Provider Billing Manual

Transcription

1 Fidelis SecureLife Medicare-Medicaid Plan (MMP) Provider Billing Manual 1 P a g e

2 BILLING MANUAL TABLE OF CONTENTS INTRODUCTORY BILLING INFORMATION 5 BILLING INSTRUCTIONS 5 GENERAL BILLING GUIDELINES 5 CLAIM FORMS 6 BILLING CODES 6 CPT CATEGORY II CODES 6 ENCOUNTERS VS CLAIM 6 BILLING GUIDELINES FOR ATYPICAL PROVIDER PROVIDERS 7 CLEAN CLAIM DEFINITION 8 NON-CLEAN CLAIM DEFINITION 8 REJECTION VERSUS DENIAL 8 CLAIM PAYMENT 8 CONTACT INFORMATION 9 CLAIMS PAYMENT INFORMATION 10 SYSTEMS USED TO PAY CLAIMS 10 CLAIMS FOR WAIVER AND SUPPORTIVE LIVING FACILITIES 10 CLAIMS FOR LONG TERM CARE FACILITIES 10 PATIENT CREDIT FILE FOR LONG TERM CARE FACILITIES 11 ELECTRONIC CLAIMS SUBMISSION 11 PAPER CLAIM SUBMISSION 11.BASIC GUIDELINES FOR COMPLETING THE CMS-1500 CLAIM FORM 12 ELECTRONIC FUNDS TRANSFERS (EFT) AND ELECTRONIC REMITTANCE ADVICES (ERA) 12 COMMON CAUSES OF CLAIMS PROCESSING DELAYS AND DENIALS 13 2 P a g e

3 COMMON CAUSES OF UP FRONT REJECTIONS 13 CLIA ACCREDITATION 14 HOW TO SUBMIT A CLIA CLAIM 14 CLAIM REQUESTS FOR RECONSIDERATION, CLAIMS DISPUTES AND CORRECTED CLAIMS 15 PROVIDER REFUNDS 16 THIRD PARTY LIABILITY / COORDINATION OF BENEFITS 16 BILLING THE MEMBER / MEMBER ACKNOWLEDGEMENT STATEMENT 16 AUDITING EDITING 17 CODE AUDITING 17 CODE EDITING ASSISTANT 21 BILLING RULES AND TIPS 23 HEALTH CARE ACQUIRED CONDITIONS (HCAC) INPATIENT HOSPITAL 23 REPORTING AND NON PAYMENT FOR PROVIDER PREVENTABLE CONDITIONS (PPCS) 23 NON-PAYMENT AND REPORTING REQUIREMENTS PROVIDER PREVENTABLE CONDITIONS 23 (PPCS)- INPATIENT OTHER PROVIDER PREVENTABLE CONDITIONS (OPPCS) OUTPATIENT 23 NON-PAYMENT AND REPORTING REQUIREMENTS OTHER PROVIDER PREVENTABLE 23 CONDITIONS (OPPCS) OUTPATIENT LESSER OF LANGUAGE 24 TIMELY FILING 24 USE OF ASSISTANT SURGEONS 24 APPEALS 24 APPENDICES APPENDIX I: COMMON HIPAA COMPLIANT EDI REJECTION CODES 28 3 P a g e

4 APPENDIX II: INSTRUCTIONS FOR SUPPLEMENTAL INFORMATION 30 APPENDIX III: INSTRUCTIONS FOR SUBMITTING NDC INFORMATION 32 APPENDIX IV: CLAIMS FORM INSTRUCTIONS CMS APPENDIX V CLAIMS FORM INSTRUCTONS UB 47 4 P a g e

5 INTRODUCTORY BILLING INFORMATION BILLING INSTRUCTIONS Fidelis Secure Care of Michigan follows CMS rules and regulations for billing and reimbursement. GENERAL BILLING GUIDELINES Physicians, other licensed health professionals, facilities, and ancillary provider s contract directly with Fidelis SecureCare for payment of covered services. It is important that providers ensure Fidelis SecureCare has accurate billing information on file. Please confirm with our Provider Relations department that the following information is current in our files: Provider name (as noted on current W-9 form) National Provider Identifier (NPI) Tax Identification Number (TIN) Taxonomy code Physical location address (as noted on current W-9 form) Billing name and address Providers must bill with their NPI number in box 24Jb. We encourage our providers to also bill their taxonomy code in box 24Ja to avoid possible delays in processing. Claims missing the required data will be returned, and a notice sent to the provider, creating payment delays. Such claims are not considered clean and therefore cannot be accepted into our system. We recommend that providers notify Fidelis SecureCare 30 days in advance of changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a Provider s TIN and/or address are NOT acceptable when conveyed via a claim form. Claims eligible for payment must meet the following requirements: The member must be effective on the date of service (see information below on identifying the member) The service provided must be a covered benefit under the member s contract on the date of service, and Referral and prior authorization processes must be followed, if applicable Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual. When submitting your claim, you need to identify the member. There are two ways to identify the member: The Fidelis SecureCare member number found on the member ID card or the provider portal. The Medicaid Number provided by the found on the member ID card or the provider portal. 5 P a g e

