The standard CMS 1500 Claim Form or UB-04 Claim Form is required for Security Health Plan billing.

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1 Payment Issues Federal Funds The provider acknowledges that payments the provider receives from Security Health Plan to provide services to dvocare members are, in whole or part, from federal funds. Therefore, the provider and any of its subcontractors are subject to certain laws that are applicable to individuals and entities receiving federal funds, including but not limited to, Title VI of the Civil Rights ct of 1964 as implemented by 45 CFR part 84; the ge Discrimination ct of 1975 as implemented by 45 CFR part 91; and the mericans With Disabilities ct. Prompt Payment Security Health Plan will reimburse providers within 60 days of receipt of a complete claim. Claims that require additional information or are subject to coordination of benefits will be paid promptly upon receipt of requested information. Security Health Plan s illing and Reporting Claims illing Requirements The standard CMS 1500 Claim Form or U-04 Claim Form is required for Security Health Plan billing. Providers must use the universal CPT codes, HCPCS codes or Revenue codes when billing Security Health Plan. Include all information on the forms as required by Original Medicare. Claims Mailing/Submitting Requirements Submit all dvocare claims for payment/reporting to Security Health Plan by mailing to: Security Health Plan ttn: Claims Department P.O. o 8000 Marshfield, WI Claims Filing Limit Refer to Medicare s claim filing time limit policy. Successful Claims Submission Tips Submit complete and accurate claims using the guidelines outlined in this section. Incomplete claims will result in possible delays in processing. Security Health Plan follows Medicare guideline for claims submission timelines. Clean Claims clean claim is a complete and accurate form that includes all provider and member information, as well as records, additional information, and documents needed from the member or provider to enable Security Health Plan to process the claim. The clean claim date is the date on which all such necessary information has been received. 6-1 n 10/10

2 Sample Claim Form: U-04 Name & ddress of Facility Federal Ta ID Number Dates of Service Patient ccount # Type of ill Date & Time of dmission a PT. 4 TYPE CNTL # OF ILL b. MED. REC. # 6 STTEMENT COVERS PERIOD 7 5 FED. TX NO. FROM THROUGH 8 PTIENT NME a 9 PTIENT DDRESS a b b c d DMISSION CONDITION CODES 29 CDT DHR 17 STT DTE 10 IRTHDTE 11 SEX HR 14 TYPE 15 SRC STTE 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPN 36 OCCURRENCE SPN 37 CODE DTE CODE DTE CODE DTE CODE DTE CODE FROM THROUGH CODE FROM THROUGH Subscriber a Name & ddress 3-digit Revenue Code b VLUE CODES VLUE CODES VLUE CODES CODE MOUNT CODE MOUNT CODE MOUNT a d 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RTE / HIPPS CODE 45 SERV. DTE 46 SERV. UNITS 47 TOTL CHRGES 48 NON-COVERED CHRGES 49 b c e a b 1 Total Charges Noncovered Charges 2 3 Description of 4 Revenue Code, 5 e. Lab, 7 Radiology, etc HCPC Codes Insurance Company Subscriber Name Diagnosis Codes dmitting C Diagnosis Code Procedures/ Surgeries/Labs Performed PGE OF CRETION DTE TOTLS 52 REL. 53 SG. 50 PYER NME 51 HELTH PLN ID 54 PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI INFO EN. 57 OTHER C PRV ID 58 INSURED S NME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNCE GROUP NO. C 63 TRETMENT UTHORIZTION CODES 64 DOCUMENT CONTROL NUMER 65 EMPLOYER NME 66 DX 67 C D E F G H I J K L M N O P Q 69 DMIT 70 PTIENT 71 PPS DX RESON DX a b c CODE ECI a b c 74 PRINCIPL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DTE CODE DTE CODE DTE 76 TTENDING NPI QUL LST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DTE CODE DTE 77 OPERTING NPI QUL CODE DTE LST FIRST 81CC 80 REMRKS a 78 OTHER NPI QUL C C C National Provider Identifier Total Due SSN or MHN Group Number Group Name ttending Physician U-04 CMS-1450 Miscellaneous Notes rea PPROVED OM NO b LST FIRST c 79 OTHER QUL NPI d LST FIRST THE CERTIFICTIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF. National Uniform NUC illing Committee 6-2 n 10/10

