Provider Manual. Billing and Payment

Transcription

1 Provider Manual Billing and Payment

2 Billing and Payment Kaiser Permanente s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If you have a question or concern about the information in this section, please call or

3 KAISER PERMANENTE COLORADO Table of Contents SECTION 5: BILLING AND PAYMENT CONTACTS FOR QUESTIONS METHODS OF CLAIMS FILING Paper Claim Forms Record Authorization Number One Member/ Provider per Claim Form No Fault/ Workers Compensation/Other Accident Record the Name of the Provider You Are Covering For Submission of Multiple Page Claim Entering Dates Multiple Dates of Services and Place of Services Surgical and/or Obstetrical Procedures Billing Inpatient Claims That Span Different Years Interim Inpatient Bills Supporting Documentation for Paper Claims Where to Mail/Fax Paper Claims Electronic Data Interchange (EDI) Electronic Claims Forms / Submissions CLAIM FILING REQUIREMENTS Clean Claims Claims Submission Timeframes Claims Processing Turn-Around Time Proof of Timely Claims Submission Appeal of Timely Claims Submission... Error! Bookmark not defined CLAIM ADJUSTMENTS/ CORRECTIONS (REQUIRED)

4 KAISER PERMANENTE COLORADO Incorrect Claims Payments Rejected Claims Due to EDI Claims Error REQUIRED IDENTIFICATION INFORMATION Federal Tax ID Number Changes in Federal Tax ID Number National Provider Identification (NPI) MEMBER COST SHARE MEMBER CLAIMS INQUIRIES VISITING MEMBERS CODING FOR CLAIMS Coding Standards Modifiers in CPT and HCPCS Modifier Review Coding & Billing Validation Claims Editing Software Programs Types of edits Modifiers Coding Edit Rules MEDICAL CLAIMS REVIEW (REQUIRED) Major Categories of Claim Coding Errors/Inconsistencies Procedure Unbundling Incidental Procedures Separate Procedures Mutually Exclusive Procedures Age and Gender (Sex) Conflicts Obsolete/Deleted Codes

5 KAISER PERMANENTE COLORADO Multiple/ Duplicate Component Billing THIRD PARTY LIABILITY (TPL) WORKERS COMPENSATION THIRD PARTY ADMINISTRATOR (TPA) (REQUIRED) PROVIDER CLAIMS APPEALS (REQUIRED) Provider Claim Payment Appeals Process CLAIM FORM EXAMPLES AND INSTRUCTIONS CMS-1500 (08/05) FIELD DESCRIPTIONS CMS-1450 (UB-04) Field Descriptions BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES Capitation Payments Evaluation Management (E/M) Services Inpatient E/M Services: Surgical Procedure that Include E/M Services: Preventive Medicine Services: Emergency Rooms Two Physicians Involved in Admitting a Patient from the ER Emergency in the Office Setting Non-Emergency Services Provided in the Emergency Department Emergency Room and Urgent Care Services Submitted on a UB Critical Care Services Patient Located in a Critical Care Unit Not Receiving Critical Care Services Observation Services Injection/ Immunizations Vaccine Immunizations Allergy Immunotherapy

6 KAISER PERMANENTE COLORADO Obstetrical Services Admissions for False Labor Anesthesia Services Provided with Deliveries Multiple Physicians Provide Different Components of the Obstetrical Care Antepartum Care Newborn Services Newborn Care When Baby Is Discharged with Mother Newborn Care When Baby is Discharged without Mother Boarder Babies Who Stay Beyond Their Mother s Discharge Date Mother who stays beyond their baby discharge date Surgery Global Period / Surgical Package Endoscopic Procedures Included in the Surgical Package Anesthesia Procedures Included in the Surgical Package Topical/Local/Digital Block Anesthesia Included in the Surgical Package Preoperative Care/Services Included in the Surgical Package Preoperative Care/Services Excluded from the Surgical Package Postoperative Follow-Up Care Included in the Surgical Package Postoperative Follow-Up Care Excluded from the Surgical Package Same-Day Services Excluded from the Surgical Package Assistant Surgeon Co-Surgery (Two Surgeons) Team Surgery Duplicate / Bilateral Procedures Multiple Surgery Reimbursement for Professional and Facility Claims Exploratory/Diagnostic Procedures Cardiac Procedures Cardiac Catheterization Billing

7 KAISER PERMANENTE COLORADO Electrophysiologic Studies (EPS), Cardiac Mapping and Ablations EPS and Cardiac Catheterization Cardiac Rehabilitation Transplants Anesthesia Behavioral Health Services... Error! Bookmark not defined Durable Medical Equipment... Error! Bookmark not defined Laboratory Procedures Radiology Services Radiation Treatment Interventional Radiology Therapy: Physical/ Occupational/Speech (P.O.S.) COORDINATION OF BENEFITS (COB) (REQUIRED) How to Determine the Primary Payor Description of COB Payment Methodologies COB Claims Submission Requirements and Procedures Members Enrolled in Two Kaiser Permanente Plans COB Claims Submission Timeframes COB FIELDS ON THE UB-92 and UB-04 CLAIM FORM COB FIELDS ON THE CMS-1500 (HCFA-1500) CLAIM FORM EXPLANATION OF PAYMENT (EOP) (REQUIRED)

8 It is your responsibility to submit itemized claims for services provided to in accordance with your Agreement, this Manual and applicable law. The Member s Payor is responsible for payment of claims in accordance with your Agreement. Please note that this manual does not address submission of claims under tier 2 and 3 of POS product. Health Plan agrees to implement any new or revised CMS Fee Schedule within 45 calendar days after the CMS File Publish Date or CMS Implementation Date, whichever is later. Contacts For Questions Central Referral Center or , FAX Provides authorization prior to rendering services. Specialists are limited to procedures and services defined on the Referral Authorization Form. Members must return to Kaiser Permanente for services that have not been pre-authorized. Claims and Member Service Department or Provides information related to claims payment for services provided. All billings should be sent to the address listed below. Claims should be submitted on a CMS 1500 or CMS 1450 form. Clean claims will be paid or denied within the timeframes required by applicable federal or state law. Kaiser Permanente Claims and Referral Department PO Box Denver, CO Member Service Department - Benefit Information or Provides benefits or eligibility of a Kaiser Permanente member. Providers can also find benefit information on Kaiser Permanente ID cards. All member cost share should be collected at the time services are provided. This department also documents, reports and facilitates the response to member complaints. Provider Credentialing Requirements Our Credentialing Committee prior to rendering services must approve all consultants contracting with Kaiser Permanente. If you add new providers to your practice, you must contact your contract manager to have them properly credentialed

9 5.1. Methods of Claims Filing Paper Claim Forms CMS-1500 must be used for all professional services and suppliers. CMS-1450 must be used by all facilities (e.g., hospitals) Record Authorization Number All services that require prior authorization must have an authorization number reflected on the claim form. CMS 1500 Form Enter the Authorization Number (Field 23) and the Name of the Referring Provider (Field 17) on the claim form, to ensure efficient claims processing and handling One Member/ Provider per Claim Form One Member per Claim Form/One Provider per claim Do not bill for different Members on the same claim form Do not bill for different Providers on the same claim form. Separate claim forms must be completed for each Member and for each Provider No Fault/ Workers Compensation/Other Accident Be sure to indicate on the CMS-1500 (HCFA-1500) Claim Form in the Is Patient s Condition Related To fields (Fields 10a -10c), whenever No Fault, Workers Compensation, or Other Accident situations apply Record the Name of the Provider You Are Covering For When covering for another Provider, submit a CMS-1500 (HCFA-1500) claim form for these services and enter the name of the physician you are covering for in Field 19 (Reserved for Local Use). NOTE: If a non-contracting Provider will be covering for you in your absence, please notify that individual of this requirement Submission of Multiple Page Claim If due to space constraints you must use a second claim form, please write continuation at the top of the second form, and attach the second claim form to the first claim with a paper clip. Enter the TOTAL CHARGE (Field 28) on the last page of your claim submission