6 CLAIM FORMS Fidelis SecureCare only accepts the CMS 1500 (8/05) and CMS 1450 (UB-04) paper claim forms. Other claim form types will be rejected and returned to the provider. Professional providers and medical suppliers complete the CMS 1500 (8/05) form and institutional providers complete the CMS 1450 (UB-04) claim form. Fidelis SecureCare does not supply claim forms to providers. Providers should purchase these from a supplier of their choice. It is preferred that all paper claim forms be typed or printed and in the original red and white version to ensure clean acceptance and processing. If the form is hand-written, the information must be clear, must be written in black or blue ink and all data must be within the pre-determined lines/boxes on the form. If you have questions regarding what type of form to complete, contact Fidelis SecureCare at BILLING CODES Fidelis SecureCare requires claims to be submitted using codes from the current version of ICD-9-CM, ICD-10, ASA, DRG, CPT4, and HCPCS Level II for the date the service was rendered. These requirements may be amended to comply with federal and state regulations as necessary. Below are some code related reasons a claim may reject or deny: Code billed is missing, invalid, or deleted at the time of service Code is inappropriate for the age or sex of the member Diagnosis code is missing the 4th or 5th digit as appropriate Procedure code is pointing to a diagnosis that is not appropriate to be billed as primary Code billed is inappropriate for the location or specialty billed Code billed is a part of a more comprehensive code billed on same date of service Written descriptions, itemized statements, and invoices may be required for non-specific types of claims or at the request of Fidelis SecureCare. CPT CATEGORY II CODES CPT Category II Codes are supplemental tracking codes developed to assist in the collection and reporting of information regarding performance measurement, including HEDIS. Submission of CPT Category II Codes allows data to be captured at the time of service and may reduce the need for retrospective medical record review. Uses of these codes are optional and are not required for correct coding. They may not be used as a substitute for Category I codes. However, as noted above, submission of these codes can minimize the administrative burden on providers and health plans by greatly decreasing the need for medical record review. ENCOUNTERS VS CLAIM An encounter is a claim which is paid at zero dollars as a result of the provider being pre-paid or capitated for the services he/she provided our members. For example; if you are the PCP for a Fidelis SecureCare member and receive a monthly capitation amount for services, you must file an encounter (also referred to as an proxy claim ) on a CMS 1500 for each service provided. Since you will have received a pre-payment in the form of capitation, the encounter or proxy claim is paid at zero dollar amounts. It is mandatory that your office submits encounter data. Fidelis SecureCare utilizes the 6 P a g e

7 encounter reporting to evaluate all aspects of quality and utilization management, and it is required by HFS and by the Centers for Medicare and Medicaid Services (CMS). Encounters do not generate an EOP. A claim is a request for reimbursement either electronically or by paper for any medical service. A claim must be filed on the proper form, such as CMS 1500 or UB 04. A claim will be paid or denied with an explanation for the denial. For each claim processed, an EOP will be mailed to the provider who submitted the original claim. Claims will generate an EOP. You are required to submit either an encounter or a claim for each service that you render to a Fidelis SecureCare member. BILLING GUIDELINES FOR A-TYPICAL PROVIDERS Through Fidelis SecureCare s waiver services program, a variety of atypical providers contract directly with Fidelis SecureCare for payment of covered services. Atypical providers may include adult day service, home/car adaptations, day habilitation, homemaker services, home delivered meals, personal emergency response systems, respite, specialized medical equipment and supplies and supportive living facilities (SLFs). It is important that providers ensure Fidelis SecureCare has accurate billing information on file. Please confirm with our Provider Relations department that the following information is current in our files: Provider name (as noted on current W-9 form) Tax Identification Number (TIN) Physical location address (as noted on current W-9 form) Billing name and address Claims missing the required data will be returned, and a notice sent to the provider, creating payment delays. Such claims are not considered clean and therefore cannot be accepted into our system. We recommend that providers notify Fidelis SecureCare 30 days in advance of changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a Provider s TIN and/or address are NOT acceptable when conveyed via a claim form. Claims eligible for payment must meet the following requirements: The member must be effective on the date of service The service provided must be a covered benefit under the member s contract on the date of service, and Prior authorization processes must be followed Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual. 7 P a g e

8 CLEAN CLAIM DEFINITION A clean claim means a claim received by Fidelis SecureCare for adjudication, in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider of the services in order to be processed and paid by Fidelis SecureCare. NON-CLEAN CLAIM DEFINITION Non-clean claims are submitted claims that require further documentation or development beyond the information contained therein. The errors or omissions in claims result in the request for additional information from the provider or other external sources to resolve or correct data omitted from the bill; review of additional medical records; or the need for other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues regarding medical necessity and include claims not submitted within the filing deadlines. REJECTION VERSUS DENIAL All paper claims sent to the claims office must first pass specific minimum edits prior to acceptance. Claim records that do not pass these minimum edits are invalid and will be rejected or denied. REJECTION: A list of common upfront rejections can be found listed in Appendix I. Rejections will not enter our claims adjudication system, so there will be no Explanation. A REJECTION is defined as an unclean claim that contains invalid or missing data elements required for acceptance of the claim into the claim processing system. The provider will receive a letter or a rejection report if the claim was submitted electronically. DENIAL: If all minimum edits pass and the claim is accepted, it will then be entered into the system for processing. A DENIAL is defined as a claim that has passed minimum edits and is entered into the system, however has been billed with invalid or inappropriate information causing the claim to deny. An EOP will be sent that includes the denial reason. A comprehensive list of common delays and denials can be found below. CLAIM PAYMENT Clean claims will be adjudicated (finalized as paid or denied) at the following levels: 90% within 30 business days of the receipt 99% within 90 business days of the receipt 8 P a g e

9 Contact Information Plan Address / Administrative Office Fidelis SecureCare, Inc. 800 Tower Road, Suite 200, Troy, MI Phone: Fax: Provider/Enrollee Services: Claims Submission Address Fidelis Customer Service: Fidelis SecureCare of Michigan Attn: Claims P.O. Box 3060 Farmington, MO (TTY users should call 711). Open Monday through Friday from 8:00 AM to 8:00 PM. 9 P a g e

10 CLAIMS PAYMENT INFORMATION SYSTEMS USED TO PAY CLAIMS Fidelis SecureCare uses three main systems to process reimbursement on a claim. Those systems are: Amisys DST Pricer Rate Manager AMISYS Our core system; All claims are processed from this system and structures are maintained to meet the needs of our provider contracts. However, we are not limited within the bounds of this one system. We utilize multiple systems to expand our universe of possibilities and better meet the needs of our business partners. DST PRICER The DST Pricer is a system outside our core system where we have some flexibility on addressing your contractual needs. It allows us to be more responsive to the market demands. It houses both Fee Schedules and procedure codes and mirrors our Amisys system, but with a more attention to detail. RATE MANAGER Rate Manager s primary function is to price Facility claims. It can price inpatient DRG or Outpatient APC. Inpatient claims are based on the type of DRG and the version. Each Hospital in the country is assigned a base rate and add-ons by Medicaid and Medicare based on state or federal guidelines. The add-ons include Education, Burn per diem, Capital etc. The basic DRG calculation is: Hospital Base Rate x DRG Relative weight + Add-ons The payment can be effected by discharge status, length of stay and other allowed charges. Outpatient facilities claims are based on APC. APC stands for Ambulatory Payment Classification system. This is a prospective payment system for outpatient services based on HCPCS and CPT codes. APCs are groups or CPT/HCPCS which make up groups of common types of services or delivery methods... Weights are assigned like with DRGs, but unlike DRGs, more than one APC can be assigned per claim. CLAIMS FOR WAIVER SERVICES AND SUPPORTIVE LIVING FACILITIES Atypical providers, excluding Home Health, and supportive living facilities will be required to submit claims to Fidelis SecureCare on a CMS 1500 form. This can be done through our secure provider portal or via submission of paper claims. Instructions for our online secure provider portal are available on our website at (Note: Per CMS guidelines, Home Health must submit on a UB) CLAIMS FOR LONG TERM CARE FACILITIES Long Term Care facilities are required to bill on a UB-04 claim form. Both short term acute stays and 10 P a g e

