1. Section Modifications

Table of Contents 1. Section Modifications... 1 2. UB04 Claim Form... 4 3. Completing the UB04... 5 3.1. Helpful Tips for Filling out a Paper Claim... 5 3.2. Claim Form Field s... 5 4. Billing Information... 12 Appendix A. Home Health Policy - Institutional... 12 Appendix B. Hospice Institutional... 14 Appendix C. Hospital... 16 C.1 Accommodation/Room enue s... 16 C.2 Special Charges... 19 C.3 Ancillary enue s... 20 C.4 Free Standing Dialysis... 36 Appendix D. Long Term Care Facility... 37 Appendix E. Bill Types... 38 E.1 Home Health Outpatient... 38 E.2 Hospice... 38 E.3 Hospital... 38 E.4 Skilled Nursing Facility/Long Term Care Bill Types... 39 E.5 Renal Dialysis Bill Types... 39 August 28, 2015 Page i

1. Section Modifications Version Section/Column Modification Publish Date 26.0 All Published version 8/28/15 TQD 25.1 3.2 Claim Form Field s Updated for ICD-10 8/28/15 A Coppinger C Taylor D Baker 25.0 All Published version 7/2/15 TQD 24.1 C.3 Ancillary enue s Updated description for 0413 Hyperbaric oxygen therapy SME 7/2/15 C Van Zile D Baker C Taylor 24.0 All Published version 6/26/15 TQD 23.2 Appendix E.1 Home Updated bill types per RQ 40911; removed 6/26/15 D Baker Health Outpatient outpatient designation 23.1 Appendix A Home Health Updated bill types per RQ 40911 6/26/15 D Baker Policy Institutional 23.0 All Published version 3/30/15 TQD 22.1 C.3 Ancillary enue s Updated description for rev code 0943 3/30/15 A Coppinger C Taylor 22.0 All Published version 2/26/15 TQD 21.1 C.3 Ancillary enue Corrected service name for 0404 and 2/26/15 C Taylor s removed reference to outdated IR. 21.0 All Published version 12/18/14 TQD 20.1 C.1 Accommodation/Room Removed codes from C.1 and inserted into new C.2 Special Charges table 12/18/14 C Taylor D Baker enue s C.2 Special Charges 20.0 All Published version 12/4/14 TQD 19.1 C.2 Ancillary enue s Added note that CPT codes marked with an asterisk (*) must be used for outpatient billing only. 12/4/14 C Coyle C Taylor 19.0 All Published version 10/9/14 TQD 18.1 C.2 Ancillary enue s Added rev code 0637 for self-administrable drugs 10/9/14 A Coppinger C Taylor 18.0 All Published version 08/08/14 TQD 17.1 C.2 Ancillary enue Added code 0780 for Telemedicine 08/08/14 C Taylor s 17.0 All Published version 07/01/14 TQD 16.1 C.2 Ancillary enue s Added 0948 to show not covered 07/01/14 C Taylor D Baker 16.0 All Published version 05/23/14 TQD 15.2 C.2 Ancillary enue Updated description for s 0230, 05/23/14 C Taylor s 0231, 0232, 0233, 0234 15.1 3.2 Claim Form Field Updated dates for ICD-10 to 2015 05/23/14 C Taylor s 15.0 All Published version 04/11/14 TQD 14.1 3.2 Claim Form Field s Clarified information for entering PA number in field 63. 04/11/14 D Decrevel D Baker 14.0 All Published version 03/28/14 TQD 13.4 3.2 Claim Form Field Reworded fields 76 (NPI) and 76 (QUAL and 03/28/14 C Taylor s ID) for clarity 13.3 3.2 Claim Form Field Field 67 A-Q, changed to required 03/28/14 C Taylor s 13.2 3.2 Claim Form Field Updated field 66, 67, 67 A-Q, 72, 74, and 03/28/14 C Taylor s 74a-e for ICD-10 13.1 3.2 Claim Form Field Added field 63 and requirements 03/28/14 C Taylor s 13.0 All Published version 01/10/14 TQD August 28, 2015 Page 1 of 39

Version Section/Column Modification 12.1 Appendix C.2 Ancillary enue s Removed references for PW; added statement that pregnancy related diabetic diagnosis is required in Education/Training table Publish Date SME 01/10/14 C Taylor 12.0 All Published version 10/25/13 TQD 11.1 Appendix E Added missing 0s to bill type codes and 10/25/13 C Taylor clarified descriptions relating to Medicare Part A and B. Changed ICF/MR to ICF/ID. 11.0 All Published version 10/04/13 TQD 10.3 Added Appendix E. Bill Types Added bill types for Home Health, Hospice, SNF/LTC, Renal Dialysis 10/04/13 K McNeal C Taylor 10.2 C.2 Ancillary enue s Updated 0274, 0510, 0541, 0544, 5048, and 0549 10/04/13 K McNeal W Walther C Taylor 10.1 3.2 Claim Form Field s Updated fields 66, 67, 67 A-Q 10/04/13 D Decrevel C Taylor 10.0 All Published version 7/25/13 D Baker 9.1 3.2 Claim Form Field Inserted field 70 a,b,c 7/25/13 D Baker s 9.0 All Published version 6/24/13 D Baker 8.1 C.1 Accomodation enue s Split section C.1 into two tables, C.1 Accomodation/Room enue s and C.2 Ancillary s 6/24/13 D Baker 8.0 All Published version 2/21/13 TQD 7.3 C.1 Accomodation Updated information for 0510 2/21/13 C Taylor enue s 7.2 C.1 Accomodation Updated information for 0456 2/21/13 C Taylor enue s 7.1 C.1 Accomodation Updated information for 0274 2/21/13 C Taylor enue s 7.0 All Published version 10/02/12 TQD 6.3 C.1 Accommodation Updated description for rev codes 0420, 10/02/12 C Taylor enue s 0430, and 0440 6.2 C.1 Accommodation Updated description for rev code 0126 10/02/12 A Farmer enue s 6.1 C.1 Accommodation Added rev code 0456 10/02/12 S Pugatch enue s 6.0 All Published version 02/28/12 TQD 5.1 3.2 Claim Form Field Added ME to NDC unit of measure 02/28/12 J Decrevel s 5.0 All Published version 11/23/11 TQD 4.1 Appendix C Hospital Corrected s 0307 and 0320 11/23/11 D Decrevel 4.0 All Published version 10/20/11 TQD 3.5 C.2 Free Standing Dialysis Updated enue code information for 0821 10/20/11 K Mcneal 3.4 C.1 Accommodation enue s Updated enue code 0183, 0189, 0420, 0430, 0440 information 10/20/11 B Rassmussen 3.3 Appendix A Home Health Updated description for enue code 0658 10/20/11 Policy - Institutional Room and Board Care 3.2 3.2 Claim Form Field Added 10/20/11 K Mcneal s Field 80 3.1 3.2 Claim Form Field Added note 10/20/11 K Mcneal s Fields 18, 35-a-b, and 36 a-b 3.0 All Published version 8/27/10 TQD 2.6 C.1 Combined tables for ease of use 8/27/10 TQD 2.5 C.2 Added 0450 0459 8/27/10 M Meints 2.4 C.1 Removed NDC number is required when available for outpatient services for 0250 8/27/10 M Meints August 28, 2015 Page 2 of 39