10 Entering Dates Below is an example of how to enter dates on the CMS-1500 (HCFA-1500) Claim Form Multiple Dates of Services and Place of Services Multiple dates of services at the same location can be filed on the same claim form but must be entered on a separate line. Multiple dates of service at different locations must be filed on a separate claim form. Same date of the service at the same location can be filed on the same claim form. Same date of service at different locations must be filed on a separate claim form Surgical and/or Obstetrical Procedures If any surgical and/or obstetrical procedures were performed, record the ICD-9-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-9-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). When submitting the UB-04, use Field 74a-e (Principal Procedure Code and Date) Billing Inpatient Claims That Span Different Years When an inpatient claim spans different years (for example, the patient was admitted in December and was discharged in January of the following year), it is NOT necessary to submit two claims for these services. Bill all services for this inpatient stay on one claim form (if possible), reflecting the correct date of admission and the correct date of discharge. Kaiser Permanente will apply the appropriate/applicable

11 payment methodologies when processing these claims Interim Inpatient Bills For inpatient services only, we will accept separately billable claims for services in an inpatient facility on a bi-weekly basis. Interim hospital billings should be submitted under the same Member account number as the initial bill submission. DRG/Case Rate/Other Reimbursement Contracts: Facilities contracted with Kaiser Permanente under a DRG or a case-rate payment methodology CANNOT submit interim inpatient bills; bills can only be submitted upon patient discharge. Per Diem: Skilled nursing facilities contracted with Kaiser Permanente uner a per diem methodology may submit interim inpatient bills on a monthly basis for prolonged patient hospitalization. Be sure to indicate via appropriate codes in Field 22 (Discharge Status Code) and Field 4 (Type of Bill) that this is an interim inpatient bill Supporting Documentation for Paper Claims Supporting documentation is only required when requested upon the denial or pending of a claim. You will receive written notice if you need to provide written documentation in order to reprocess your claim. When billing with an unlisted CPT code, to expedite claims processing and adjudication, providers should submit supporting written documentation Where to Mail Paper Claims Paper claims are accepted; however EDI (electronic) submission is preferred. Paper claims are not accepted via fax due to HIPAA regulations. Mail all paper claims to: Kaiser Permanente of Colorado Claims Administration P.O. Box Denver, CO Electronic Data Interchange (EDI) Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of claims

12 EDI is an electronic exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI transactions replace the submission of paper claims. Required data elements (for example, claims data elements) are entered into the computer only ONCE - typically at the Provider s office, or at another location where services were rendered. Benefits of EDI Submission 1 Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated. 2 Improved Data Accuracy: Because the claims data submitted by the Provider is sent electronically to Kaiser Permanente via the Clearinghouse, data accuracy is improved, as there is no need for re-keying or re-entry of data. 3 Low Error Rate: Additionally, up-front edits applied to the claims data while information is being entered at the Provider s office, and additional payer-specific edits applied to the data by the Clearinghouse before the data is transmitted to the appropriate payer for processing, increase the percentage of clean claim submissions. 4 Bypass US Mail Delivery: The usage of envelopes and stamps is eliminated. Providers save time by bypassing the U.S. mail delivery system. 5 Standardized Transaction Formats: Industry-accepted standardized medical claim formats may reduce the number of exceptions currently required by multiple payers. NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under a capitated arrangement, periodic interim payments (PIP), or other reimbursement methodology, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500/08/05 or 12/90 or CMS-1450/UB-04 or UB92 as applicable), and to follow all claims completion instructions set forth in this Manual Electronic Claims Forms / Submissions Kaiser Permanente of Colorado accepts all claims submitted by mail or electronically. Professional and facility claims can be submitted electronically via the current version of: 837P must be used for all professional services and suppliers. 837I must be used by all facilities (e.g., hospitals).below Supporting Documentation for EDI Claims Currently, Kaiser Permanente Colorado does not have the capability to accept claims with electronic attachments. These types of submissions will need to be submitted via the paper process. To Initiate Electronic Claims Submissions

13 Trading Partners or Trading Parties interested in implementing EDI transactions with Kaiser Permanente should contact Regional EDI Business Operations for information via Providers with existing electronic connectivity, please use the Payer ID list below: SSI 837I only Envoy/NEIC/WebMD/Emdeon 837I/P Self Funded use ENS/Ingenix/OptumInsight 837I/P COKSR Relay Health 837I/P-RH or for new customers and for existing customers 5.2. Claim Filing Requirements Clean Claims Kaiser Permanente follows all state and Federal clean claim requirements. Please refer to Kaiser Permanente considers a claim clean when the following requirements are met: Correct Form - Kaiser Permanente requires all professional claims to be submitted using the CMS Form 1500 and all facility claims (or appropriate ancillary services) to be submitted using the CMS Form CMS 1450 (UB04 or 92 based on CMS guidelines. Standard Coding All fields should be completed using industry standard coding. Applicable Attachments Attachments should be included in your submission when circumstances require additional information. Completed Field Elements for CMS Form 1500 or CMS 1450 (UB-04 or UB92 based on CMS guidelines) All applicable data elements of CMS forms should be completed. A claim is not considered to be Clean or payable if one or more of the following are missing or are in dispute: The format used in the completion or submission of the claim is missing required fields or codes are not active. The eligibility of a member cannot be verified

14 The responsibility of another payor for all or part of the claim is not included or sent with the claim. Other coverage has not been verified. Additional information is required for processing such as COB information, operative report or medical notes (these will be requested upon denial or pending of claim). The claim was submitted fraudulently. NOTE: Failure to include all information will result in a delay in claim processing and payment and will be returned for any missing information. A claim missing any of the required information will not be considered a clean claim Claims Submission Timeframes Timeframes for filing a claim: New Claims - The standard is 90 days from the date of service, for both Commercial and Medicare members. COB Claims - COB information must be received within 12 months of the request for Commercial members and 24 months for Medicare/Medicaid Members. (If within the last three months of the year, Medicare/Medicaid Members have 27 months.) Processing of your claim may be delayed for receipt of COB information. Claim Corrections - When a claim is received within the contractual timely filing period but is received with missing information, the provider will be required to submit a corrected claim to Kaiser Permanente within forty five (45) calendar days from the date of the original Statement of Remittance (SOR) Claims Processing Turn-Around Time Clean claims will be processed pursuant to the timeframe specified by applicable law for Commercial lines of business and 30 calendar days from receipt for Senior Advantage/Medicare lines of business Proof of Timely Claims Submission Claims submitted for consideration or reconsideration of timely filing must be reviewed with information that indicates the claim was initially submitted within the appropriate time frames outlined in Section of this Manual. Acceptable proof of timely filing may include the following documentation and/or situations: EDI Transmission reports) Remit notices Denial notices