3 Claims Processing Procedures: U-04 U-04 claim completion for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies, and other institutional providers. The data elements are listed as fields on the claim form. Required information must be filled in completely, accurately, and legibly. If the information is inaccurate or incomplete, the claim cannot be processed. Instead it will be returned with a request for needed information. complete claim should include the following to the etent applicable: 1. Provider name, address and telephone number This field contains the name of the provider submitting the bill and the complete mailing address to which the provider wishes payment sent. (Required) 2. Pay to or billing address This field contains the name of the provider submitting the bill and the complete mailing address where the provider wishes payment sent. 3a. Patient control number unique number assigned by the provider to retrieve individual patient accounts and case records, and to post payments. (Required) 3b. Patient medical record number 4. Type of bill Provides specific information about the bill for Medicare (or other payer) billing purposes. The first digit of the three-digit number identifies the type of facility, the second digit classifies the type of care being billed, and the third digit indicates the sequence of the bill for a specific episode of care. (Required) 5. Federal ta number The federal ta number is the number assigned to the provider by the federal government for ta purposes. Should be reported as XX-XXXXXXX. (Required) 6. Statement covers period This field is used for reporting the beginning and ending dates of service for the entire period reflected on the bill. (Required) 7. Unlabeled 8a. Patient ID 8b. Patient name Not used for provider reporting, for State use only. 9. a e Patient address Full mailing address of the patient. (Required) 10. Patient birth date The patient s birth date must be reported with all positions fully coded in the MM/DD/YY format. (Required) 11. Patient se The gender of the patient as recorded at the time of registration as an inpatient or outpatient or at the start of care. (Required) 12. dmission/start-of-care date The date the patient was admitted to the provider for inpatient care, outpatient services or other start of care. (Required) 13. dmission hour The hour during which the patient was admitted for inpatient or outpatient care. Hours are entered in military time using two numeric characters. 14. Type of admission/visit code that indicates the priority of admission/visit. (Required) 15. Source of admission code that indicates the source of admission or service: inpatient, outpatient, hospital, home health and inpatient SNF. (Required) 6-3 n 10/10

4 16. Discharge hour The hour during which the patient was discharge from inpatient care (in military time). 17. Patient status code indicating the patient s disposition as of the ending date of service for the period of care reported. (Required) Condition codes Codes identifying conditions that may affect payer processing of this bill. The codes help determine patient eligibility and benefits and are used to administer primary or secondary insurance coverage. (Required) 29. ccident state 30. Unlabeled Occurrence codes and dates Define a specific event relating to this bill that may affect payer processing. Codes are used to determine liability, coordinate benefits and administer subrogation clauses in benefit programs. (Required) Occurrence span codes and dates Identify an event that relates to payment of the claim. These codes identify occurrences that happened over a span of time. Report the code, the beginning ( from ) date and the ending ( through ) date associated with the reported occurrence span code. (Required) 37. Unlabeled 38. Subscriber name and address The name and address of the party responsible for the bill. This information must be accurate Value Codes and mounts Contain codes and the related dollar amounts identifying monetary data required for processing claims. The information is required for benefit determination and provides reporting capability for data elements that are used routinely but do not warrant a separate field assignment. 42. Revenue code Use this field to report the appropriate numeric code corresponding to each narrative description or standard abbreviation that identifies a specific accommodation and/or ancillary service. Revenue 001 must be the final entry on all bills. (Required) 43. Revenue description narrative description or standard abbreviation for each revenue code category reported on the U-04 claim form. 44. HCPCS/rates/HIPPS rate codes The Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary services for outpatient claims, the HIPPS rate code or the accommodation rate for inpatient claims. (For outpatient claims, HCPCS procedure codes are required.) 45. Service date The date on which the indicated service was provided. This field is required for billing outpatient Medicare claims. 46. Service units quantitative measure of services rendered, by revenue category, to or for the patient, including items such as the number of accommodation days, visits, miles, pints of blood, units of treatments. (Required for Medicare billing.) 47. Total charges The total charges pertaining to the related revenue code for the current billing period as entered in the Statement Covers Period field, including both covered and noncovered charges. (Required) 48. Noncovered charges The total noncovered charges for the primary payer pertaining to a particular revenue code. (Required) 49. Unlabeled field This is not used for provider reporting. For national use only. 6-4 n 10/10