11 custodial care are covered benefits. When submitting claims for short term sub-acute stays, facilities must ensure they are utilizing the appropriate revenue codes reflecting the short term stay. PATIENT CREDIT FILE FOR LONG TERM CARE FACILITIES In order for Long Term Care facility claims to be processed, the member the facility is billing for must be on the Patient Credit File. This file is provided by the Michigan Department of Health and Human Services and shows the amount the member needs to pay for residing in the facility. In certain instances, there can be a delay in the member appearing on the Patient Credit File. As a result, some LTC facility claims may be denied. A specific code, call an Explanation Code or an EX code will display on the denied claim that reads DENY: Mbr not currently on PT Credit File will reconsider once on file. Fidelis SecureCare has put a process in place to ease the administrative burden of long term care facilities in these instances. Each month when the Patient Credit File is received, Fidelis SecureCare will check each member on the file against any previously denied claims. If there are claims that have been denied as a result of the member not appearing on the Patient Credit File, and all other necessary information is included in the claim, Fidelis SecureCare will process and pay the previously denied claim. It is important to note, that LTC providers must still submit claims within 180 days. ELECTRONIC CLAIMS SUBMISSION Network providers are encouraged to participate in Fidelis SecureCare s electronic claims/encounter filing program. Fidelis SecureCare can receive ANSI X12N 837 professional, institution or encounter transactions. In addition, it can generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). Providers that bill electronically have the same timely filing requirements as providers filing paper claims. In addition, providers that bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters. Fidelis SecureCare s Payor ID is Our Clearinghouse vendors include Emdeon, Envoy, WebMD, and Gateway EDI. Please visit our website for our electronic Companion Guide which offers more instructions. For questions or more information on electronic filing please contact: FIDELIS SECURECARE C/O CENTENE EDI DEPARTMENT , extension Or by at EDIBA@centene.com PAPER CLAIM SUBMISSION For Fidelis SecureCare members, all claims and encounters should be submitted to: FIDELIS SECURECARE ATTN: CLAIMS DEPARTMENT Box 3060 Farmington, MO P a g e

12 REQUIREMENTS Fidelis SecureCare uses an imaging process for paper claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules: Do s Do use the correct P.O. Box number Do submit all claims in a 9 x 12 or larger envelope Do type all fields completely and correctly Do use typed black or blue ink only at 9-point font or larger Do include all other insurance information (policy holder, carrier name, ID number and address) when applicable Do attach the EOP from the primary insurance carrier when applicable Note: Fidelis SecureCare is able to receive primary insurance carrier EOP [electronically] Do submit on a proper original form - CMS 1500 or UB 04 Don ts Don t submit handwritten claim forms Don t use red ink on claim forms Don t circle any data on claim forms Don t add extraneous information to any claim form field Don t use highlighter on any claim form field Don t submit photocopied claim forms (no black and white claim forms) Don t submit carbon copied claim forms Don t submit claim forms via fax.basic GUIDELINES FOR COMPLETING THE CMS-1500 CLAIM FORM (DETAILED INSTRUCTIONS IN APPENDIX): Use one claim form for each member. Enter one procedure code and date of service per claim line. Enter information with a typewriter or a computer using black type. Enter information within the allotted spaces. Make sure whiteout is not used on the claim form. Complete the form using the specific procedure or billing code for the service. Use the same claim form for all services provided for the same recipient, same provider, and same date of service. If dates of service encompass more than one month, a separate billing form must be used for each month. ELECTRONIC FUNDS TRANSFERS (EFT) AND ELECTRONIC REMITTANCE ADVICES (ERA) Fidelis SecureCare provides Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) to its participating providers to help them reduce costs, speed secondary billings, and improve cash flow by enabling online access of remittance information, and straight forward reconciliation of payments. As a Provider, you can gain the following benefits from using EFT and ERA: 1. Reduce accounting expenses Electronic remittance advices can be imported directly into practice management or patient accounting systems, eliminating the need for manual re- 12 P a g e

13 keying 2. Improve cash flow Electronic payments mean faster payments, leading to improvements in cash flow 3. Maintain control over bank accounts You keep TOTAL control over the destination of claim payment funds and multiple practices and accounts are supported 4. Match payments to advices quickly You can associate electronic payments with electronic remittance advices quickly and easily For more information on our EFT and ERA services, please contact our Provider Services Department at COMMON CAUSES OF CLAIMS PROCESSING DELAYS AND DENIALS Incorrect Form Type Diagnosis Code Missing Digits Missing or Invalid Procedure or Modifier Codes Missing or Invalid DRG Code Explanation of Benefits from the Primary Carrier is Missing or Incomplete Invalid Member ID Invalid Place of Service Code Provider TIN and NPI Do Not Match Invalid Revenue Code Dates of Service Span Do Not Match Listed Days/Units Missing Physician Signature Invalid TIN Missing or Incomplete Third Party Liability Information Fidelis SecureCare will send providers written notification via the EOP for each claim that is denied, which will include the reason(s) for the denial. COMMON CAUSES OF UP FRONT REJECTIONS Unreadable Information Missing Member Date of Birth Missing Member Name or Identification Number Missing Provider Name, Tax ID, or NPI Number The Date of Service on the Claim is Not Prior to Receipt Date of the Claim Dates Are Missing from Required Fields Invalid or Missing Type of Bill Missing, Invalid or Incomplete Diagnosis Code Missing Service Line Detail Member Not Effective on The Date of Service Admission Type is Missing Missing Patient Status Missing or Invalid Occurrence Code or Date Missing or Invalid Revenue Code Missing or Invalid CPT/Procedure Code 13 P a g e