15 *Hand-written or typed documentation is not acceptable proof of timely filing. Corrected/Replacement Claims Timely receipt of Corrected/Replacement claims When a claim is received within the contractual timely filing period but has missing or incorrect information, the provider will be required to submit the requested information within forty five (45) calendar days from the date of the Kaiser Permanente request letter. Timely receipt of claims filed for reconsideration When provider requests reconsideration on a claim, the provider will have 45 days from the date of the original SOR to submit the additional documentation. Correcting a previously submitted claim If your claim requires correction, you will receive a notice accompanying your rejected claim detailing the error. If corrections can be made, you should submit a corrected claim. The timeframe for submitting a corrected claim via paper is either detailed in the notice you receive requesting corrections, or will default to the timely filing limit if not specified. Contracted providers can submit a claim correction if he/she has the following justifications: Original claim submitted with incorrect diagnosis Original claim submitted with incorrect procedure(s) Original claim submitted with incorrect member Original claim submitted with incorrect date of service Original claim submitted with incorrect contract rates applied Authorization has been obtained Any other information that has been added/corrected on the original claim Procedures for submitting a paper claim correction to Kaiser Permanente for processing: Write CORRECTED CLAIM in the top (blank) portion of the standard claim form. Attach a copy of the corresponding page of Kaiser Permanente s Statement of Remittance (SOR) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip. Mail the corrected claim(s) to Kaiser Permanente: Kaiser Permanente of Colorado Claims Administration P.O. Box Denver, CO

16 A detailed explanation of what should be adjusted and the reason(s) why it Should be adjusted must be accompanied by supporting documentation to support the adjustment. Allow thirty (30) days from the receipt of your request to research and resolve your adjustment/correction request Claim Adjustments/ Corrections (Required) Claim Adjustments We reserve the right to audit claims for adjustments and corrections to ensure services rendered are medically necessary, coding requirements are met as stated in this Manual, and payment is according to your Agreement. Necessary adjustments may be made by offsetting against future claims to any and all claims prior to or after payment. Periodically, Kaiser Permanente will perform audits on claims to determine if payments have been made appropriately. If our audit determines that an overpayment was made, you will be notified in writing of the amount of the overpayment and given instructions on the process and time frame for reimbursing Kaiser Permanente for the amount overpaid. If you do not send a check for the amount of the overpayment within the timeframe specified in your notice, future claims will be offset. Remit notices for claims that have been offset will reflect the amount deducted from the expected payment. Multiple claims may be affected until the entire balance of the overpayment is recovered Incorrect Claims Payments For an Underpayment Error: Write or call Claims Customer Service ((303) or (800) ) and explain the error. If Kaiser Permanente agrees that there has been an error, appropriate corrections will be made by Kaiser Permanente and the underpayment amount owed will be added to/reflected in your next Kaiser Permanente reimbursement check. For an Overpayment Error: You have responsibility to identify and notify us of any overpayments. If you have identified an overpayment, the following options are available to you. Write a refund check to Kaiser Permanente for the excess amount paid to you by Kaiser Permanente. Attach a copy of Kaiser Permanente s SOR to your refund check, as well as a brief note explaining the error

17 NOTE: If Kaiser Permanente s SOR is not available, please record the Member s Medical Record Number on the payment check you are returning. Mail your refund check (and brief note) to: Kaiser Permanente Health Plan of Colorado P.O. Box Denver, CO Attn: Refund Recovery Department Send the appropriate refund to Kaiser Permanente within thirty (30) days from when you confirm that you are not entitled to the payment for claims within 12 months of the date of service. Write or call Claims Customer Service and explain the error. Appropriate corrections will be made and the overpayment amount will be automatically deducted from your next Kaiser Permanente reimbursement check. If you discover an overpayment and you do not choose one of the above options, Kaiser Permanente reserves the right to offset future payments for the amount owed Rejected Claims Due to EDI Claims Error The submitting provider is responsible for monitoring the acceptance and reject reports provided by the clearinghouse and to resolve transmission and format issues with the clearinghouse. Issues between the clearinghouse and Kaiser Permanente will be addressed by Kaiser Permanente Required Identification Information Federal Tax ID Number The Federal Tax ID Number as reported on any and all claim form(s) must match the information filed with the Internal Revenue Service (IRS). 1 When completing IRS Form W-9, please note the following: Name: This should be the equivalent of your entity name, which you use to file your tax forms with the IRS. Sole Provider/Proprietor: List your name, as registered with the IRS. Group Practice/Facility: List your group or facility name, as registered with the IRS. 2 Business Name: Leave this field blank, unless you have registered with the IRS as a Doing Business As (DBA) entity. If you are doing business under a different name, enter that name on the IRS Form W

18 3 Address/City, State, Zip Code: Enter the address where Kaiser Permanente should mail your IRS Form Taxpayer Identification Number (TIN): The number reported in this field (either the social security number or the employer identification number) MUST be used on all claims submitted to Kaiser Permanente. Sole Provider/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are doing business as an entity under a different name). Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN). If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your Federal Taxpayer ID Number on your claim forms, please contact the IRS help line in your area or refer to the following website: Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente Attn: Provider Contracting E. Dakota Avenue Denver, CO IMPORTANT: If your Federal Tax ID Number should change, please notify us immediately, so that appropriate corrections can be made to Kaiser Permanente s files Changes in Federal Tax ID Number If your office/facility changes any pertinent information (i.e., tax identification number, phone or fax number, billing address, practice address, etc.) please mail or fax written notice, including the effective date of the change, as soon as possible, or if at all possible, with 90 days advance notice. For changes in Federal Tax-ID numbers, please include a W-9 form with the correct information. Kaiser Permanente Attn: Provider Contracting E. Dakota Avenue Denver, CO National Provider Identification (NPI) Kaiser Permanente will not be able to process electronic claims unless they contain the NPI

19 Individual (Type 1) and Organization/Group (Type 2) NPI applications and instructions can be accessed at: Member Cost Share Depending on the benefit plan, Kaiser Permanente Members may be responsible to share some cost of the services provided. Copayment, co-insurance and deductible (collectively, Member Cost Share ) are the fees a Member is responsible to pay a Provider for certain covered services. This information varies by plan and all Providers are responsible for collecting Member Cost Share in accordance with Kaiser Permanente Member s benefits. Please verify applicable Member Cost Share at the time of service. Member Cost Share information can be obtained from: Member ID Card. Copayments, co-insurance and deductible information are listed on the front of the Member ID card when applicable Member Claims Inquiries Members seeking information regarding claims should contact Kaiser Permanente Customer Service at Visiting Members Claims for members visiting from Kaiser Permanente regions other than Colorado should be submitted as you would normally and will be paid at the same rates pursuant to your agreement. Please contact Member Services to obtain a visiting member identification number at or Coding for Claims Contracted providers are responsible to ensure that billing codes used on claims forms are current and accurate. Individual physician evaluation and management coding statistics are routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators Coding Standards Coding All fields should be completed using industry standard coding as outlined below. ICD-9 (soon to be ICD-10) To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or five-digit codes, depending on the specific disease or injury being described