Version Section/Column Modification Publish Date SME 2.3 C.1 Removed not covered from 0183 and 0189 8/27/10 M Meints 2.2 C.1 Corrected from 1081 to 0181 8/27/10 M Meints 2.1 Field 4 Updated for clarity 8/27/10 M Wood 2.0 All Published Version 06/14/10 TQD 1.7 2.0 Updated for clarity 06/14/10 E Charles 1.6 2.0 Changed field name from Required to Use, 06/14/10 E Charles and updated the column entries to Required, etc. 1.5 Field 2 Changed 11 to 14-digit to 12 to 14-digit 06/14/10 E Charles 1.4 Field 64 Added this sentence: 06/14/10 E Charles Only enter if submitting a replacement or void to a previously submitted claim, otherwise leave blank. 1.3 Field 79 (NPI) Updated Notes: 06/14/10 E Charles Enter Referring Physician s NPI 1.2 Field 79 (QUAL and ID) Updated Notes: 06/14/10 E Charles Enter 1D followed by Referring Physician Medicaid Provider ID only If Referring Physician has not registered their NPI with Idaho Medicaid 1.1 All Sections were renumbered to accommodate 06/14/10 C Stickney additional information 1.0 All Initial document 5/7/2010 TQD August 28, 2015 Page 3 of 39

2. UB04 Claim Form August 28, 2015 Page 4 of 39

3. Completing the UB04 3.1. Helpful Tips for Filling out a Paper Claim Do not enter any data or documentation on the claim form that is not listed as required below. A maximum of twenty-two (22) line items per claim can be accepted; if the number of services performed exceeds twenty-two (22) lines, prepare a new claim form and complete the required data elements; total each claim separately. You can bill with a date span (From and To Dates of ) only if the service was provided every consecutive day within the span. 3.2. Claim Form Field s Field No. Field Name Use Notes 1 PROVIDER NAME AND ADDRESS 2 SERVICE FACILITY NAME AND ADDRESS Required Required if Applicable Billing Provider s Name, Address, City, State, and Zip. Enter name and address of service facility only if service location is different than billing provider name and address in box 1, otherwise leave box 2 blank. Enter 12 or 14-digit Facility Identifier following Facility name and address in box 2 only if service location identifier is different than billing provider box 1, otherwise leave box 2 completely blank. SERVICE FACILITY ID 3a PAT. CNTL # Required CNTL Number - The patient s unique alpha-numeric control number assigned by the provider. 3b MED REC # Required Medical Record Number Medical/Health Record Number: The number assigned to the participant s medical/health record. 4 Type of Bill Required Enter 0 and the 3-digit type of bill code. Example: 0141 If submitting the replacement on a UB-04 claim form, the last digit of the bill type is the frequency code. In Box 4, the bill type must show a 7 or 8 in the frequency position and the original claim number in box 64. 5 Fed. Tax No. Required Enter numeric 9 digit Federal Tax ID August 28, 2015 Page 5 of 39

Field No. Field Name Use Notes 6 Statement Covers Period Required Statement Covers Period From/Through: The beginning and ending service dates of the period included on the bill. Enter each date as MMDDYY or MMDDCCYY 8a s Medicaid Member ID Required Enter the Participant s Idaho Medicaid ID number exactly as it appears on their Medicaid ID card. 8b PATIENT NAME Required s name and address is required 9a s Required Enter participant s street address. Address 9b s City Required Enter participant s city 9c s State Required Enter participant s state 9d s Zip Required Enter participant s zip code 10 Date of Birth Required Enter participant s date of birth. Formatted: MMDDCCYY 11 Sex Required Enter participant s one digit gender code F Female M Male U Unknown 12 Admission Date Required if Inpatient, Enter the month, day, and year the participant entered the facility. Enter as MMDDYY Hospice, Nursing Home 13 Admission Hour Required if Inpatient, Enter the 2-digit hour the participant was admitted for inpatient or outpatient care in military time. Outpatient, Examples: Enter 01 for 1:00 a.m. Enter 10 for 10:00 a.m. Enter 22 for Hospice, 10:00 p.m. Nursing Home 14 Admission Type Required if Enter one (1) digit Admission Type code Inpatient 15 Admission Source Required if Inpatient Enter one (1) digit Admission Source 16 Discharge Hour (DHR) Required, on all final Inpatient Discharge Hour: Enter the 2-digit hour the participant was discharged in military time. Examples: Enter 01 for 1:00 a.m. Enter 10 for 10:00 a.m. Enter 22 for 10:00 p.m. Required for inpatient claims August 28, 2015 Page 6 of 39

Field No. Field Name Use Notes 17 Required if If applicable (STAT) Inpatient 18-28 Condition s Desired Use the codes listed in the NUBC billing manual. Enter up to 11 codes. NOTE: For Home Health: If the participant has Medicare and Home Health services are not homebound, use Condition 12. 31a thru 34a 31b thru 34b 35a-b and 36a-b 39 a-d, 40 a-d, and 41 a-d Occurrence and Occurrence Date Occurrence and Occurrence Date Occurrence Span and Occurrence Span From and Through Date Value s and Amounts Desired Desired Desired Required 42 enue Required, Inpatient Use the codes listed in the NUBC billing manual and enter the date of the occurrence. Up to eight occurrences. Use the codes listed in the NUBC billing manual and enter the date of the occurrence. Up to eight occurrences. Enter Occurrence (s) and their related date spans. Dates formatted as MMDDYY Note: For Home Health: Occurrence Span dates indicate the dates of the physician signed plan of care. The Statement Covers Period must be the same as or within the occurrence span dates. Value s and corresponding amounts/days. Up to twelve. For Days fields use: Value code 80 = Covered Days Value code 81 = Non-Covered Days Value code 82 = Coinsurance Days Value code 83 = Lifetime Reserved Days Enter the 4-digit enue. enue code 0001 is no longer to be used for the total charges; the total charges are to be entered in the designated box on line 23. Any provider billing on a UB04 form, must bill a 4-digit revenue code in order for claim to be considered for payment. August 28, 2015 Page 7 of 39