14 Incorrect Form Type Fidelis SecureCare will send providers a detailed letter for each claim that is rejected explaining the reason for the rejection. CLIA ACCREDITATION Labs who participate in the Medicare or Medicaid sector with Fidelis SecureCare must be CLIA accredited. Requirements for laboratory accreditation are contained in the Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB) located at the following link: HOW TO SUBMIT A CLIA CLAIM Via Paper Complete Box 23 of a CMS-1500 form with CLIA certification or waiver number as the prior authorization number for those laboratory services for which CLIA certification or waiver is required. *Note - An independent clinical laboratory that elects to file a paper claim form shall file Form CMS for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90. An independent clinical laboratory that submits claims in paper format may not combine non-referred (i.e., self-performed) and referred services on the same CMS claim form. When the referring laboratory bills for both non-referred and referred tests, it shall submit two separate claims, one claim for non-referred tests, the other for referred tests. If billing for services that have been referred to more than one laboratory, the referring laboratory shall submit a separate claim for each laboratory to which services were referred (unless one or more of the reference laboratories are separately billing). When the referring laboratory is the billing laboratory, the reference laboratory s name, address, and ZIP Code shall be reported in item 32 on the CMS-1500 claim form to show where the service (test) was actually performed. The NPI shall be reported in item 32a. Also, the CLIA certification or waiver number of the reference laboratory shall be reported in item 23 on the CMS-1500 claim form. Via EDI If a single claim is submitted for those laboratory services for which CLIA certification or waiver is required, report the CLIA certification or waiver number in: X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4 -Or- If a claim is submitted with both laboratory services for which CLIA certification or waiver is required and non-clia covered laboratory test, in the 2400 loop for the appropriate line report the CLIA certification or waiver number in: X12N 837 (HIPAA version) loop 2400, REF02. REF01 = X4 *Note - The billing laboratory submits, on the same claim, tests referred to another (referral/rendered) laboratory, with modifier 90 reported on the line item and reports the referral laboratory s CLIA certification or waiver number in: X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4. When the referring laboratory is the billing laboratory, the reference laboratory s name, NPI, address, and Zip Code shall be reported in loop 2310C. The 2420C loop is required if different then information provided in loop 2310C. The 2420C would contain Laboratory name and NPI. Via Web 14 P a g e

15 Complete Box 23 with CLIA certification or waiver number as the prior authorization number for those laboratory services for which CLIA certification or waiver is required. *Note - An independent clinical laboratory that elects to file a paper claim form shall file Form CMS for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90. An independent clinical laboratory that submits claims in paper format may not combine non-referred (i.e., self-performed) and referred services on the same CMS claim form. When the referring laboratory bills for both non-referred and referred tests, it shall submit two separate claims, one claim for non-referred tests, the other for referred tests. If billing for services that have been referred to more than one laboratory, the referring laboratory shall submit a separate claim for each laboratory to which services were referred (unless one or more of the reference laboratories are separately billing). When the referring laboratory is the billing laboratory, the reference laboratory s name, address, and ZIP Code shall be reported in item 32 on the CMS-1500 claim form to show where the service (test) was actually performed. The NPI shall be reported in item 32a. Also, the CLIA certification or waiver number of the reference laboratory shall be reported in item 23 on the CMS-1500 claim form. CLAIM REQUESTS FOR RECONSIDERATION, CLAIM DISPUTES AND CORRECTED CLAIMS All claim requests for reconsideration, corrected claims or claim disputes must be received within 45 calendar days from the date of the Explanation of Payment (EOP). If a provider has a question or is not satisfied with the information they have received related to a claim, there are four (4) effective ways in which the provider can contact Fidelis SecureCare. 1. Contact a Fidelis SecureCare Customer Service Representative at Providers may discuss questions with Fidelis SecureCare Customer Services Representatives regarding amount reimbursed or denial of a particular service. 2. Submit an Adjusted or Corrected Claim to Fidelis SecureCare, Attn: Corrected Claim, PO Box 3060, Farmington MO The claim must clearly be marked as RE-SUBMISSION and must include the original claim number or the original EOP must be included with the resubmission. Failure to mark the claim as a resubmission and include the original claim number (or include the EOP) may result in the claim being denied as a duplicate, a delay in the reprocessing, or denial for exceeding the timely filing limit. 3. Submit a Request for Reconsideration to Fidelis SecureCare, Attn: Reconsideration, PO Box 3060, Farmington MO A request for reconsideration is a written communication from the provider about a disagreement in the way a claim was processed but does not require a claim to be corrected and does not require medical review. The request must include sufficient identifying information which includes, at minimum, the patient name, patient ID number, date of service, total charges and provider name. The documentation must also include a detailed description of the reason for the request. 4. Submit a Claim Dispute Form to Fidelis SecureCare, Attn: Dispute, PO Box 3060, Farmington MO A claim dispute is to be used only when a provider has received an unsatisfactory response to a request for reconsideration. The Claim Dispute Form can be found in the provider section of our website at If the claim dispute results in an adjusted claim, the provider will receive a revised EOP. If the original decision is upheld, the provider will receive a revised EOP or a letter detailing the decision and steps for escalated reconsideration. 15 P a g e