5 50. Payer identification The name and, if required, the number identifying each payer organization from which the provider might epect some payment for the bill. Line 50 a. is used to report the primary payer, line 50 b. secondary payer, if applicable, and line 50 c. for the tertiary payer. (Required) 51. Health plan ID Providers current Medicare Provider Number. (Required for dvocare billing until 5/23/2007 when NPI s are required.) 52. Release of information certification indicator This field indicates whether the provider has on file a signed statement from the beneficiary permitting the provider to release data to other organizations in order to adjudicate the claim. (Required) 53. ssignment of benefit certification indicator This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service. 54. Prior payments payers and patient The amount the hospital has received toward payment of this bill prior to the billing date for the payer indicated in field 50 on lines a., b., and c. for outpatient claims and all other third-party payers. (Required) 55. Estimated amount due n estimate by the hospital of the amount due from the indicated payer in field 50 on lines a., b., and c., or from the patient (estimated responsibility less any prior payments). 56. NPI National Provider Identifier. 57. Unlabeled field This field is not used for provider reporting. For national use only. 58. Insured s name Name of the patient or insured individual in whose name the insurance is issued as qualified by the payer organization listed in field 50 on lines a., b., and c. (Required) 59. Patient s relationship to insured This field contains the code that indicates the relationship of the patient to the insured individuals identified in field 58 on lines a., b., and c. (Required) when Medicare is the secondary or tertiary payer. 60. Certificate/Social Security Number/health insurance claim/identification number The insured s identification number assigned by the payer organization. This field allows 19 alphanumeric characters in three lines. Required. 61. Insured group name The group or plan through which the health insurance coverage is provided to the insured. (Required) 62. Insurance group number The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered. 63. Treatment authorization codes number or other indicator that designates that the treatment covered by this bill has been authorized by the payer indicated in field 50 on lines a., b., and c. (Required) 64. Document control number Not required. 65. Employer name of the insured Name of the employer that provides health care coverage for the insured individual identified in field 58 on lines a., b., and c. This field allows for 24 alphanumeric characters on each of three lines. (Required) 66. Diagnosis code qualifier This reflects which ICD-9 edition used Not required. 6-5 n 10/10