Field No. Field Name Use Notes 43 Situational When billing for a drug, you must enter the NDC qualifier of N4, followed by the 11-digit NDC number, (space), and the unit of measurement followed by the metric decimal quantity or unit, followed by the unit price. Do not enter a space between the qualifier and NDC. Do not enter hyphens or spaces within the NDC number. The NDC number being submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered. Enter the NDC unit of measurement code, numeric quantity administered to the patient, and the unit price. Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. The unit of measurement codes are as follows: F2 -International Unit GR-Gram ML-Milliliter ME Milligram UN- Unit Example: N499999999999 ML 22.4 300.99 44 HCPCS /RATE/ HIPPS Required with some Enter the appropriate CPT-4 or HCPCS procedure code, followed by up to four, 2-digit modifiers CODE enue s 45 Date Required Enter the line item service date. Required for all outpatient services. Outpatient 46 Units Required Units of : Enter the total number of covered days Units of service for covered days and/or LOA days must correlate accurately to the service rendered. Example: Covered Days 31 Detail From DOS 01/01/2008: enue code 100: Units 10 Detail From DOS 01/11/2008: enue code 183: Units 3 Detail From DOS 01/14/2008: enue code 100 Units 19 47 Total Charges Required Enter service line total charge 48 Non Covered Charges Required if applicable Enter service line non-covered charges August 28, 2015 Page 8 of 39

Field No. Field Name Use Notes Line 23 Column 47 TOTAL CHARGES All LINES Required Enter service line total charge Line 23 Column 48 TOTAL NON- COVERED CHARGES ALL LINES Required if applicable Enter service line non-covered charges. In Fields 50 and 51, each field has three (3) lines: A, B, and C. If Medicaid is the only payer, enter all Medicaid data on line A. If there is one (1) other payer in addition to Medicaid, enter all primary payer data on line A and all Medicaid data on line B. If there are two (2) other payers in addition to Medicaid, enter all primary payer data on line A, all secondary payer data on line B, and all Medicaid data on line C. 50 A,B,C Payer Name A, Required B, Situational C, Situational 51 A, B,C Health Plan ID A, Required B, Situational C, Situational Enter the name identifying each payer organization from which the provider received some payment for the bill. Enter Medicaid for the State Medicaid payer identification. Enter the name of the third party payer if applicable using the following instructions: 50A for the primary payer, 50 B for the secondary payer, and 50C for the tertiary payer. If Field 56 is blank: Provider number must be 10 digits 56 NPI Required Enter billing provider s NPI 58 Insured s Name Desired Insured s Name: If the participant s name is entered, be sure it is exactly as each payer uses it. For Medicaid, enter the name as it appears on the participant s Medicaid ID card. Be sure to enter the last name first, followed by the first name, and middle initial. Enter the participant Medicaid data in the same line used to enter the Medicaid provider data. Example: Medicaid provider information is entered in 50A, and then the Medicaid participant data must be entered in 58A. 59 P. REL Desired s relationship to insured See the UB-04 Manual for the 2-digit relationship codes. 60 Insured s Unique ID Required Enter all of the insured s unique ID numbers assigned by each payer organization. The participant s Medicaid ID number must be entered and correspond with the Medicaid entry in field 50 A, B, or C. If Medicaid is primary, enter the participant s Medicaid ID in Field 60A. If Medicaid is secondary, enter the participant s Medicaid ID in Field 60B. If Medicaid is tertiary, enter the participant s Medicaid ID in Field 60C. August 28, 2015 Page 9 of 39

Field No. Field Name Use Notes 63 Treatment Authorization s Required if services need a PA Enter the PA number exactly as appears on the Notice of Decision. 64 Document Control Number 66 Diagnosis and Procedure Qualifier (ICD Version Indicator) 67 DX: principal diagnosis code Required if replacement or void Required Required Enter the Claim ID Number of the claim to be adjusted or voided. Only enter if submitting a replacement or void to a previously submitted claim, otherwise leave blank. This qualifier is used to indicate the version of ICD being used. For ICD-9, a nine (9) is required in this field. For ICD-10, a zero (0) should be used. Enter the valid ICD-9-CM diagnosis code (including fourth and fifth digits if applicable) or ICD-10-CM diagnosis code that describes the principal diagnosis for services rendered. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. 67 A-Q Other diagnosis codes and Present On Admission (POA) indicator Required 69 ADMIT DX Required if inpatient This field is for reporting all diagnosis codes in addition to the principal diagnosis that coexist, develop after admission, or impact the treatment of the patient or the length of stay. The ICD-9 or ICD-10 code completed to its fullest character must be used. The present on admission (POA) indicator applies to diagnosis codes (i.e., principal, secondary, ICD-9 E codes, ICD-10 W codes) for general acute-care hospitals or other facilities, as required by law or regulation for public health reporting. The indicator should be added in the shaded box next to the corresponding diagnosis code. Use the following values for POA. Definition Y Present at the time of inpatient admission N Not present at the time of inpatient admission U Documentation is insufficient to determine if condition is present on admission W Provider is unable to clinically determine whether condition was present on admission or not Admitting Diagnosis : Required for inpatient. August 28, 2015 Page 10 of 39

Field No. Field Name Use Notes 70 a, b, c Reason Required if Additional patient reason diagnosis required for outpatient. DX outpatient 72 External Cause - ECI Not Required External Cause of Injury : Based on dates of service, enter the ICD-9-CM or ICD-10-CM code for the external cause of an injury, poisoning or adverse effect. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. 74 Principal Procedure and Date 74a-e 76 (NPI) 76 (QUAL and ID) Other Procedure and Date Attending Physician NPI or Medicaid ID Attending Physician Last and First Name Required Desired Required Required if applicable Principal Procedure and Date: Based on dates of service, enter the ICD-9- PCS or ICD-10-PCS code identifying the principal surgical, diagnostic or obstetrical procedure. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. Procedure date is required if procedure code is used, formatted as MMDDYY. Other Procedure s and Dates: Enter all secondary surgical, diagnostic or obstetrical procedures. Use the appropriate ICD-9-PCS or ICD-10-PCS coding based on dates of service. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. Procedure date is required if procedure code is used, formatted MMDDYY. Enter the Attending Physician s NPI or Medicaid ID Required if Attending Physician NPI or Medicaid ID is Present 80 Remarks Situational Use remarks field to indicate any additional information helpful for claims processing, e.g. injury/accident how, where, and when injury/accident happened. August 28, 2015 Page 11 of 39