16 Fidelis SecureCare shall process, and finalize all adjusted claims, requests for reconsideration and disputed claims to a paid or denied status 45 business days of receipt of the corrected claim, request for reconsideration or claim dispute. PROVIDER REFUNDS When a provider sends a refund for claims processed, the refund must be sent to the following address: Fidelis SecureCare Collections Center Drive Chicago, IL THIRD PARTY LIABILITY / COORDINATION OF BENEFITS Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance, and worker s compensation) or program that is or may be liable to pay all or part of the healthcare expenses of the member. Any other insurance, including Medicare, is always primary to Medicaid coverage. Fidelis SecureCare, like all Medicaid programs, is always the payer of last resort. Fidelis SecureCare providers shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to Fidelis SecureCare members. If a member has other insurance that is primary, you must submit your claim to the primary insurance for consideration, and submit a copy of the Explanation of Benefits (EOB) or Explanation of Payment (EOP), or rejection letter from the other insurance when the claim is filed. If this information is not sent with an initial claim filed for a Member with insurance primary to Medicaid, the claim will pend and/or deny until this information is received. If a Member has more than one primary insurance (Medicaid would be the third payor), the claim cannot be submitted through EDI or the secure web portal and must be submitted on a paper claim. If the provider is unsuccessful in obtaining necessary cooperation from a member to identify potential third party resources, the provider shall inform Fidelis SecureCare that efforts have been unsuccessful. Fidelis SecureCare will make every effort to work with the provider to determine liability coverage. If third party liability coverage is determined after services are rendered, Fidelis SecureCare will coordinate with the provider to pay any claims that may have been denied for payment due to third party liability. BILLING THE MEMBER / MEMBER ACKNOWLEDGEMENT STATEMENT Fidelis SecureCare reimburses only services that are medically necessary and covered through the Fidelis SecureCare program. Providers are not allowed to balance bill for covered services if the provider s usually and customary charge for covered services is greater than our fee schedule. Providers may bill members for services NOT covered by either Medicaid or Fidelis SecureCare or for applicable copayments, deductibles or coinsurance as defined by the State of Michigan. In order for a provider to bill a member for services not covered under the Fidelis SecureCare program, or if the service limitations have been exceeded, the provider must obtain a written acknowledgment. 16 P a g e

17 AUDITING - EDITING CODE AUDITING Fidelis SecureCare uses code-auditing software to assist us in improving accuracy and efficiency in claims processing, payment and reporting and to meet HIPAA compliance. The code-auditing software will detect, correct, and document coding errors on Provider claims, prior to payment. The code editing software contains a comprehensive set of rules addressing coding inaccuracies such as unbundling, fragmentation, up-coding, duplication, invalid codes, and mutually exclusive procedures. The software offers a wide variety of edits that are based on: American Medical Association (AMA) the software utilizes the CPT Manuals, CPT Assistant, CPT Insider s View, the AMA web site, and other sources. Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) which includes column 1/column 2, mutually exclusive and outpatient code editor (OCE edits). In addition to using the AMA s CPT manual, the NCCI coding policies are based on national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. o o Medicaid NCCI edits: Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html Medicare NCCI edits: =/NationalCorrectCodInitEd/ Public-domain specialty society guidance (i.e., American College of Surgeons, American College of Radiology, American Academy of Orthopedic Surgeons). Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario. In addition to nationally-recognized coding guidelines, the software has added flexibility to its rule engine to allow business rules that are unique to the needs of individual product lines. In order to maintain its high standard of clinical accuracy, credibility and physician acceptance, our code-auditing software is updated regularly to keep current with medical practice, coding practices, annual changes to the CPT Manual and other industry standards. Fidelis SecureCare conducts regular reviews to focus on the annual changes to the CPT Manual and the specialty sections of the CPT Manual. When a change is made on your submitted code(s), we will provide a general explanation of the reason for the change on your Explanation of Payment (or remittance advice). The following list gives examples of conditions where code-auditing software will make a change on submitted codes: Unbundling - Identifies Services That Have Been Unbundled Example: Unbundling lab panels. If component lab codes are billed on a claim along with a more comprehensive lab panel code that more accurately represents the service performed, the software will bundle the component codes into the more comprehensive panel code. The 17 P a g e

18 software will also deny multiple claim lines and replace those lines with a single, more comprehensive panel code when the panel code is not already present on the claim. Code Description Status Comprehensive Metabolic Panel Disallow Complete CBC, automated and automated & automated differential WBC count Disallow Thyroid Stimulating Hormone Disallow General Health Panel Allow Explanation: 80053, and are included in the lab panel code and therefore are not separately reimbursable. Those claim lines containing the component codes are denied and only the comprehensive lab panel code is reimbursed. Fragmentation - Billing all incidental codes or itemizing the components of procedures separately when a more comprehensive code is available. Age/Gender - Submitting codes inappropriate for the Member s age or gender because of the nature of the procedure. Bilateral Surgery Identical Procedures Performed on Bilateral Anatomical Sites during Same Operative Session: Example: Fidelis SecureCare may request medical records or other documentation to assist in the determination of medical necessity, appropriateness of the coding submitted, or review of the procedure billed. Code Description Status Radiologic exam, spine, entire, survey study, anteroposterior & lateral Allow Radiologic exam, spine, entire, survey study, anteroposterior & lateral Disallow Explanation: Procedure includes radiologic examination of the lateral and anteroposterior views of the entire spine that allow views of the upper cervical vertebrae, the lower cervical vertebrae, the thoracic vertebrae, the lumbar vertebrae, the sacrum, and the coccyx. It is clinically unlikely that this procedure would be performed twice on the same date of service. Evaluation and Management Services (E/M) Submission of E/M Service Either Within a Global Surgery Period or on the Same Date of Service as Another E/M Service: Global Surgery: Procedures that are assigned a 90-day global surgery period are designated as major surgical procedures; those assigned a 10-day or 0-day global surgery period are designated as minor surgical procedures. Evaluation and management services, submitted with major surgical procedures (90-day) and minor surgical procedures (10-day), are not recommended for separate reporting because they are part of the global service. Evaluation and management services, submitted with minor surgical procedures (0-day), are not recommended for separate reporting or reimbursement because these services are part of the global service unless the service is a service listed on the state Fee Schedule with an asterisk. 18 P a g e

19 Example Global Surgery Period Code Description Status Arthroplasty, knee, condoyle and plateau; medial and lateral compartments with Allow DOS 05/20/09 or without patella resurfacing (total knee arthroplasty) DOS 06/02/09 Office or other outpatient visit for the evaluation and management of an EST patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling & coordination of care w/other providers or agencies are provided consistent w/nature of problem(s) & patient's &/or family's needs. Problem(s) are low/moderate severity. Physicians spend 15 minutes face-to-face w/patient &/or family. Disallow Explanation: Procedure code has a global surgery period of 90 days. Procedure code is submitted with a date of service that is within the 90-day global period. When a substantial diagnostic or therapeutic procedure is performed, the evaluation and management service is included in the global surgical period. E/M with Minor Surgical Procedure - When a minor procedure is performed, the evaluation and management service is considered part of the global service. Example E/M with Minor Surgical Procedure Code Description Status Debridement of extensive eczematous or infected skin; up to 10% of body Allow DOS 01/23/10 surface DOS 01/23/10 Office or other outpatient visit for the evaluation and management of an EST patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent w/ nature of problem(s) and patient's and/or family's needs. Problem(s) are low/moderate severity. Physicians spend 15 minutes face-to-face with patient and/or family. Disallow Explanation: Procedure (0-day global surgery period) is identified as a minor procedure. Procedure is submitted with the same date of service. Therefore it is consider part of the global service Same Date of Service - One evaluation and management service is recommended for reporting on a single date of service. Example: Same Date of Service 19 P a g e