20 Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth digit for coding specificity. The U.S. Department of Health and Human Services (HHS) has set the compliance date of October 1, 2014 for the implementation of the International Classification of Diseases, 10th Edition (ICD-10), which is used in administrative health care transactions. This compliance date will apply to both diagnosis and procedure (ICD-10-CM and ICD-10-PCS) codes. CPT-4 The Physicians' Current Procedural Terminology, Fourth Edition (CPT) code set is a systematic listing and coding of procedures and services performed by Participating Providers. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code. If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's Web site at or submit your request and supporting documentation to: CPT Editorial Research and Development American Medical Association 515 North State Street Chicago IL HCPCS The Healthcare Common Procedure Coding System (HCPCS) Level 2 identifies services and supplies. HCPCS Level 2 begin with letters A V and are used to bill services such as, home medical equipment, ambulance, orthotics and prosthetics, drug codes and injections. Revenue Code Approved by the Health Services Cost Review Commission for a hospital located in the State of Maryland, or of the national or state uniform billing data elements specifications for a hospital not located in that State. NDC (National Drug Codes) Prescribed drugs, maintained and distributed by the U.S. Department of Health and Human Services ASA (American Society of Anesthesiologists) Anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists DSM-IV (American Psychiatric Services) For psychiatric services, codes distributed by the American Psychiatric Association

21 5.8.2 Modifiers in CPT and HCPCS Modifiers submitted with an appropriate procedure code further define and/or explain a service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book. Note CMS-1500 Submitters: Kaiser Permanente processes up to 4 modifiers per claim line. When submitting claims, use modifiers to: Identify distinct or independent services performed on the same day Reflect services provided and documented in a patient's medical record Modifiers for Professional and Technical Services Modifier 26, Professional Component - Certain procedures consist of a physician component and a technical component. When the physician component is reported separately, adding the Modifier 26 to the CPT procedure code identifies the service. Modifier TC, Technical Component - The modifier TC is submitted with a CPT procedure code to bill for equipment and facility charges, to indicate the technical component. Use with diagnostic tests; e.g. radiation therapy, radiology, and pulmonary function tests. Indicates the Provider performed only the technical component portion of the service. Modifiers Billed with Evaluation and Management (E/M) Services Modifier 24 is used to report an unrelated evaluation and management service performed by the same physician who performed the surgery during a postoperative period. Modifier 25 is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the same date of service as a procedure or service. Modifier 25 can be used for significant, identifiable visits to be considered for reimbursement when substantiated in the medical records, which should be available upon request. Modifier 57 is used when the decision to perform a major surgery happens the day before or day of the major surgery. Modifiers Billed with Surgical Procedures Modifier 50 Bilateral Procedure Add Modifier 50 to the service line of a unilateral 5-digit CPT procedure code to indicate that a bilateral procedure was performed. Modifier 50 may be used to bill surgical procedures at the same operative session, or to bill diagnostic and therapeutic procedures that were performed bilaterally on the same day

22 Durable Medical Equipment (DME) Modifiers Modifier RR Rental (DME) Add Modifier RR to the service line of a DME procedure code to indicate that equipment is a rental. Modifier NU New Equipment Add Modifier NU to the service line of a DME procedure code to indicate that equipment is a purchase Modifier Review Kaiser Permanente reserves the right to review use of modifiers to ensure accuracy and appropriateness. Improper use of modifiers may cause claims to pend and/or the return of claims for correction Coding & Billing Validation We perform code editing to enforce both Kaiser Permanente and nationally accepted coding and payment rules (see Section 5.37 of this Manual), and to verify the codes you submit are consistent based on the services rendered. Your claims will be subjected to McKesson code editing software ( CodeReview ). CodeReview assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding of procedure(s) not their medical necessity. CodeReview provides consistent and objective claim review by accurately applying coding criteria for all clinical areas of medicine, surgery, laboratory, pathology, radiology and anesthesia. See Section 5.41 for code editing rules. CodeReview may change and edit your claim, perhaps substantially, as a result of these code editing rules. When a change is made to your submitted code(s), Kaiser Permanente will provide an explanation of the reason for the change. Possible outcomes from Code Review include: Accepting the code(s) as submitted. Changing the submitted code(s) to comply with generally accepted coding practices that are consistent with Physicians Current Procedural Terminology (CPT), the HCPCS Code Book and recommendations made by peer specialist physicians. Updating outdated or invalid codes. Denying line items. Bundling or unbundling codes as appropriate. Denying code(s) as incidental or inherent part of the more global code billed. Adjusting payment. Seeking additional information from the physician s office due to inconsistent information in the claim

23 Fraudulent coding will be investigated by Kaiser Permanente. In addition, individual physician evaluation and management coding statistics are routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators Claims Editing Software Programs Services must be reported in accordance with the reporting guidelines and instructions contained in the American Medical Association ( AMA ) CPT Manual, CPT Assistant, and HCPCS publications. Providers are responsible for accurately reporting the medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. Claims are processed utilizing claims editing software product from McKesson Code Review/ ClaimsXten. CodeReivew/ClaimsXten includes edit rules such as incidental, bundled and mutually as well as other edits that are recognized by industry guidelines. CodeReview/ClaimsXten will be updated on a quarterly basis. In addition to adding new CPT codes, HCPCS codes, and NCCI edits, McKesson continues to add and revise content based on ongoing review of the entire knowledge base. This continuous process helps to ensure that the clinical content used in CodeReview/ClaimsXten is clinically appropriate and withstands the scrutiny of both payers and providers. Code Review/ ClaimsXten is used to evaluate the accuracy of medical claims and their adherence to accepted CPT/HCPCS coding practices and it allows us to monitor the increasingly complex developments in medical technology and correct procedure coding used to process physician payments. American Medical Association Complete Procedural Terminology (CPT ), CPT Assistant, coding guidelines developed from national specialty societies, CMS, National Correct Coding Initiative ( NCCI or CCI ), Healthcare Common Procedure Coding System (HCPCS ), American Society of Anesthesiology ( ASA ), and other standard-setting organizations for claims billing procedures are considered in developing Kaiser Permanente s coding and reimbursement edits and policies Types of edits Procedure unbundling occurs when two (2) or more procedures are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed by a provider. In this instance, the two (2) codes may be replaced with the more appropriate code by our bundling system. Example 1: Laboratory Laboratory unbundling edits are applied when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should not be billed separately, but should be billed using one

24 (1) panel coding. Example 2: Electrocardiograms A claim billed with the following two (2) codes together would be considered as unbundled: Claim Detail Line Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report. Claim Detail Line Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. Example 2 Explanation: When CPT codes and are performed on the same day, the appropriate comprehensive procedure code would be Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. An incidental procedure is performed at the same time as a more complex primary procedure. The incidental procedure doesn t require significant additional physician resources and/or is clinically integral to the performance of the primary procedure. Mutually exclusive procedures are two (2) or more procedures usually not performed during the same patient encounter on the same date of service. Mutually exclusive rules may also govern different procedure code descriptions for the same type of procedure for which the physician should be submitting only one (1) procedure. Duplicate procedure editing involves duplicate procedures submitted with the same date of service or on previously submitted claim(s) or claim line(s). Duplicate line items are determined based on matches on certain key fields. Duplicate procedures include the following When the description of the procedure contains the word bilateral, the procedure may be performed only once on a single date of service. When the description of a procedure code contains the phrase unilateral/bilateral, the procedure may be performed only once on a single date of service. When the description of the procedure specifies unilateral and there is another procedure whose description specifies bilateral performance of the same procedure, the unilateral procedure may not be submitted more than once on a single date of service. When the description of one procedure specifies a single procedure and the description of a second procedure specifies multiple procedures, the single procedure may not be submitted more than once on a single date of service