4. Billing Information Appendix A. Home Health Policy - Institutional enue s Occurrence s (Fields 31-34) s (Field 17) Type of Bill Home Health 0270 Home Health Supplies 0291 Rental Durable Medical Equipment 0421 Home Health Physical Therapy Visit 0431 Home Health Occupation al Therapy Visit Includes dietary products. All items must be included in the written plan of care. All items must be included in the written plan of care. Must be included in the written plan of care. Must be included in the written plan of care. 01 Auto Accident 02 Auto Accident/No Fault 03 Accident/Tort 04 Accident/Employment Related 05 Other Accident 06 Crime Victim 24 Date Insurance Denied 25 Date Benefits Terminated by Primary Carrier 42 Date of Discharge X0 Plan of Care on file 01 Discharge to Home or self care 02 Transfer to Hospital 03 Transfer to Nursing Home 04 Transfer to Intermediate Care Facility 05 Discharged to Another Type of health care institution not defined elsewhere in this list 06 Discharge/Transfer to Home Under Care of Organized Home Health Organization in Anticipation of Covered Skilled Care (Indicate in appropriate field the status or location of patient and time they left the facility). 07 Left Against Medical Advice 08 Discharged/Transferred to Home Under Care of a Home 0321 Admit through Discharge 0322 Interim-First Claim 0323 Interim- Continuing Claim 0324 Interim-Last Claim August 28, 2015 Page 12 of 39

enue s Occurrence s (Fields 31-34) s (Field 17) Type of Bill 0441 Home Health Speech- Language Pathology Visit 0551 Skilled Nurse Visit 0571 Aide Visit 0771 Drugs Requiring Special Coding Must be included in the written plan of care. Requires the skills of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Must be included in the written plan of care. s that can be adequately performed by trained nurse aides. However, they may be performed by either licensed personnel or the home health aide. Must be included in the written plan of care. Use revenue code 771 and CPT/HCPCS code for the administration. Refer to the Allopathic and Osteopathic Physicians guidelines. IV Provider 20 Death 30 Not Discharged, Still A 40 Expired at Home 41 Expired in an Institution 42 Expired, Place Unknown 43 Discharged/transferred to a Federal Health Care Facility August 28, 2015 Page 13 of 39

Appendix B. Hospice Institutional enue s Occurrence s (Fields 31- s (Field 17) Type of Bill (Field 4) Hospice 0651 Routine Care 0652 Continuous Care 0655 Inpatient Respite Care Daily care provided for general hospice care. Care rendered during crisis conditions. Requires a minimum of eight hours. Hours are counted from midnight to midnight. This procedure must be billed using units of time in 15 minute increments. Partial blocks may be billed in 15 minute increments. s must be provided by a registered or licensed practical nurse. Respite care is limited to five days per election period (calendar month) for each participant in an approved inpatient facility. 24 Date Insurance Denied 25 Date Benefits Terminated by Primary Carrier 42 Date of Discharge 01 Discharged to Home 20 Expired 30 Still a, Not Discharged 0138 Outpatient: Void/cancel of prior claim 0811 Admit through Discharge 0812 Interim, First Claim 0817 Outpatient: Replacement of prior claim For Medicare Part A crossover claims only, use the following codes: 0813 Continuing Claim 0814 Last Claim Respite care may only be rendered in a licensed freestanding hospice or a qualified nursing facility. 0656 General Inpatient Care (Non- Respite) Participant care must be rendered in an approved inpatient hospital or freestanding hospice bed. August 28, 2015 Page 14 of 39

enue s Occurrence s (Fields 31- s (Field 17) Type of Bill (Field 4) 0657 Physician Care - Hospice-employed physician services must be billed with the appropriate CPT procedure codes on each line for each service. When the physician billing for services is an employee of the hospice, the UB-04 claim form must be used with enue 0657. 0658 Room and Board Care Room and Board reimbursement for a hospice participant only occurs when the participant has been approved for a level of care in a long-term care facility. Medicaid is always the primary payer of the hospice room and board charge. Per diems are paid for Medicaid or dually eligible hospice participants residing in a Medicare certified nursing facility. The reimbursement rate will be 95 percent of the nursing facility rate on file in which the hospice participant is a resident. The 9-digit Medicaid Nursing Home provider number must be submitted on the claim in field 80 of the UB-04 claim form or in the appropriate field of the electronic claim form. Any participant liability will be withheld from the total hospice payments. Prior Authorization is required. August 28, 2015 Page 15 of 39

Appendix C. Hospital C.1 Accommodation/Room enue s PO These revenue codes must have a signed physician s order attached to the claim form. 0100 All inclusive room-board plus ancillary and swing bed Not covered. Except in hospitals approved for swing bed status. 0101 All inclusive room-board In 0110 Private PO Covered with medically necessary documentation. In 0111 Medical/Surgical/Gyn PO In 0112 Obstetric (OB) PO When using this revenue code for birthing room accommodation, make sure the facility has an accommodation rate on file and specify Birthing In Room in the Remarks field (field 80) of the UB-04 claim form. 0113 Pediatric PO In 0114 Psychiatric PO In 0115 Hospice Must be billed using hospice provider number. 0116 Detoxification Medicaid will reimburse for acute level of care medical conditions only. The physician s order must In be attached. 0117 Oncology PO In 0118 Rehabilitation PO In 0119 Other Not covered 0120 Room and board, semiprivate In enue 671 0121 Medical/Surgical/Gyn In 0122 OB In 0123 Pediatric In 0124 Psychiatric In 0125 Hospice Not covered 0126 Detoxification Medicaid will reimburse for acute level of care medical conditions only. Prior Authorization for In detoxification procedures is required August 28, 2015 Page 16 of 39

0127 Oncology In 0128 Rehabilitation In 0129 Other Not covered 0130 Semiprivate, 3 and 4 beds In 0131 Medical/Surgical/Gyn In 0132 OB In 0133 Pediatric In 0134 Psychiatric In 0135 Hospice Not covered 0136 Detoxification Medicaid will reimburse for acute level of care medical conditions only. The physician s order must In be attached. 0137 Oncology In 0138 Rehabilitation In 0139 Other Not covered 0140 Private (luxury) PO In 0141 Medical/Surgical/Gyn PO (luxury) In enue 671 0142 OB (luxury) PO In 0143 Pediatric (luxury) PO In 0144 Psychiatric (luxury) PO In 0145 Hospice Not covered 0146 Detoxification (luxury) PO Medicaid will reimburse for acute level of care medical conditions only. The physician s order must In be attached. 0147 Oncology (luxury) PO In 0148 Rehabilitation (luxury) PO In 0149 Other Not covered 0150 Room and board, ward In 0151 Medical/Surgical/Gyn In 0152 OB In 0153 Pediatric In 0154 Psychiatric In 0155 Hospice Not covered August 28, 2015 Page 17 of 39

0156 Detoxification PO Medicaid will reimburse for acute level of care medical conditions only. The physician s order must In be attached. 0157 Oncology In 0158 Rehabilitation In 0159 Other Not covered 0160 Other room and board Not covered 0164 Room and board, sterile environment PO In 0167 Self care Not covered 0169 Other Not covered 0170 Nursery In 0171 Newborn - level 1 In 0172 Premature - level II In 0173 Newborn - level III In 0174 Newborn - level IV, Neonatal Intensive Care Unit (NICU) In 0179 Other, nursery Not covered 0180 LOA Not covered 0181 Reserved Not covered 0182 Participant convenience Not covered 0183 Leave of absence/therapeutic Must be billed using LTC provider number enue 671 0189 Other leave of absence Must be billed using LTC provider number 0200 Intensive Care Unit (ICU) In 0201 Surgical In 0202 Medical In 0203 Pediatrics In 0204 Psychiatric In 0206 Post ICU Not covered 0207 Burn care In 0208 Trauma In 0209 Other intensive care Not covered 0210 Coronary Care Unit (CCU) In 0211 Myocardial infarction In August 28, 2015 Page 18 of 39