6 67. Principal diagnosis code The full ICD-9-CM diagnosis code, including the fourth and fifth digits, if applicable, that describes the principal diagnosis (the condition established after study to be chiefly responsible for causing the hospitalization or use of other hospital services). (Required) 67. a q Other diagnosis codes This field contains the full ICD-9-CM diagnosis codes (including the fourth and fifth digits, if applicable) corresponding to all conditions that coeist at the time of admission, that develop subsequently or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay should be ecluded. (Required) 68. Unlabeled field This field not used for provider reporting. For state use only. 69. dmitting diagnosis/patient s reason for visit Reporting the complete ICD-9-CM code describing the patient s diagnosis or reason for visit at the time of admission or outpatient registration, including the fourth and fifth digits when appropriate. (Required) 70. Patients reason for visit codes 71. PPS code Not used. 72. Eternal cause of injury The full ICD-9-CM code, including the fourth and fifth digits. Health Care of activities are encouraged to report an E Code whenever there is a diagnosis of an injury, poisoning or other adverse effect. 73. Unlabeled field This field not used for provider reporting. For state use only. 74. Principal procedure code and date The ICD-9-CM code for the principal procedure performed during the period covered by the bill and the date on which the principal procedure described on the bill was performed. (Required) For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated. 74. a e Other procedure code and dates This field allows reporting of up to five ICD-9-CM codes to identify the significant procedures performed during the billing period, other than the principal procedure, and the corresponding dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. (Required) For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated. 75. Unlabeled field This field not used for provider reporting. For state use only. 76. ttending physician ID The name and/or number of the licensed physician who normally would be epected to certify and re-certify the medical necessity of the services rendered and/or who has primary responsibility for the patient s medical care and treatment. Include NPI on line 1 and name on line 2. (Required) 77. Operating physician Include NPI on line 1 and name on line 2. (Required) Other physician ID Name and/or number of the licensed physician other than the attending physician, as defined by the payer organization. Include NPI on line 1 and name on line 2. (Required for Medicare billing.) 80. Remarks This field is used to make notations relating to specific third-party payer needs. Provide any additional information that is necessary to adjudicate the claim or otherwise fulfill the payer s reporting requirements. 81. a d dditional code Code field not used at this time. 6-6 n 10/10

7 Standard information must be completed in addition to below. See Group and Direct Pay Claims Processing Policies and Procedures section of the Security Health Plan Provider Manual for standard information. CMS 1500: Sample Claim Form Doe, Jane th Street nywhere WI Doe, Jane 123 6th Street nywhere WI Security Health Plan Signature on file 2/26/09 Signature on file Scully, Hillary M.D L00000X Riverview Hospital nesthesia ssoc. of WI Rapids 410 Dewey Street 3666 Poysphere Circle Gregory Naze, M.D. Wisconsin Rapids, WI Chicago, IL /1/ L00000X 6-7 n 10/10

8 Claims Processing Policies and Procedures CMS 1500 Instructions The Security Health Plan Processing System is designed to process standard health insurance claim forms (CMS 1500) using CPT-4 Procedure Codes or HCF Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-9-CM Diagnosis Codes. Security Health Plan Processing Systems require that a compliant red form be used. If the form is not red, it will be returned with a request for a red form. Required information must be filled in completely, accurately, and legibly. If the information is inaccurate or incomplete, your claim cannot be processed. Instead, it will be rejected with a note eplaining the rejection. complete claim is considered to have the following data elements (numbered as shown on claim form): 1a. Insured s ID number which includes either the subscriber number, medical history number, Social Security number and medicaid number. 2. Patient s name (last name, first, middle initial) 3. Patient s date of birth (month/day/year), and gender 4. Insured s name (last name, first, middle initial) 5. Patient s address (street, city, state, and ZIP code) 6. Patient s relationship to insured 7. Subscriber s address (if different from patient s) 8. Patient status 9. Other insured s name (last name, first name, middle initial) if applicable. Please include the actual insurance carrier name if available, not the name of a repricing company 10. If patient s condition is related to: employment auto accident other accident 11c. Insurance plan name or program name 13. Insured s or authorized person s signature 17. Name of referring physician or other source and NPI 18. Hospitalization dates related to current services 20. Outside lab 21. Diagnosis (ICD-9-CM) or nature of illness or injury 24a. Date of service 24b. Place of service 24c. Tpe of service 24d. CPT/HCPCS modifier 24e. Diagnosis code 24f. Charge (for each service) 6-8 n 10/10