25 The global duplicate value is the total number of times it s clinically possible or Medically Necessary to perform a given procedure on a single date of service across all anatomic sites. Age edits occur when the provider assigns an age-specific procedure or diagnosis code to a patient whose age is outside the designated age range. Gender edits occur when the provider assigns a gender-specific procedure or diagnosis code to a patient of the opposite sex. Frequency edits occur when a procedure is billed more often than would be expected. Frequency edits occur when: Procedure Maximum Frequency Per Day Identifies procedure codes billed on a claim that have maximum quantities allowed within a twenty-four (24) hour period. Deny Base Code with Quantity Greater than One (1) Identifies situations on a claim where the base code with quantity is billed rather than the appropriate add on code(s). Add-on procedures should be submitted in addition to the primary (base code) procedure. Primary (base code) procedures are typically billed with a quantity of one (1). Additional services beyond the primary (base code) procedure should be billed as an add-on procedure code. Global Surgical Packaging identifies Evaluation & Management (E&M) codes and supplies billed on a claim within the global period. Procedure codes have a time frame associated with them which includes services and supplies associated with the procedure. The time frames are set by both the Center of Medicare and Medicaid Services (CMS) and broadly accepted industry sources. New Patient Code for Established Patient identifies new patient visits that are billed for established patients. The new patient procedure code may only be billed once every three (3) years. History Editing occurs when a previously submitted historical claim that is related to current claim submission is identified. This identification/edit may result in adjustments to claims previously processed. An example of such a historical auditing action would occur when an E/M visit is submitted on one (1) claim and then a surgery for the same service date is submitted on a different claim. If a determination that the E/M visit paid in history is included in the allowable for the surgery, an adjustment of the E/M claim will be necessary, this may result in an overpayment recovery History editing capability are not limited to; global surgery, multiple visits per day, pre/post-operative visits, new patient visits, frequency rules, incidental, mutually exclusive and rebundle edits and maternity services

26 Place of Service edits identify the reporting of an inappropriate place of service for a particular procedure, either due to the descriptive verbiage of the code, or due to published CPT coding guidelines which indicate that a specific procedure is not intended to be reported in a certain setting Deleted Procedure Code identifies a deleted or expired code billed on a claim. The Center of Medicare and Medicaid Services (CMS) does not permit reimbursement of AMA deleted codes when they are submitted after the deletion date and beyond the submission period. Multiple/Duplicate Component Billing identifies when a procedure billed on a claim may be billed with a professional or technical components (i.e., with Modifiers 26 or TC) submitted. The edits ensures that the total reimbursement amount does not exceed the allowable amount for the procedure without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total Modifiers In certain circumstances, it is appropriate to use modifiers to report services that warrant reimbursement separately from what would usually be expected. The use of these modifiers should not be routine. Modifier 25 is used to indicate that on the day a procedure or preventive exam was performed, the patient s condition required a significant, separately identifiable E/M service beyond the usual care associated with the procedure or preventive exam. Without the modifier-25 designation, the E/M code is bundled into the procedure, or preventive exam. Only append modifier 25 to E/M codes Modifier 50 is used to indicate a bilateral procedure and using CMS guidelines when processing bilateral surgeries/procedures. When a procedure is not identified by its terminology as a bilateral procedure it is billed on one line with the surgical procedure code, one unit of service and modifier 50. Bilateral surgeries/procedures are considered one surgery. We will be using CMS guidelines to determine appropriateness. If the code is reported as a bilateral procedure, and is reported with other procedure codes on the same day, then the bilateral adjustment will be applied before applying any multiple procedure rules. Modifier 51 is used to indicate when multiple procedures are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or services(s) shall be identified by appending modifier 51 to the additional procedure or service codes(s). Modifier 51 should not be appended to designated add-on codes. We will be using CMS guidelines to determine appropriateness. Modifier 52 is used to identify reduced services. Under certain circumstances, a

27 service or procedure is partially reduced or eliminated at the physician s discretion. These services may be reviewed. Modifier 57 is used to identify the patient encounter that resulted in the decision to perform surgery. Without the modifier, the E/M code is bundled to the surgical procedure when performed the day of or the day before a major surgical procedure, Modifier 59 is used to identify procedures/services that aren t normally reported together but are appropriate under the circumstances. This may include a different procedure or surgery, a different site, or a separate incision/excision, lesion or patient encounter. Append modifier 59 to procedures or surgeries; Modifier 59 is not appropriate for supplies, DME codes, drugs or J codes or E/M codes If modifier 59 is appended to inappropriate codes, it will be disregarded or denied as inappropriate use of the modifier Modifier 80, 81, 82 or AS is used to identify assist surgeon procedures. We will be using CMS guidelines to determine appropriateness. Multiple modifiers: Kaiser Permanente systems adjudicate using the first and second modifier on the claim line. If all modifiers are used to make payment determination, the claim will be held for manual adjudication and review Coding Edit Rules Kaiser Permanente applies coding edit rules to all claims submitted. The following descriptions outline some of the major categories of our coding edit rules, some of which CodeReview/ClaimsXten applies automatically as part of coding and billing validation. These rules are subject to change and may be edited from time to time. There may be situations where your contract supersedes these rules. Should you have any questions regarding your contract and code editing, please contact your Contract manager or Claims Customer Service Major Categories of Claim Coding Errors/Inconsistencies: AMA and CMS Guidelines CodeReview/ClaimsXten will correct input codes without valid modifiers to closely correspond to accepted coding practices by flagging potential errors while accepting coding practices judged to be conventional by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). The CPT and HCPCS manuals explicitly detail and outline many of the rules included in

28 CodeReview/ClaimsXten. HCPCS codes related to CPT codes CodeReview/ClaimsXten also evaluates the combination of HCPCS codes and CPT codes. These codes are cross walked to identify where a HCPCS code is related to one or many CPT codes, and are evaluated based on the existing CPT rules. Unnecessary or disallowed codes are then rejected. Example: HCPCS code D7872 is defined as diagnostic arthroscopy of the temporomandibular joint, with or without biopsy. D7872 is related to the CPT code diagnostic arthroscopy of temporomandibular joint. Since both codes have the same narrative, the CPT code should be used. If both codes are submitted for the same date of service, CodeReview denies the HCPCS code as part of the CPT code. In addition, additional rules regarding CPT and HCPCS codes will be applied, so in this example, if or (IV infusion) were also on the claim, they would be denied as part of the global services. HCPCS codes not related to CPT codes CodeReview also detects situations where HCPCS codes are not related to CPT codes. Rules developed as appropriate that are the result of the review of non-cpt related HCPCS codes are part of the knowledge base supporting CodeReview and do not conflict with the National Correct Coding Policy Initiative (NCCPI). Example: E1050 is denied in conjunction with E1060. The description for E1050 is fully reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests. The description for E1060 is fully reclining wheelchair, detachable arms, swing away detachable elevating leg rests. Procedure Unbundling Procedure unbundling occurs when two or more procedure codes are used to describe a procedure performed, when a single more comprehensive procedure code exists that accurately describes the entire procedure performed. Example 1: Laboratory unbundling occurs when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should NOT be billed separately, but should be billed using ONE panel code. Example 2: Billing the following two codes together is considered unbundling Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only