0212 Pulmonary care In 0213 Heart transplant In 0214 Post CCU Not covered 0219 Other coronary care Not covered enue 671 C.2 Special Charges 0220 Special charges Not covered 0221 Admission charge Not covered 0222 Technical support charge Not covered 0223 UR service charge Not covered 0224 Late discharge, medically necessary Not covered 0229 Other special charges Not covered enue 671 August 28, 2015 Page 19 of 39

C.3 Ancillary enue s PO These revenue codes must have a signed physician s order attached to the claim form. CPT These revenue codes must be billed with a valid CPT code on all outpatient bill types. HCPCS These revenue codes must be billed with a valid HCPCS code on all outpatient bill types. 0230 Incremental nursing charge Justification for extraordinary nursing services must be noted in the medical record. In 0231 Nursery Justification for extraordinary nursing services must be noted in the medical record. In 0232 OB Justification for extraordinary nursing services must be noted in the medical record. In 0233 ICU Justification for extraordinary nursing services must be noted in the medical record. In 0234 CCU Justification for extraordinary nursing services must be noted in the medical record. In 0235 Hospice Must bill using hospice provider number 0239 Other Not covered 0240 All inclusive ancillary Not covered 0249 Other inclusive ancillary Not covered 0250 Pharmacy 0251 Generic drugs 0252 Nongeneric drugs 0253 Take home drugs Must be under $4. Do not reduce charge to $4 and bill as an outpatient service. Bill correct amount on Out the Pharmacy claim form if amount exceeds $4 0254 Drugs incident to other diagnostic Not covered services 0255 Drugs incident to radiology 0256 Experimental drugs Not covered 0257 Non-prescription 0258 IV solutions enue 671 CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 20 of 39

0259 Other pharmacy Not covered 0260 IV therapy 0261 Infusion pump 0262 IV therapy pharmacy services 0263 IV Therapy/Drug/ Supply delivery 0264 IV Therapy/Supplies 0269 Other IV therapy Not covered 0270 Medical/Surgical supplies and devices Extraordinary volume on TPN with prior approval only 0271 Non-sterile supply 0272 Sterile supply 0273 Take home supplies Not covered 0274 CPT Prosthetic/Orthotic devices Medicaid pays for permanent or temporary medical prosthetics to reinforce or replace a biological part implanted through surgery. Devices must be prescribed by the physician. Devices without Federal Drug Administration (FDA) approval are not covered. Providers must submit documentation for specific device information. Out patient claims require corresponding CPT/HCPCS codes. Inpatient claims do not. Out enue 671 0275 Pacemaker 0276 Intraocular lens 0277 Oxygen, take home Not covered 0278 Other implant Document in the remarks field (field 80) of the UB- 04 claim form the specific device or implant used. See the Ambulatory Healthcare Facility guidelines section on Payment under Ambulatory Surgical Center for more specific information. 0279 Other devices Not covered 0280 Oncology general Yes 0289 Oncology other Yes CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 21 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0290 Durable medical equipment DME (other Not covered than rental) 0291 Rental Out 0292 Purchase of new DME Not covered 0293 Purchase of used DME Not covered 0294 Supplies/Drugs for DME Not covered 0299 Other equipment Not covered 0300 Laboratory CPT* Yes 0301 Chemistry CPT* Yes 0302 Immunology CPT* Yes 0303 Renal patient (home) CPT* Yes 0304 Non-routine dialysis CPT* Yes 0305 Hematology CPT* Yes 0306 Bacteriology and microbiology CPT* Yes 0307 Urology CPT* Yes 0309 Other laboratory Not covered 0310 Laboratory pathological Yes 0311 Cytology Yes 0312 Histology Yes 0314 Biopsy Yes 0319 Other Not covered 0320 Radiology diagnostic CPT* Yes 0321 Angiocardiography CPT* Yes 0322 Arthrography CPT* Yes 0323 Arteriography CPT* Yes 0324 Chest x-ray CPT* Yes 0329 Other Not covered 0330 Radiology therapeutic Yes 0331 Chemotherapy, injected Yes 0332 Chemotherapy, oral Yes 0333 Radiation therapy Yes 0335 Chemotherapy - IV Yes 0339 Other Not covered August 28, 2015 Page 22 of 39

enue 671 0340 Nuclear medicine CPT* Yes 0341 Diagnostic CPT* Yes 0342 Therapeutic Yes 0343 Diagnostic radiopharmaceuticals Not covered 0344 Therapeutic Not covered 0349 Other Not covered 0350 CT scan CPT* Yes 0351 Head scan CPT* Yes 0352 Body scan CPT* Yes 0359 Other Computed tomography (CT) Not covered scans 0360 Operating room services CPT* 0361 Minor surgery CPT* 0362 Organ transplant, other than kidney 0367 Kidney transplant 0369 Other OR services Not covered 0370 Anesthesia 0371 Anesthesia incident to radiology 0372 Anesthesia incident to other diagnostic services 0374 Acupuncture Not covered 0379 Other anesthesia Not covered 0380 Blood Yes 0381 Packed red cells Yes 0382 Whole blood Yes 0383 Plasma Yes 0384 Platelets Yes 0385 Leukocytes Yes 0386 Other components Yes 0387 Other derivatives (cryopricipitates) Yes 0389 Other blood Not covered 0390 Blood storage and processing Yes 0391 Blood administration (E.g. transfusions) Yes CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 23 of 39

enue 671 0399 Other blood storage/ Not covered Processing 0400 Other imaging service CPT* Yes 0401 Diagnostic mammography CPT* Must be physician ordered Yes 0402 Ultrasound CPT* Yes 0403 Screening mammography CPT* Physician s order is not required. Participant must be age 40 or older. Yes 0404 Positron emission tomography (PET) HCPCS Must report appropriate HCPCS code. Yes 0409 Other imaging service Not covered 0410 Respiratory services Yes 0412 Inhalation services 0413 Hyperbaric oxygen therapy CPT* HCPCS G0277 is required for outpatient. No HCPCS required for inpatient. Limit of 8 units per day. 0419 Other respiratory service Not covered 0420 Physical therapy (PT) CPT* Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations. Outpatient limitation: Only 25 visits per calendar year are allowed, regardless of provider. Effective January 1, 2012 both Physical Therapy and Speech Therapy visits combined are subject to a yearly capitation rate of $1870.00. 0421 Visit charge Not covered 0422 Hourly charge Not covered 0423 Group rate Not covered 0424 Evaluation or re-evaluation CPT* 0429 Other PT Not covered Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT procedure code rather than the outpatient rate for the revenue code billed. CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 24 of 39

