crossover claims do not appear on your Remittance Advice within 60 days, submit your invoice to MA with the EOHB attached. Place the number of attachments and attachment code 05 in Block 19. For Medicare cases involving abortions, sterilizations, and hysterectomies, submit your invoice to MA with the EOMB and federal forms attached. Place the number of attachments and attachment code 05 in addition to either attachments 03-abortion, 04-sterilization or 06-hysterectomy in Block 19. Claims denied by Medicare will not be crossed over to Medical Assistance.

20 BLOCK 25 FEDERAL TAX I.D. NUMBER (MUST) Enter the physician/supplier Federal Tax Employer Identification Number (EIN) or Social Security Number and place an "X" in the appropriate block. BLOCK 26 PATIENT'S ACCOUNT NO. (OPTIONAL, BUT RECOMMENDED) Enter a patient file number or the patient's name (up to ten [10] digits or letters). This will appear on the Remittance Advice and will help identify your claim. It is recommended that you use this field as it will provide a second claim identifier if the recipient eligibility number does not match the Department's file. Patient Account Number DOE M Patient s Account Number BLOCK 27 ACCEPT ASSIGNMENT? (LEAVE BLANK) BLOCK 28 TOTAL CHARGE (OPTIONAL) Enter the sum of all charges reported on the claim in item 24F. For example, if the sum of your usual charges for the services provided is $60.00, enter: Total Charges BLOCK 29 AMOUNT PAID (MUST, IF APPLICABLE) Total Patient Pay The local county assistance office determines when recipients are responsible to pay a portion of their Medical expenses. This is "patient pay liability." If the patient is to pay a portion of their medical bills, enter the amount paid by the patient. DO NOT ENTER ANY PATIENT COPAYMENT AMOUNT IN THIS FIELD.

21 BLOCK 30 BALANCE DUE (LEAVE BLANK) BLOCK 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREE OR CREDENTIALS (MUST) 1. Provider's Signature (MUST) The provider rendering the service must sign the invoice. The signature certifies that the service has been provided in accordance with Medical Assistance regulations. A signature stamp is acceptable, except for abortions, if the provider authorizes its use and assumes responsibility for the information on the invoice. ******************************************************** ALL UNSIGNED INVOICES WILL BE RETURNED TO YOU ******************************************************** NOTE: FOR MACHINE PRINTED CONTINUOUS PINFED INVOICES OR MAGNETIC TAPE BILLING, PLEASE REFER TO THE BILLING INFORMATION SECTION OF YOUR HANDBOOK FOR SPECIAL INSTRUCTIONS CONCERNING SIGNATURE REQUIREMENTS ON THE MA307, SIGNATURE TRANSMITTAL FORM. 2. Invoice Date (MUST) Enter the date the invoice is being submitted to the Department for processing. Use a six-digit format for all dates. For example, if the submission date is January 30, 1994, enter: Invoice Date (MMDDYY) BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (MUST, IF APPLICABLE) Facility Name/MAID Number This item is completed if the place of service was inpatient hospital, short procedure unit, ambulatory surgical center, hospital special treatment room, or emergency room. For provider type 08, leave this item blank. Enter the facility name and under the facility name enter the facility's seven-digit identification number. (See the appropriate Appendix in your provider handbook for a listing of hospital identification numbers.)

22 For example, if the patient was admitted to Community Hospital, enter: COMMUNITY HOSPITAL If services were rendered in a Nursing Facility, enter the name of the Nursing Facility or Center. The facility MAID number will be blank. SUBURBAN NURSING HOME If the practitioner is billing for services rendered in a Renal Dialysis center, enter the name of the Renal Dialysis center and the center's MAID number. CARE DIALYSIS CENTER BLOCK 33 PHYSICIAN'S SUPPLIER'S BILLING NAHE, ADDRESS, ZIP CODE, AND TELEPHONE NUMBER <MUST OR MUST, IF APPLICABLE) Use this field for the Provider MAID Number/Address Code, and for the Payee MAID Number/Address Code. The provider type and payee provider type are not required. Provider MAID Number (MUST) Place your seven-digit Medical Assistance identification number in the space after "PIN#" on the form. The identification number is assigned by the Department. Provider Address Code (MUST) Place a slash after the provider number and follow it with the two-digit address code for the office where the service was provided. If you are billing for inpatient hospital or home, services, enter your main office address code. The address code is found on the enrollment notice sent to you by the Department. Provider MAID / Address Code /01

23 Payee MAID Number (MUST, IF APPLICABLB) The payee must be enrolled with the Department and will be issued a separate and distinct MAID Number. Do not complete this area if there is not a payee designated. Place the seven-digit ID number assigned to the designated payee in the space after "GRP#" on the form. Payee Address Code (MUST, IF APPLICABLB) Place a slash after the payee number and follow it with the correct two-digit address code to identify the payee location. This field may be used to have checks and Remittance Advices sorted and mailed to each billing location or service delivery address. Other options are available for sorting Remittance Advices by service address codes. If interested, contact the Department. FOR ASSISTANCE CALL: PRACTITIONER UNIT PROVIDER TYPE 01,03,04,06,07,08,41,42,43,44,49,50 PHARMACY & ANCILLARY OR PROVIDER TYPE 05,09,10,11,12,15,16,18,19,20,21,22,23,26,28,29,30,33,37 HOURS AVAILABLE: MONDAY THRU THURSDAY 10am to 3 pm EST