29 When and are performed on the same day the appropriate comprehensive procedure code would be Incidental Procedures An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately. Separate Procedures Procedures designated as a separate procedure in the CPT code book are commonly performed as an integral part of a total, larger procedure, and normally does NOT warrant separate identification. Therefore, these services are typically included as part of the global charges submitted for the related, larger procedure. However, when the procedure is performed as a separate, independent service not in conjunction with any normally related procedure it may be billed as a separate procedure. If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement. Mutually Exclusive Procedures Mutually exclusive procedures are two or more procedures that are usually NOT performed at the same operative session on the same member on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedure(s), for which the physician should be submitting only ONE of the procedure codes. Age and Gender (Sex) Conflicts An age conflict occurs when the contracted provider bills an age-specific procedure code for a member outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a member of the opposite gender. Example 1: The contracted provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old member. Example 2: Code Total abdominal hysterectomy is submitted for a male member. Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother s contract and are excluded from the age processing rules. The following age categories are examined for conflicts: Newborn (age less than 1 year old) Pediatric (ages 1-17 years old)

30 Maternity (ages years old) Adult (ages over 14 years old) Obsolete/Deleted Codes If obsolete or deleted codes cannot be cross walked to current or updated codes, claims submitted may be denied. Obsolete or deleted codes are updated each calendar year and are not accepted past the end date specified by CMS. Medicare claims with outdated codes will be subject to denial as per CMS guidelines. Multiple/ Duplicate Component Billing When procedures are billable for professional and technical components (i.e., with Modifiers 26 and TC), Kaiser Permanente monitors that the total amount paid for the service does not exceed what would have been paid if the procedure had been billed without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total. Denied codes Certain codes are always denied. To obtain a full list of these codes, please contact Claims Member Service at Kaiser Permanente reserves the right to revise the list from time to time. In general, these codes relate to personal comfort items, non-covered services, benefit exceptions, and codes not reimbursable when billed in conjunction with Emergency services (i.e., X-ray interpretation, After-Hours codes.) CodeReview/ ClaimXten assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding of the procedure(s) not their medical necessity Medical Claims Review (Required) Medical claims review is performed by comparing billing records with medical records to determine payment accuracy and to ensure claims are paid only for services delivered. Physician orders are carefully checked to make sure services delivered were ordered by a physician. We perform medical claims review on an ongoing basis as a monitoring function and for the purpose of trending for aberrance. In addition, medical claims review may occur as the result of a complaint or compliance violation. If you should be contacted regarding medical claims review, we expect you to respond within the timeframe specified in our request Major Categories of Claim Coding Errors/Inconsistencies Procedure Unbundling

31 Incidental Procedures Definition: An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately Separate Procedures Definition: Procedures designated as a separate procedure in the CPT code book are commonly performed as an integral part of a total, larger procedure, and normally do NOT warrant separate identification. Therefore, these services are typically included as part of the global charges submitted for the related, larger procedure. However, when the procedure is performed as a separate, independent service not in conjunction with any normally related procedure it may be billed as a separate procedure. If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement Mutually Exclusive Procedures Definition: Mutually exclusive procedures are two or more procedures that are usually NOT performed at the same operative session on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedure(s), for which the physician should be submitting only ONE of the procedure codes Age and Gender (Sex) Conflicts Definition: An age conflict occurs when the Provider bills an age-specific procedure code for a patient outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a patient of the opposite gender. [Example 1: The Provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old patient. Example 2: Code Total abdominal hysterectomy is submitted for a male patient. Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother s contract and are excluded from the age processing rules. The following age categories are examined for conflicts: Newborn (age less than 1 year old) Pediatric (age 1-17 years old) Maternity (age years old) Adult (age over 14 years old)]

32 Obsolete/Deleted Codes Claims submitted with obsolete or deleted codes may be denied. Obsolete or deleted codes are upays against deleted codes for as long as the code billed was valid for the date of service on the claim Multiple/ Duplicate Component Billing When procedures are billable for professional and technical components (i.e. with modifiers 26 and TC), Kaiser Permanente monitors that the total amount paid for the service does not exceed what would have been paid if the procedure had been billed without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total Third Party Liability (TPL) Third Party Liability is coordinated thru Healthcare Recovery Incorporated (HRI). P.O. BOX Louisville, KY TEL: Fax: (502) Hours of Operations 8:30 a.m. to 5:00 p.m. Monday-Friday (Eastern Time) Workers Compensation Workers Compensation claims are not covered by Kaiser Permanente. We will deny all claims related to Workers Compensation Third Party Administrator (TPA) (Required) Ground Ambulance is paid by a TPA for all lines of business. All Ground Ambulance claims should be mailed to the below address: Employers Mutual 9716 San Jose Blvd. Jacksonville, FL Provider Claims Appeals (Required) Refer to Section 4 of this Manual for the information on provider claims appeals Provider Claim Payment Appeals Process If your office/facility has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact Claims Customer Service at Many

33 questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone. If your issue cannot be resolved through this initial contact, you have the right to appeal. See Section 6 of this Manual for a full explanation of this process. For information on self-funded claim disputes or appeals, call In most cases, they will be able to answer and resolve any issues you may have. For further information, please refer to the Self-Funded Program Provider Manual Claim Form Examples and Instructions CMS-1500 The fields identified in the table below as Required must be completed when submitting a CMS-1500 (08/05) claim form to Kaiser Permanente for processing: Note: The required fields for submission shown below are required by Kaiser Permanente but not necessarily required by CMS or other payers. For Medicare Members, please refer to Medicare Billing Requirements for appropriate field requirements and instructions/examples. FIELD NUMBER FIELD NAME 1 MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER REQUIRED FIELDS FOR CLAIM SUBMISSIONS Not Required INSTRUCTIONS/EXAMPLES Check the type of health insurance coverage applicable to this claim by checking the appropriate box. 1a INSURED S I.D. NUMBER Required Enter the subscriber s plan identification number. 2 PATIENT S NAME Required Enter the patient s name. When submitting newborn claims, enter the newborn s first and last name. 3 PATIENT S BIRTH DATE AND SEX Required Enter the patient s date of birth and gender. The date of birth must include the month, day and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/ INSURED S NAME Required Enter the name of the insured (Last Name, First Name, and Middle Initial), unless the insured and the patient are the same then the word SAME may be entered