0430 Occupational therapy (OT) CPT* Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations. Outpatient limitation: Only 25 visits per calendar year are allowed, regardless of provider. Effective January 1, 2012 Occupational Therapy visits are subject to a yearly capitation rate of $1870.00. 0431 Visit charge Not covered 0432 Hourly charge Not covered 0433 Group rate Not covered 0434 Evaluation or re-evaluation OT CPT* 0439 Other OT Not covered 0440 Speech/ Language Pathology CPT* Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations. 0441 Visit charge Not covered 0442 Hourly charge Not covered Outpatient limitation: Only 40 visits per calendar year are allowed, regardless of provider. Effective January 1, 2012 both Physical Therapy and Speech Therapy visits combined are subject to a yearly capitation rate of $1870.00. enue 671 Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT procedure code rather than the outpatient rate for the revenue code billed. Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT procedure code rather than the outpatient rate for the revenue code billed. CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 25 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0443 Group rate Not covered 0444 Evaluation or re-evaluation Speech/Language CPT* 0449 Other Speech/Language pathology Not covered 0450 Emergency room 0456 Urgent Care 0459 Other emergency room Not covered 0460 Pulmonary function Yes 0469 Other pulmonary function Not covered 0470 Audiology Yes 0471 Diagnostic Yes 0472 Treatment Yes 0479 Other audiology Not covered 0480 Cardiology Yes 0481 Cardiac catheter lab Yes 0482 Stress test Yes 0483 Echocardiology 0489 Other cardiology Yes 0490 Ambulatory surgical care CPT or HCPCS Must report appropriate CPT or HCPCS when applicable Out 0499 Other Ambulatory surgical centers Not covered (ASC) Care 0500 Outpatient services Out 0509 Other, outpatient services Not covered 0510 Clinic CPT Covered Out 0511 Chronic pain center Not covered 0512 Dental clinic Not covered 0513 Psychiatric clinic Not covered 0514 Obstetrician and gynecologist (OB-GYN) Not covered clinic 0515 Pediatric clinic Not covered 0519 Other clinic Not covered 0520 Free standing clinic not covered on this claim type. Must bill on a CMS-1500 claim form August 28, 2015 Page 26 of 39

0521 Rural health, clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0522 Rural health, home not covered on this claim type. Must bill on a CMS-1500 claim form 0523 Family practice clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0529 Other free standing clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0530 Osteopathic services Not covered 0531 Osteopathic therapy Not covered 0539 Other osteopathic service Not covered 0540 Ambulance: Ground ambulance, nonemergency Hospital owned and operated ambulance services should be billed using the hospital s Medicaid provider number. Requires Medicaid Ambulance iew Authorization. Out enue 671 0541 Ambulance supplies Includes oxygen related supplies Out Yes 0542 Medical transport: Ground ambulance Hospital owned and operated ambulance services emergency should be billed using the hospital s Medicaid provider number. Requires Medicaid Ambulance Out Yes iew Authorization. 0543 Heart mobile Not Covered 0544 Ambulance oxygen Oxygen only Out Yes 0545 Air ambulance: All levels of life support Out Yes 0546 Neonatal ambulance services: Ground or air ambulance Out Yes 0547 Ambulance pharmacy Out Yes 0548 Ambulance EKG services Electrocardiogram (EKG) Out Yes 0549 Other ambulance s downgraded: Respond and Evaluate or Treat and Release Out Yes CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 27 of 39

0550 Skilled nursing HCPCS (S9123) HCPCS code must be indicated in field 44 on the UB-04 claim form. Restricted to pregnant women only. Not to exceed 2 visits per pregnancy. Also used to bill home health services. Must bill using home health provider number. 0551 Skilled nursing visit Must bill using home health provider number. 0552 Hourly charge Not covered 0560 Medical social services In 0561 Individual and family social services (S9127) HCPCS HCPCS code must be indicated in field 44 on the UB-04 claim form. Restricted to pregnant women only. Not to exceed 2 visits. Out enue 671 0562 Hourly charge Not covered 0569 Risk reduction follow-up (G9005) HCPCS HCPCS code must be indicated in field 44 on the UB-04 claim form. Restricted to pregnant women Out only. 0570 Home health aide Not covered 0571 Home health visit charge Home health claims are billed on a UB-04 claim form. Out 0572 Hourly charge Not covered 0579 Other home health aide Not covered 0580 Other visits, home health Not covered 0581 Visit charge Not covered 0582 Hourly charge Not covered 0589 Other home health visits Not covered 0590 Units of service, home health Not covered 0599 Home health, other units Not covered 0600 Oxygen, home health Not covered 0601 Oxygen, equipment, supply, Cont. Not covered 0602 Oxygen, state, equipment, supply, Not covered under 1 LPM 0603 Oxygen, state, equipment, over 4 LPM Not covered 0604 Oxygen, portable add-on Not covered 0610 Magnetic resonance tomography (MRT) CPT* Yes CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 28 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0611 Magnetic resonance imaging (MRI), brain and brainstem CPT* Yes 0612 MRI, spine and spinal cord CPT* Yes 0614 MRI, other 0615 Magnetic resonance angiogram (MRA), head and neck CPT* 0616 MRA, lower extremities CPT* 0618 MRA, other CPT* 0619 Other MRT Not covered 0621 Supplies incident to radiology 0622 Supplies incident to other diagnostic services 0623 Surgical dressings 0630 Drug home IV solution Not covered 0631 Single source Not covered 0632 Multiple source Not covered 0633 Restrictive prescription Not covered 0634 EPO < 10000 units CPT Less than 10,000 units Out 0635 EPO > 10000 units CPT More than 10,000 units NDC information required Out 0636 Drugs requiring detailed coding CPT NDC information required Out 0637 Self-administrable drugs Not covered 0640 IV Therapy services Not covered 0641 Non-routine nursing, central line Not covered 0642 IV site care, central line. Not covered 0643 IV Start/Change, peripheral line Not covered 0644 Non-routine nursing, peripheral line Not covered 0645 Training participant/caregiver, central Not covered line 0646 Training disabled participant, central Not covered line 0647 Training participant caregiver, peripheral line Not covered August 28, 2015 Page 29 of 39