20 Code Description Status Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent w/ nature of problem(s) and patient's and/or family's needs. Usually, problem(s) are moderate/high severity. Physicians spend 40 minutes face-to-face with patient and/or family. Allow Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling/coordination of care with other providers oragencies are provided consistent with nature of problem(s) and patient's/family's needs. Presenting problem(s) are low severity. Physicians spend 30 minutes face-to-face with patient/family. Disallow Explanation: Procedure is used to report an evaluation and management service provided to an established patient during a visit. Procedure is used to report an office consultation for a new or established patient. Separate reporting of an evaluation and management service with an office consultation by a single provider indicates a duplicate submission of services. Interventions, provided during an evaluation and management service, typically include the components of an office consultation Modifiers Codes Added to the Main Procedure Code to Indicate the Service Has Been Altered by a Specific Circumstance: NOTE: Modifier -24 is used to report an unrelated evaluation and management service by the same physician during a post-operative period. Modifier -25 is used to report a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure. Modifier -79 is used to report an unrelated procedure or service by the same physician during the post-operative period. When modifiers -24 and -25 are submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, the evaluation and management service is questioned and a review of additional information is recommended. When modifier -79 is submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, separate reporting of the evaluation and management service is recommended. Modifier -26 (professional component) 20 P a g e

21 Definition: Modifier -26 identifies the professional component of a test or study. If modifier - 26 is not valid for the submitted procedure code, the procedure code is not recommended for separate reporting. When a claim line is submitted without the modifier -26 in a facility setting (for example, POS 21, 22, 23, 24), the rule will replace the service line with a new line with the same procedure code and the modifier -26 appended. Example Code Description Status Acute gastrointestinal blood loss imaging Disallow POS = Inpatient POS = Inpatient Acute gastrointestinal blood loss imaging Allow Explanation: Procedure code is valid with modifier -26. Modifier -26 will be added to procedure code when submitted without modifier -26. Modifier -80, -81, -82, and -AS (assistant surgeon) Definition: This edit identifies claim lines containing procedure codes billed with an assistant surgeon modifier that typically do not require an assistant surgeon. Many surgical procedures require aid in prepping and draping the patient, monitoring visualization, keeping the wound clear of blood, holding and positioning the patient, and assisting with wound closure and/or casting (if required). This assistance does not require the expertise of a surgeon. A qualified nurse, orthopedic technician, or resident physician can provide the necessary assistance. Example Code Description Status Tonsillectomy and adenoidectomy; under age 12 Disallow Explanation: Procedure code is not recommended for Assistant Surgeon reporting because a skilled nurse or surgical technician can function as the assistant in the performance this procedure. CODE EDITING ASSISTANT A web-based code auditing reference tool designed to mirror how code auditing product(s) evaluate code combinations during the auditing of claims is available for participating providers via the secure provider portal. This allows Fidelis SecureCare to share with Providers the rationale we use to pay claims. You can access the tool in the Claims Module by clicking Claim Auditing Tool. This tool offers many benefits: Prospectively access the appropriate coding and supporting clinical edit clarifications for services before claims are submitted 21 P a g e

22 Proactively determine the appropriate code/code combination representing the service for accurate billing purposes The tool will review what was entered and will determine if the code or code combinations are correct based on the age, sex, location, modifier (if applicable), or other code(s) entered. The Code Editing Assistant is intended for use as a what if or hypothetical reference tool. It is meant to apply coding logic only. The tool does not take into consideration historical claims information which may have been used to determine an edit. The tool assumes all CPT codes are billed on a single claim. The tool will not take into consideration individual fee schedule reimbursement, authorization requirements or other coverage considerations. 22 P a g e

23 BILLING RULES AND TIPS HEALTH CARE ACQUIRED CONDITIONS (HCAC) INPATIENT HOSPITAL Fidelis SecureCare follows Medicare s policy on reporting Present on Admission (POA) indicators on inpatient hospital claims and non-payment for HCACs. Acute care hospitals and Critical Access Hospitals (CAHs) are required to report whether a diagnosis on a Medicaid claim is present on admission. Claims submitted without the required POA indicators are denied. For claims containing secondary diagnoses that are included on Medicare s most recent list of HCACs and for which the condition was not present on admission, the HCAC secondary diagnosis is not used for DRG grouping. That is, the claim is paid as though any secondary diagnoses (HCAC) were not present on the claim. POA is defined as "present" at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered Present on Admission. A POA indicator must be assigned to principal and secondary diagnoses. Providers should refer to the CMS Medicare website for the most up to date POA reporting instructions and list of HCACs ineligible for payment. REPORTING AND NON PAYMENT FOR PROVIDER PREVENTABLE CONDITIONS (PPCS) Provider Preventable Conditions (PPCs) addresses both hospital and non-hospital conditions identified by Fidelis SecureCare for non-payment. PPCs are defined as Health Care Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs). Medicaid providers are required to report the occurrence of a PPC and are prohibited from payment. NON-PAYMENT AND REPORTING REQUIREMENTS PROVIDER PREVENTABLE CONDITIONS (PPCS) - INPATIENT Fidelis SecureCare follows the Medicare billing guidelines on how to bill a no-pay claim, reporting the appropriate Type of Bill (TOB 110) when the surgery/procedure related to the NCDs service/procedure (as a PPC) is reported. If covered services/procedures are also provided during the same stay, Fidelis SecureCare follows Medicare s billing guidelines requiring hospitals submit two claims: one claim with covered services, and the other claim with the non-covered services/procedures as a non-pay claim. Inpatient hospitals must appropriately report one of the designated ICD diagnosis codes for the PPC on the no-pay TOB claim. Fidelis SecureCare follows the Medicare billing guidelines on how to bill a nopay claim, reporting the appropriate Type of Bill (TOB 110) when the surgery/procedure related to the NDC service/procedure (as a PPC) is reported. OTHER PROVIDER PREVENTABLE CONDITIONS (OPPCS) OUTPATIENT Medicaid follows the Medicare guidelines and national coverage determinations (NCDs), including the list of HAC conditions, diagnosis codes and OPPCs. Conditions currently identified by CMS include: Wrong surgical or other invasive procedure performed on a patient; Surgical or other invasive surgery performed on the wrong body part; and Surgical or other invasive procedure performed on the wrong patient. NON-PAYMENT AND REPORTING REQUIREMENTS OTHER PROVIDER PREVENTABLE CONDITIONS (OPPCS) OUTPATIENT Medicaid follows the Medicare guidelines and NCDs, including the list of HAC conditions, diagnosis 23 P a g e