34 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 5 PATIENT S ADDRESS Required Enter the patient s mailing address and telephone number. On the first line, enter the STREET ADDRESS; the second line is for the CITY and STATE; the third line is for the ZIP CODE and PHONE NUMBER. 6 PATIENT S RELATIONSHIP TO INSURED Required 7 INSURED S ADDRESS Required if Applicable Check the appropriate box for the patient s relationship to the insured. Enter the insured s address (STREET ADDRESS, CITY, STATE, and ZIP CODE) and telephone number. When the address is the same as the patient s the word SAME may be entered. 8 Reserved for NUCC Use Not required 9 OTHER INSURED S NAME Required if Applicable 9a OTHER INSURED S POLICY OR GROUP NUMBER Required if Applicable 9b RESERVED FOR NUCC USE Required if Applicable 9c RESERVED FOR NUCC USE Required 9d 10a-c INSURANCE PLAN NAME OR PROGRAM NAME IS PATIENT CONDITION RELATED TO if Applicable Required if Applicable Required When additional insurance coverage exists, enter the last name, first name and middle initial of the insured. Enter the policy and/or group number of the insured individual named in Field 9 (Other Insured s Name) above. NOTE: For each entry in Field 9A, there must be a corresponding entry in Field 9d. Enter the name of the other insured s INSURANCE PLAN or program. Check Yes or No to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in field 24. NOTE: If yes there must be a corresponding entry in Field 14 (Date of Current Illness/Injury). 10d CLAIM CODES Not Required Leave blank. Place (State) - enter the State postal code. 11 INSURED S POLICY NUMBER OR FECA NUMBER Not Required If there is insurance primary to Medicare, enter the insured s policy or group number. 11a INSURED S DATE OF BIRTH Not Required Enter the insured s date of birth and sex, if different from Field 3. The date of birth must include the month, day, and FOUR digits for the year (MM/DD/YYYY)

35 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES Example: 01/05/ b OTHER CLAIM ID Not Required Leave blank 11c INSURANCE PLAN OR PROGRAM NAME Not Required Enter the insurance plan or program name. 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Required Check yes or no to indicate if there is another health benefit plan. For example, the patient may be covered under insurance held by a spouse, parent, or some other person. If yes then fields 9 and 9a-d must be completed. 12 PATIENT S OR AUTHORIZED PERSON S SIGNATURE 13 INSURED S OR AUTHORIZED PERSON S SIGNATURE 14 DATE OF CURRENT ILLNESS, INJURY, PREGNANCY 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Not Required Not Required Required if Applicable Not Required Not Required Have the patient or an authorized representative SIGN and DATE this block, unless the signature is on file. If the patient s representative signs, then the relationship to the patient must be indicated. Have the patient or an authorized representative SIGN this block, unless the signature is on file. Enter the date of the current illness or injury. If pregnancy, enter the date of the patient s last menstrual period. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2006 Enter the previous date the patient had a similar illness, if applicable. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2006 Enter the from and to dates that the patient is unable to work. The dates must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/

36 FIELD NUMBER FIELD NAME 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if Applicable INSTRUCTIONS/EXAMPLES Enter the FIRST and LAST NAME of the referring or ordering physician. 17a OTHER ID # Not Required In the shaded area, enter the non-npi ID number of the physician whose name is listed in Field 17. Enter the qualifier identifying the number in the field to the right of 17a. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number EI - Employer s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy 17b NPI NUMBER Required In the non-shaded area enter the NPI number of the referring provider 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 19 ADDITIONAL CLAIM INFORMATION Not Required Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization. Leave Blank 20 OUTSIDE LAB CHARGES Not Required Required 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the diagnosis/condition of the patient, indicated by an ICD-9-CM code number. Enter up to 12 diagnostic codes, in PRIORITY order (primary, secondary condition). 22 RESUBMISSION CODE Not Required 23 PRIOR AUTHORIZATION NUMBER Required Enter the prior authorization number for those procedures requiring prior approval. 24 a-j SUPPLEMENTAL INFORMATION Required Supplemental information can only be entered with a corresponding, completed service line. SUPPLEMENTAL INFORMATION, con t. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service

37 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES When reporting additional anesthesia services information (e.g., begin and end times), narrative description of an unspecified code, NDC, VP HIBCC codes, OZ GTIN codes or contract rate, enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not enter a space, hyphen, or other separator between the qualifier and the number/code/information. The following qualifiers are to be used when reporting these services. 7 - Anesthesia information ZZ - Narrative description of unspecified code N4 - National Drug Codes (NDC) VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ - Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN) CTR - Contract rate 24a DATE(S) OF SERVICE Required Enter the month, day, and year (MM/DD/YY) for each procedure, service, or supply. Services must be entered chronologically (starting with the oldest date first). For each service date listed/billed, the following fields must also be entered: Units, Charges/Amount/Fee, Place of Service, Procedure Code, and corresponding Diagnosis Code. IMPORTANT: Do not submit a claim with a future date of service. Claims can only be submitted once the service has been rendered (for example: durable medical equipment). 24b PLACE OF SERVICE Required Enter the place of service code for each item used or service performed. (see page 38 for list of common codes.) 24c EMG Not Required Enter Y for YES or leave blank if NO to indicate an EMERGENCY as defined in the electronic 837 Professional 4010A1 implementation guide. 24d PROCEDURES, SERVICES, OR Required Enter the CPT/HCPCS codes and MODIFIERS (if

38 FIELD NUMBER FIELD NAME SUPPLIES: CPT/HCPCS, MODIFIER REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES applicable) reflecting the procedures performed, services rendered, or supplies used. IMPORTANT: Enter the anesthesia time, reported as the beginning and end times of anesthesia in military time above the appropriate procedure code. 24e DIAGNOSIS POINTER Required Enter the diagnosis code reference number (pointer) as it relates the date of service and the procedures shown in Field 21, When multiple services are performed, the primary reference number for each service should be listed first, and other applicable services should follow. The reference number(s) should be a 1, or a 2, or a 3, or a 4; or multiple numbers as explained. IMPORTANT: (ICD-9-CM diagnosis codes must be entered in Item Number 21 only. Do not enter them in 24E.) 24f $ CHARGES Required Enter the FULL CHARGE for each listed service. Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, co-pays etc). Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number. 24g DAYS OR UNITS Required Enter the number of days or units in this block. (For example: units of supplies, etc.) 24h EPSDT FAMILY PLAN Not Required When entering the NDC units in addition to the HCPCS units, enter the applicable NDC units qualifier and related units in the shaded line. The following qualifiers are to be used: F2 - International Unit ML - Milliliter GR - Gram UN Unit 24i ID. QUAL Required Enter in the shaded area of 24I the qualifier identifying if the number is a non-npi. The Other ID# of the rendering provider is reported in 24J in the shaded area. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number

39 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES EI - Employer s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy 24j RENDERING PROVIDER ID # Required Enter the non-npi ID number in the shaded area of the field. Enter the NPI number in the non-shaded area of the field. Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b. 25 FEDERAL TAX ID NUMBER Required Enter the physician/supplier federal tax I.D. number or Social Security number. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked. IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS. 26 PATIENT S ACCOUNT NO. Required Enter the Members account number assigned by the Provider s/provider s accounting system. 27 ACCEPT ASSIGNMENT Not Required IMPORTANT: This field aids in patient identification by the Provider/Provider. 28 TOTAL CHARGE Required Enter the total charges for the services rendered (total of all the charges listed in Field 24f). 29 AMOUNT PAID Required if Applicable Enter the amount paid (i.e., Member copayments or other insurance payments) to date in this field for the services billed. 30 BALANCE DUE Not Required Enter the balance due (total charges less amount paid). 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32 SERVICE FACILITY LOCATION INFORMATION Required Required if Applicable Enter the signature of the physician/supplier or his/her representative, and the date the form was signed. For claims submitted electronically, include a computer printed name as the signature of the health care Provider or person entitled to reimbursement. The name and address of the facility where services were rendered (if other than patient s home or physician s office)