enue 671 0648 Training disabled participant, peripheral Not covered line 0649 Other IV therapy services Not covered 0650 Hospice services Must bill using hospice provider number. 0651 Routine home care Must bill using hospice provider number. 0652 Continuous home care Must bill using hospice provider number. 0655 Inpatient respite care Must bill using hospice provider number. 0656 General inpatient care Must bill using hospice provider number. 0657 Physician services CPT* Must bill using hospice provider number. 0659 Other hospice Must bill using hospice provider number. 0660 Respite care/hha Not covered 0661 Hourly charge/skilled nursing Not covered 0662 Hourly charge/home health Not covered 0671 Outpatient special residence charges, hospital based administratively Out Yes necessary day (AND) 0700 Cast room 0709 Other cast room Not covered 0710 Recovery room 0719 Other recovery room Not covered 0720 Labor room/delivery 0721 Labor 0722 Delivery 0723 Circumcision 0724 Birthing center Charge must reflect a service area not an accommodation (inpatient bed, etc.). 0729 Other labor/delivery Not covered 0730 EKG/ECG Yes 0731 Holter monitor Yes 0732 Telemetry (including fetal monitor) Yes 0739 Other EKG/ECG Not covered 0740 Electroencephalogram (EEG) Yes 0749 Other EEG Not covered 0750 Gastro-intestinal services Yes CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 30 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0759 Other gastro-intestinal Not covered 0760 Treatment/Observation room 0761 Treatment room 0762 Observation room 0769 Other treatment room Not covered 0771 Vaccine administration CPT Out 0780 Telemedicine HCPCS Out 0790 Lithotripsy Yes 0799 Other lithotripsy Not covered 0800 Inpatient renal dialysis In 0801 Inpatient hemodialysis In 0802 Inpatient peritoneal (non-capd) In 0803 Inpatient CAPD In 0804 Inpatient CCPD In 0809 Other inpatient dialysis Not covered 0810 Organ acquisition 0811 Living donor A liver transplant from a live donor is not covered by Medicaid. Yes 0812 Cadaver donor Yes 0813 Unknown donor Yes 0814 Unsuccessful organ search, donor bank charges Used only when costs incurred for an organ search does not result in an eventual organ acquisition and transplantation. 0815 Cadaver donor 0816 Other heart acquisition 0817 Donor, liver A liver transplant from a live donor is not covered by Medicaid. 0819 Other organ acquisition Yes 0820 Hemodialysis outpatient or home Out Yes 0821 Hemodialysis/Composite or other rate CPT Out Yes 0822 Home supplies Not covered 0823 Home equipment Not covered 0824 Maintenance 100 percent Not covered August 28, 2015 Page 31 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0825 Support services Not covered 0829 Other outpatient hemodialysis Not covered 0830 Peritoneal dialysis, outpatient or home Out Yes 0831 Peritoneal/Composite or other rate CPT Out Yes 0832 Home supplies Not covered 0833 Home equipment Not covered 0834 Maintenance 100 percent Not covered 0835 Support services Not covered 0839 Other outpatient peritoneal Not covered 0840 CAPD outpatient or home Out Yes 0841 CAPD composite or other rate CPT Out Yes 0842 Home supplies Not covered 0843 Home equipment Not covered 0844 Maintenance 100 percent Not covered 0845 Support services Not covered 0849 Other outpatient CAPD Not covered 0850 CCPD outpatient or home Out Yes 0851 CCPD/Composite or other rate CPT Out Yes 0852 Home supplies Not covered 0853 Home equipment Not covered 0854 Maintenance 100 percent Not covered 0855 Support services Not covered 0859 Other outpatient CCPD Not covered 0880 Miscellaneous dialysis Yes 0881 Ultrafiltration Yes 0882 Home dialysis aid visit Not covered 0889 Other miscellaneous dialysis Yes 0890 Other donor bank 0891 Bone 0892 Organ other than kidney, liver, and heart 0893 Skin Not payable if for cosmetic surgery 0899 Other donor bank Not covered August 28, 2015 Page 32 of 39

CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. enue 671 0900 Psychiatric/Psychological treatments Not covered 0901 Electroshock treatment 0902 Milieu therapy Not covered 0903 Play therapy Not covered 0904 Activity therapy Not covered 0909 Other Not covered 0910 Psychiatric services Not covered 0911 Rehabilitation Not covered 0912 Partial hospitalization, less intensive Not covered 0913 Partial hospitalization, intensive Not covered 0914 Individual psychiatric therapy 0915 Group psychiatric therapy 0916 Family psychiatric therapy 0917 Bio feedback Not covered 0918 Testing psychiatric services 0919 Other Not covered 0920 Other diagnostic services Document specific diagnostic services rendered. 0921 Peripheral vascular lab Yes 0922 Electromyogram (EMG) Yes 0923 Pap smear Yes 0924 Allergy test CPT*/HCPCS Yes 0925 Pregnancy test Yes 0929 Other diagnostic services Not covered 0940 Other therapeutic services Document specific therapeutic services rendered. 0941 Recreational therapy In 0942 Education/Training HCPCS For diabetes education and training, use HCPCS G0108 (Individual Counseling) and G0109 (Group Counseling). Out When billing for PW members a pregnancy related diabetic diagnosis is required. 0943 Cardiac rehabilitation Indicate the date of the cardiac surgery and document specific cardiac rehabilitation services rendered. 0944 Drug rehabilitation August 28, 2015 Page 33 of 39

enue 671 0945 Alcohol rehabilitation 0946 Complex medical equipment, routine e.g., Air fluidized support bed. Yes 0947 Complex medical equipment, ancillary Yes 0948 Pulmonary rehabilitation Not covered 0949 Other therapeutic service Not covered 0960 Professional fees CPT* not covered 0961 Psychiatric not covered on this claim type. Must bill on 0962 Ophthalmology not covered on this claim type. Must bill on 0963 Anesthesiologist (Medical doctor) not covered on this claim type. Must bill on 0964 Anesthetist (Certified Registered Nurse Anesthetist - CRNA) Must bill on a CMS-1500 claim form using the CRNA s provider number, unless there is a Medicare exception to bill using the UB-04 claim form. 0969 Other professional fees not covered on this claim type. Must bill on 0971 Laboratory not covered on this claim type. Must bill on 0972 Radiology diagnostic not covered on this claim type. Must bill on 0973 Radiology, therapeutic not covered on this claim type. Must bill on 0974 Radiology, nuclear medicine not covered on this claim type. Must bill on 0975 Operating room not covered on this claim type. Must bill on 0976 Respiratory therapy not covered on this claim type. Must bill on 0977 PT not covered on this claim type. Must bill on 0978 OT not covered on this claim type. Must bill on CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 34 of 39

0979 Speech pathology not covered on this claim type. Must bill on 0981 Emergency department not covered on this claim type. Must bill on 0982 Outpatient services not covered on this claim type. Must bill on 0983 Clinic not covered on this claim type. Must bill on 0984 Medical social services not covered on this claim type. Must bill on 0985 EKG not covered on this claim type. Must bill on 0986 EEG not covered on this claim type. Must bill on 0987 Hospital visit not covered on this claim type. Must bill on 0988 Consultation not covered on this claim type. Must bill on 0989 Private duty nurse Not covered 0990 convenience items Not covered 0991 Cafeteria/Guest tray Not covered 0992 Private linen service Not covered 0993 Telephone/Telegraph Not covered 0994 TV/Radio Not covered 0995 Non-patient room rentals Not covered 0996 Late discharge rate Not covered 0997 Admission kit In 0998 Beauty/Barber shop Not covered 0999 Other member convenience Not covered enue 671 CPT* CPT codes marked with an asterisk (*) must be used only for outpatient billing. August 28, 2015 Page 35 of 39