24 codes and OPPCs. Outpatient providers must use the appropriate claim format, TOB and follow the applicable NCD/modifier(s) to all lines related to the surgery(s). LESSER OF LANGUAGE Unless specifically contracted otherwise, Fidelis SecureCare s policy is to pay the lesser of billed charges and negotiated rate. Example 1 Code Billed $600. Negotiated Rate is $500. Fidelis SecureCare pays $500 negotiated rate. Example 2 Code Billed $500. Negotiated Rate is $600. Fidelis SecureCare pays $500 billed rate. TIMELY FILING Providers must submit all claims and encounters within 180 calendar days of the date of service. The filing limit may be extended where the eligibility has been retroactively received by Fidelis SecureCare up to a maximum of 180 days. When Fidelis SecureCare is the secondary payer, claims must be received within 180 calendar days of the final determination of the primary payer. All claim requests for reconsideration, corrected claims or claim disputes must be received within 60 calendar days from the date of notification of payment or denial is issued. USE OF ASSISTANT SURGEONS An Assistant Surgeon is defined as a physician who utilizes professional skills to assist the Primary Surgeon on a specific procedure. All Assistant Surgeon s procedures are subject to retrospective review for Medical Necessity by Medical Management. All Assistant Surgeon s procedures are subject to Fidelis SecureCare policies and are not subject to policies established by contracted hospitals. Hospital medical staff bylaws that require an Assistant Surgeon be present for a designated procedure are not grounds for reimbursement. Medical staff bylaws alone do not constitute medical necessity. Nor is reimbursement guaranteed when the patient or family requests an Assistant Surgeon be present for the surgery. Coverage and subsequent reimbursement for an Assistant Surgeon s service is based on the medical necessity of the procedure itself and the Assistant Surgeon s presence at the procedure. APPEALS AND GRIEVANCES IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS There are two kinds of appeals: Internal Appeal If you don t agree with a decision we make about services or payment, you have the right to appeal. An Internal Appeal (also called a Level 1 Appeal) is the first appeal to our plan. We will review our decision and let you know what we have decided. We ll give you a written decision on a standard appeal 30 calendar days after we get your appeal. However, if you ask for more time, or if we 24 P a g e

25 need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will send you a letter that explains why we need more time. You must ask for an Internal Appeal within 60 calendar days from the date on the letter we sent to tell you our decision. Fast Appeal We ll give you a decision on a fast appeal within 72 hours after we get your appeal. We ll automatically give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we ll decide if your request requires a fast appeal. If we don t give you a fast appeal, we ll give you a decision within 30 calendar days. How to ask for an appeal with Fidelis SecureLife (MMP). Step 1: You, your representative, or your doctor must ask us for an appeal. Your written request must include: Your name Address Member number Reasons for appealing Any evidence you want us to review, such as medical records, doctor s letter, or other information that explains why you need the item or service. Call your doctor if you need this information. You can ask to see the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision. Step 2: Mail, fax, hand-deliver your appeal or call us. For an Internal Appeal: Fidelis SecureLife (MMP) ATTN: Appeals and Grievances 7700 Forsyth Blvd. St. Louis, MO Phone: (TTY: 711) Fax: Hours of operation are from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. If you ask for a standard appeal by phone, we will send you a letter confirming what you told us. For a Fast Appeal: 25 P a g e

26 Phone: (TTY: 711) Fax: Hours of operation are from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. What happens next? If you ask for an appeal and we continue to deny your request for a service or payment of a service, we ll send you a written decision and automatically send your case to an independent reviewer. If the independent reviewer denies your request, the written decision will explain if you have additional appeal rights. There are two ways to make an External Appeal for Medicaid services and items: 1) Fair Hearing and/or 2) External Review. 1) Fair Hearing You have the right to request a Fair Hearing from the Michigan Administrative Hearings System (MAHS). A Fair Hearing is an impartial review of a decision made by Fidelis SecureLife (MMP). You may request a Fair Hearing before, during, after, or instead of the Internal Appeal with Fidelis SecureLife (MMP). You must ask for a Fair Hearing within 90 calendar days from the date on the letter that told you that a Medicaid covered service was denied, reduced, or stopped. If you are asking for Fair Hearing because the plan decided to reduce or stop a service you were already getting, you must file your appeal within 12 calendar days from the date of the adverse action notice or prior to the date of action if you want your benefits for that service to continue while the appeal is pending. To ask for a Fair Hearing from MAHS, you must complete a Request for Hearing form. We will send you a Request for Hearing form with the coverage decision letter. You can also get the form by calling the Medicaid Beneficiary Help Line at (TTY: ), open Monday through Friday from 8:00 AM to 7:00 PM. Complete the form send it to: Michigan Administrative Hearing System Department of Community Health PO Box Lansing, MI FAX: You can also ask for an expedited (fast) Fair Hearing by writing to the address or faxing to the number listed above. 26 P a g e