9 Claims Processing Policies and Procedures 24g. Days or units 24j. NPI 24k. Reserved for local use (Security Health Plan provider number) 25. Ta Identification Number (TIN) 26. Patient s account number 28. Total charge 29. mount paid by other insurance carrier. Do not include discounts, only actual payments 31. Signature of physician or supplier 32. Name and address of facility where services were rendered (if other than home or office) 33. Physician s supplier s billing name, address, zip code, phone number and NPI If there are any questions regarding claims submission, contact the Claims Processing Department at ffiliated providers can mail claims to: Security Health Plan P.O. o 8000 Marshfield, WI Nonhospital Provider Claims Submission Requirements Security Health Plan dvocare follows CPT guidelines developed by the M and will accept current CPT codes, national HCPCS codes and modifiers. Claims should be submitted on the CMS 1500 claim form and must include the provider s NPI. Claims for professional services, durable medical equipment, supplies and hospital owned clinics should be submitted on the CMS 1500 claim form. ll claims submitted to Security Health Plan dvocare must be complete and accurate and follow Medicare s billing guidelines. Hospital Claims Submission Requirements When a Security Health Plan dvocare member is admitted to the hospital, it is essential for the dmitting Department to notify Security Health Plan of the admission within 24 hours of the first business day. Claims for all inpatient and outpatient services should be submitted on standard claim forms utilizing the appropriate revenue, CPT, HCPCS codes and necessary modifiers as indicated by Medicare billing guidelines. Refer to the Care Management section for additional information regarding requirements for hospital stays. Provider Payment Inquiries Questions concerning claim status, adjustments, or corrective options, should be directed to the assigned claims reviewer at , et n 10/10

10 ppeal Process for Denied Claims Payment Reference the Provider Grievance and ppeal Process for information related to the appeals process. High End Imaging (HEI) Security Health Plan requires prior notification for all outpatient HEI tests: MRI, CT (ecluding SPECT) and PET scans. Security Health Plan will deny high-end imaging global or professional (26 modifier) and technical service (TC modifier) claims for no prior notification. NSI Denial Codes Regarding HEI Radiology claims administratively denied for no prior notification are identified using the NSI denial code CO197. Radiology claims administratively denied if there is prior notification but no referring provider listed on claim are identified using the NSI denial code CO125 (billing error) with ON286 remark code identifying the reason for the billing error. Radiology claims administratively denied if the CPT code provided for prior notification does not match the actual CPT performed are identified using the NSI denial code CO125 with the remark code ON54. dditional HEI Claims Information Primary/Secondary: No notification is required when Security Health Plan is secondary to any other payer, including Medicare. Receipt of notification number does not guarantee payment. Claim questions or appeals should be submitted through the regular Security Health Plan protocol outlined in Plan Provider and Facility Manuals. There is no need to put the notification number on the claim form; however, the provider may do so at their discretion. Members may not be balanced billed for denials related to absence of prior notification for a highend imaging procedure. For detailed information on Security Health Plan s High-End Notification process such as frequently asked questions, specific CPT codes that require prior notification, either a) Visit Security Health Plan s main Web site: > Providers > Provider Relations Center b) Visit Security Health Plan s online provider portal > login with your username and password; under NEW from Security Health Plan, then nnouncements 6-10 n 10/10

11 Coordination of enefits Coordination of benefits is the determination of whether Security Health Plan is the primary or secondary payer on claims submitted for dvocare members. Coordination of enefit Rules: Who Pays First If the member is age 65 or older and has coverage under an employer group health plan either through his/her current employment or the employment of a spouse, that coverage pays before Security Health Plan. This rule applies to the health plans of employers with 20 or more employees. If the member is under age 65 and entitled to Medicare due to a disability (other than end stage renal disease), is an dvocare member, and has group health coverage under an employer with 2 99 employees, either through his/her own employment or the employment of a family member, Security Health Plan pays first. The group health coverage will pay first if the employer has 100 or more employees. If the member is eligible for Medicare solely on the basis of end stage renal disease (ESRD) and is covered under an employer group health plan, Security Health Plan pays secondary for the first 30 months with the employer plan paying primary. Workers Compensation, for treatment of a work-related sickness or injury or veterans benefits for treatment of service-connected disability, will be primary. Security Health Plan will follow the same guidelines as Medicare. Subrogation If a third-party is potentially responsible, Security Health Plan will pay claims first according to benefits available, then will pursue subrogation against the responsible person, insurer, or organization. ll claims for Security Health Plan s dvocare members should be submitted to Security Health Plan n 10/10