C.4 Free Standing Dialysis enue s Type of Bill 0821 Outpatient dialysis, CPT code 90999 (hemodialysis composite or other rate). Requires documentation. 0270 Dialysis supplies (medical surgical supplies). 0272 Special supplies (sterile supplies). 0634 Epoetin up to 10,000 units. (One billing unit = 1000 Units.) CPT Freestanding 0635 Epoetin over 10,000 units. (One billing unit = 1000 Units.) CPT Dialysis Dialysis drugs CPT (drugs requiring detailed coding), use the appropriate 0721 through 0724 Units corresponding J-code from the most current HCPCS Level II Manual and attach 0636 the NDC detail attachment with the claim form (see Medicaid Information Release MA03-69). 0831 Peritoneal composite rate, 90945 or 90947 CPT. 0841 CAPD composite or other rate, 90945/90947 or 90993 CPT. 0851 CCPD composite or other rate; 90945/90947 or 90993 CPT. CPT Must indicate a valid CPT procedure code when billing outpatient claims. Swing Bed 0100 0131 August 28, 2015 Page 36 of 39

Appendix D. Long Term Care Facility enue s (Field 42) 0100 Inpatient days (NF, ICF/ID, or swing bed) 0101 All Inclusive R&B LTC (For Special Rate or participant Specific Pricing) 0183 LOA (NF therapeutic leave to home) 0189 ICF/ID LOA (Other Leave of Absence) Admission -3 -Elective -The participant s condition permits adequate time to schedule the availability of a suitable accommodation. 1 Physician Referral 2 Clinic Referral 3 HMO Referral 4 5 6 Transfer from a Hospital Transfer from a Nursing Facility or Skilled Nursing Facility Transfer from Another Health Care Facility 7 Emergency Department 8 Court/Law Enforcement Source of Admission s (Field 17) Type of Bill The participant was admitted to this facility upon recommendation of his/her personal physician. The participant was admitted to this facility upon recommendation of this facility s clinic physician. The participant was admitted to this facility upon the recommendation of a health maintenance organization physician. The participant was admitted to this facility as a transfer from an acute care facility where he/she was an inpatient. The participant was admitted to this facility as a transfer from a nursing facility or skilled nursing facility where he/she was an inpatient. The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility, a nursing facility, or skilled nursing facility. This includes transfers from ICF/ID Long Term Care facilities. Not applicable to Long Term Care facilities. The participant was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. 01 Discharge to home 0211 Admit through discharge 02 Transfer to hospital 0212 Interim, first claim 03 Transfer to Long Term Care facility 0213 Interim, continuing claim 04 Transfer to state hospital 0214 Last claim 05 Discharged to another type of institution for inpatient care or referred for outpatient services 06 Discharge/transfer to other (Indicate in field 80 of the UB-04 claim form or in the appropriate field of the electronic claim form, the status or location of the participant and the time they left the Long Term Care facility) 07 Left against medical advice 08 Discharged/transferred to home under care of a home IV provider 20 Death 30 Not discharged, still a patient 40 Expired at home 41 Expired in an institution 42 Expired, place unknown 0215 Late charges only August 28, 2015 Page 37 of 39

Appendix E. Bill Types E.1 Home Health 0321 Home Health (Admit - Through - Discharge Claim) (Including Medicare Part A) 0322 Home Health (Interim - First Claim) (Including Medicare Part A) 0323 Home Health (Interim - Continuing Claim) (Including Medicare Part A) 0324 Home Health (Interim - Last Claim) (Including Medicare Part A) 0327 Home Health (Replacement of Prior Claim) (Including Medicare Part A) E.2 Hospice 0811 Hospice - Non-Hospital Based (Admit - Through - Discharge Claim) 0812 Hospice - Non-Hospital Based (Interim - First Claim) 0813 Hospice - Non-Hospital Based (Interim - Continuing Claim) 0814 Hospice - Non-Hospital Based (Interim - Last Claim) 0817 Hospice - Non-Hospital Based (Replacement of Prior Claim) 0821 Hospice - Hospital Based (Admit - Through - Discharge Claim) 0822 Hospice - Hospital Based (Interim - First Claim) 0823 Hospice - Hospital Based (Interim - Continuing Claim) 0824 Hospice - Hospital Based (Interim - Last Claim) 0827 Hospice - Hospital Based (Replacement of Prior Claim) E.3 Hospital 0110 Not covered due to Healthcare Acquired Conditions (HAC) 0111 Hospital inpatient, admit through discharge. (Including Medicare Part A) 0112 Hospital inpatient, interim first claim. (Including Medicare Part A) 0113 Hospital inpatient, interim continuing claim. (Including Medicare Part A) 0114 Hospital inpatient, interim last claim. (Including Medicare Part A) 0117 Hospital inpatient, replacement of prior claim (electronic claims only). 0118 Hospital inpatient, void/cancel of a prior claim (electronic claims only). 0121 Hospital inpatient, admit through discharge. (Medicare Part B only) 0122 Hospital inpatient, interim first claim. (Medicare Part B only) 0123 Hospital inpatient, interim continuing claim. (Medicare Part B only) 0124 Hospital inpatient, interim last claim. (Medicare Part B only) 0127 Hospital inpatient, replacement of prior claim. (Medicare Part B only) 0128 Hospital inpatient, void/cancel of a prior claim. (Medicare Part B only) 0131 Hospital outpatient, admit through discharge. 0137 Hospital outpatient, replacement of prior claim. 0138 Hospital outpatient, void/cancel of a prior claim. 0141 Hospital other, admit through discharge. 0831 Hospital ASC surgery (ASC services to hospital outpatient) admit through discharge. 0837 Hospital ASC surgery (ASC services to hospital outpatient) replacement of prior claim. 0838 Hospital ASC surgery (ASC services to hospital outpatient) void/cancel of prior claim. 0851 Critical access hospital, admit through discharge August 28, 2015 Page 38 of 39

E.4 Skilled Nursing Facility/Long Term Care Bill Types 0211 Skilled Nursing - Inpatient (Admit - Through - Discharge Claim) (Including Part A) 0212 Skilled Nursing - Inpatient (Interim - First Claim) (Including Part A) 0213 Skilled Nursing - Inpatient (Interim - Continuing Claim) (Including Part A) 0214 Skilled Nursing - Inpatient (Interim - Last Claim) (Including Part A) 0215 Skilled Nursing - Inpatient (Late Charge Only) (Including Part A) 0217 Skilled Nursing - Inpatient (Adjustment/Replacement of Prior Claim) (Including Part A) E.5 Renal Dialysis Bill Types 0721 Clinic or Hospital Based or Independent Renal Dialysis Facility (Admit - Through - Discharge Claim) 0722 Clinic or Hospital Based or Independent Renal Dialysis Facility (Interim - First Claim) 0723 Clinic or Hospital Based or Independent Renal Dialysis Facility (Interim - Continuing Claim) 0724 Clinic or Hospital Based or Independent Renal Dialysis Facility (Interim - Last Claim) 0725 Clinic or Hospital Based or Independent Renal Dialysis Facility (Late Charge Only) 0727 Clinic or Hospital Based or Independent Renal Dialysis Facility (Replacement of Prior Claim) August 28, 2015 Page 39 of 39