27 After your Fair Hearing request is received by MAHS, you will get a letter telling you the date, time, and place of your hearing. Hearings are usually conducted over the phone, but you can request that your hearing be conducted in person. MAHS must give you an answer in writing within 90 calendar days of when it gets your request for a Fair Hearing. If you qualify for an expedited Fair Hearing, MAHS must give you an answer within 72 hours. However, if MAHS needs to gather more information that may help you, it can take up to 14 more calendar days. Following receipt of the MAHS final decision, you have 30 calendar days from the date of the decision to file a request for rehearing/reconsideration and/or to file an appeal with the Circuit Court. 2) External Review You also have the right to request an External Review through the Michigan Department of Insurance and Financial Services (DIFS). You must go through our Internal Appeals process first before you can ask for this type of External Appeal. Your request for an External Review must be submitted within 60 days of your receipt of our Internal Appeal decision. If you qualified for continuation of benefits during the Internal Appeal and you submit your request for an External Review within 12 calendar days from the date of the Internal Appeal decision, you can continue to receive the disputed service during the review. To ask for an External Review from DIFS, you must complete the Health Care Request for External Review form. We will send you this form with our appeal decision letter. You can also get a copy of the form by calling DIFS at Complete the form and send it with all supporting documentation to: DIFS Office of General Counsel Health Care Appeals Section PO Box Lansing, MI FAX: If your request does not involve reviewing medical records, the External Review will be conducted by the Director of DIFS. If your request involves issues of medical necessity or clinical review criteria, it will be sent to a separate Independent Review Organization (IRO). If the review is conducted by the Director and does not require review by an IRO, the Director will issue a decision within 14 calendar days after your request is accepted. If the review is referred to an IRO, the IRO will give its recommendation to DIFS within 14 calendar days after it is assigned the review. The Director will then issue a decision within 7 business days after it receives the IRO s recommendation. 27 P a g e

28 If the standard timeframe for review would jeopardize your life or health, you may be able to qualify for an expedited (fast) review. An expedited review is completed within 72 hours after your request. To qualify for an expedited review, you must have your doctor verify that the timeframe for a standard review would jeopardize your life or health. If you disagree with the External Review decision, you have the right to appeal to Circuit Court in the county where you live or the Michigan Court of Claims within 60 days from the date of the decision. For more information, or contact numbers that enrollees/physicians can use for process or status questions, please call Fidelis SecureLife (MMP) at from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.. 28 P a g e

29 APPENDIX I: COMMON HIPAA COMPLIANT EDI REJECTION CODES These codes are the standard national rejection codes for EDI submissions. All errors indicated for the code must be corrected before the claim is resubmitted. Code Description 1 Invalid Mbr DOB 2 Invalid Mbr 6 Invalid Prv 7 Invalid Mbr DOB & Prv 8 Invalid Mbr & Prv 9 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 17 Invalid Diag 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 23 Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc 43 Mbr not valid at DOS; Invalid Proc 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 74 Services performed prior to Contract Effective Date 75 Invalid units of service 29 P a g e

30 APPENDIX II: INSTRUCTIONS FOR SUPPLEMENTAL INFORMATION CMS-1500 (8/05) Form, Shaded Field 24A-G The following types of supplemental information are accepted in a shaded claim line of the CMS 1500 (8/05) form field 24A-G: Anesthesia duration Narrative description of unspecified/miscellaneous/unlisted codes National Drug Codes (NDC) for drugs Vendor Product Number Health Industry Business Communications Council (HIBCC) Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN), formerly Universal Product Code (UPC) for products The following qualifiers are to be used when reporting these services. 7 Anesthesia information ZZ Narrative description of unspecified/miscellaneous/unlisted codes N4 National Drug Codes (NDC) The following qualifiers are to be used when reporting NDC units: F2 GR ML UN OZ VP International Unit Gram Milliliter Unit Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN) Vendor Product Number- Health Industry Business Communications Council (HIBCC) Labeling Standard To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the NDC, HIBCC, or GTIN number/code. When reporting a service that does not have a qualifier, enter two blank spaces before entering the information. More than one supplemental item can be reported in a single shaded claim line IF the information is related to the un-shaded claim line item it is entered on. When entering more than one supplemental item, enter the first qualifier at the start of 24A followed by the number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the NDC, HIBCC, or GTIN number/code. After the entry of the first supplemental item, 30 P a g e

31 enter three blank spaces and then the next qualifier and number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the NDC, HIBCC, or GTIN number/code. 31 P a g e

32 APPENDIX III: INSTRUCTIONS FOR SUBMITTING NDC INFORMATION Instructions for Entering the NDC: (Use the guidelines noted below for all claim types including WebPortal submission) CMS requires the 11-digit National Drug Code (NDC), therefore, providers are required to submit claims with the exact NDC that appears on the actual product administered, which can be found on the vial of medication. The NDC must include the NDC Unit of Measure and NDC quantity/units. When reporting a drug, enter identifier N4, the eleven-digit NDC code, Unit Qualifier, and number of units from the package of the dispensed drug. 837I/837P Data Element NDC Unit of Measure Unit Price Quantity Loop Segment/Element 2410 LIN CTP CTP CTP04 For Electronic submissions, this is highly recommended and will enhance claim reporting/adjudication processes, report in the LIN segment of Loop ID Paper Claim Type Field CMS 1500 (08/05) 24 A (shaded claim line) UB Facility Paper, use Form Locator 43 of the CMS1450 and UB04 (with the corresponding HCPCS code in Locator 44) for Outpatient and Facility Dialysis Revenue Codes and Physician Paper, use the red shaded detail of 24A on the CMS1500 line detail. Do not enter a space, hyphen, or other separator between N4, the NDC code, Unit Qualifier, and number of units. The NDC must be entered with 11 digits in a digit format. The first five digits of the NDC are the manufacturer s labeler code, the middle four digits are the product code, and the last two digits are the package size. If you are given an NDC that is less than 11 digits, add the missing digits as follows: For a digit number, add a 0 to the beginning For a digit number, add a 0 as the sixth digit. For a digit number, add a 0 as the tenth digit. 32 P a g e

33 Enter the Unit Qualifier and the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. The Unit Qualifiers are: F2 - International Unit GR -Gram ML - Milliliter UN Unit 33 P a g e

34 APPENDIX IV: CLAIMS FORM INSTRUCTIONS CMS 1500 CMS 1500 (8/05) Claim Form Instructions Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. NOTE: Claims with missing or invalid Required (R) field information will be rejected or denied. 34 P a g e

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46 The CMS 1500 Form 46 P a g e

47 APPENDIX V CLAIMS FORM INSTRUCTONS UB UB-04/CMS 1450 (8/05) Claim Form Instructions Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. NOTE: Claims with missing or invalid Required (R) field information will be rejected or denied. 47 P a g e

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