40 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES Enter the name and address information in the following format: 1 st Line Name 2 nd Line Address 3 rd Line City, State and Zip Code Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101 ). Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen. 32a NPI # Required Enter the NPI number of the service facility. 32b OTHER ID # Required Enter the two digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. Required 33 BILLING PROVIDER INFO & PH # Enter the name, address and phone number of the billing entity. 33a NPI # Required Enter the NPI number of the service facility location in 32a. 33b OTHER ID # Required Enter the two digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. If available, please enter your provider or unique vendor number

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42 KAISER PERMANENTE CMS-1450 (UB-04) Field Descriptions The fields identified in the table below as Required must be completed when submitting a CMS-1450 (UB-04) claim form to Kaiser Permanente for processing. Please Note: The fields required for submission below are required by Kaiser Permanente but not necessarily by CMS or other payers. For Medicare members, please refer to Medicare s billing requirements for appropriate field requirements and instructions or examples. FIELD NUMBER FIELD NAME 1 PROVIDER NAME and ADDRESS 2 PAY-TO NAME, ADDRESS, CITY/STATE, ID # 3a PATIENT CONTROL NUMBER 3b MEDICAL RECORD NUMBER REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required Required Required Not Required INSTRUCTIONS/EXAMPLES Enter the name and address of the hospital or person who rendered the services being billed. Enter the name and address of the hospital or person to receive the reimbursement. Enter the member s control number. IMPORTANT: This field aids in patient identification by the Provider/Provider. Enter the number assigned to the patient s medical/health record by the provider. 4 TYPE OF BILL Required Enter the appropriate code to identify the specific type of bill being submitted. This code is required for the correct identification of inpatient vs. outpatient claims, voids, etc. 5 FEDERAL TAX NUMBER 6 STATEMENT COVERS PERIOD - FOR REFERENCE ONLY Required Required Enter the federal tax ID of the hospital or person entitled to reimbursement. Enter the beginning and ending date of service included in the claim. 7 BLANK Not Required Leave blank. 8 PATIENT NAME Required Enter the member s name. 9 PATIENT ADDRESS Required Enter the member s address. 10 PATIENT BIRTH DATE Required Enter the member s birth date. 11 PATIENT SEX Required Enter the member s gender. 12 ADMISSION DATE Required For inpatient claims only, enter the date of admission. 13 ADMISSION HOUR Required For either inpatient OR outpatient care, enter the 2-digit code for the hour during which the member was admitted or seen. 14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency, urgent, elective, and newborn). 15 ADMISSION SOURCE Required Enter the source of the admission type code. 16 DISCHARGE HOUR Required if Enter the two-digit code for the hour during which the (DHR) member was discharged. Applicable 17 PATIENT STATUS Required Enter the discharge status code CONDITION CODES Required if Applicable Enter any applicable codes which identify conditions relating to the claim that may affect claims processing. 29 ACCIDENT (ACDT) STATE Not Required Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment.

43 KAISER PERMANENTE FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS 30 BLANK Not Required Leave blank OCCURRENCE CODES AND DATES OCCURRENCE SPAN CODES AND DATES Required if Applicable Required if Applicable 37 BLANK Not Required Leave blank. INSTRUCTIONS/EXAMPLES Enter the code and the associated date defining a significant event relating to this bill that may affect claims processing. Enter the occurrence span code and associated dates defining a significant event relating to this bill that may affect claims processing. 38 RESPONSIBLE PARTY Not Required Enter the responsible party name and address VALUE CODES and Required if AMOUNT Applicable Enter the code and related amount/value which is necessary to process the claim. 42 REVENUE CODE Required Identify the specific accommodation, ancillary service, or billing calculation, by assigning an appropriate revenue code. 43 REVENUE DESCRIPTION 44 PROCEDURE CODE AND MODIFIER Not Required Required Enter the revenue description. For ALL outpatient claims, enter BOTH a revenue code in Field 42 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field. 45 SERVICE DATE Required Outpatient Series Bills: A service date must be entered for all outpatient series bills whenever the from and through dates in Field 6 (Statement Covers Period: From/Through) are not the same. Submissions that are received without the required service date(s) will be rejected with a request for itemization. Multiple/Different Dates of Service: Multiple/different dates of service can be listed on ONE claim form. List each date on a separate line on the form, along with the corresponding revenue code (Field 42), procedure code (Field 44), and total charges (Field 47). 46 UNITS OF SERVICE Required The units of service. 47 TOTAL CHARGES Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field BLANK Not Required Leave blank. 48 NON COVERED CHARGES Not Required Enter any non-covered charges. - FOR REFERENCE ONLY

44 KAISER PERMANENTE FIELD NUMBER FIELD NAME - FOR REFERENCE ONLY REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 50 PAYER NAME Required Enter (in appropriate ORDER on lines A, B, and C) the NAME and NUMBER of each payer organization from whom you are expecting payment towards the claim. 51 HEALTH PLAN ID Required Enter the provider number. 52 RELEASE OF INFORMATION (RLS INFO) Not Required Enter the release of information certification number 53 ASSIGNMENT OF BENEFITS (ASG BEN) Required if Applicable 54a-c PRIOR PAYMENTS Required if Applicable Not Required Enter the assignment of benefits certification number. If payment has already been received toward the claim by one of the payers listed in Field 50 (Payer) prior to the billing date, enter the amounts here. 55 ESTIMATED AMOUNT DUE Enter the estimated amount due. 56 NATIONAL PROVIDER Required Enter the service provider s National Provider Identifier IDENTIFIER (NPI) (NPI). 57 OTHER PROVIDER ID Required Enter the service provider s Kaiser-assigned provider ID. 58 INSURED S NAME Required Enter the subscriber s name. 59 PATIENT S RELATION TO INSURED Required if Applicable Enter the member s relationship to the subscriber. 60 INSURED S UNIQUE ID Required Enter the insured person s unique individual member identification number (medical/health record number), as assigned by Kaiser. 61 INSURED S GROUP NAME 62 INSURED S GROUP NUMBER 63 TREATMENT AUTHORIZATION CODE 64 DOCUMENT CONTROL NUMBER Required if Applicable Required if Applicable Required if Applicable Not Required 65 EMPLOYER NAME Required if Applicable Not Required 66 DX VERSION QUALIFIER 67 PRINCIPAL DIAGNOSIS CODE 67 A-Q OTHER DIAGNOSES CODES Required Required if Applicable 68 BLANK Not Required Leave blank. 69 ADMITTING DIAGNOSIS 70 REASON FOR VISIT (a-c) (PATIENT REASON DX) Required Not Required Enter the insured s group name. Enter the insured s group number as shown on the identification card. For Prepaid Services claims enter PPS. For ALL inpatient and outpatient claims, enter the referral number. Enter the document control number related to the member or the claim. Enter the employer s name. Indicate the type of diagnosis codes being reported. Note: At the time of printing, Kaiser only accepts ICD-9- CM diagnosis codes on the UB-04. Enter the principal diagnosis code, on all inpatient and outpatient claims. Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail. Enter the admitting diagnosis code on all inpatient claims. Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration.

45 KAISER PERMANENTE FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS 71 PPS CODE Required if Applicable 72 EXTERNAL CAUSE OF Required if INJURY CODE (ECI) Applicable 73 BLANK Not required Leave blank. 74 PRINCIPAL PROCEDURE CODE AND DATE 74 (a e) OTHER PROCEDURE CODES AND DATES Required if Applicable Required if Applicable 75 BLANK Not required Leave blank. 76 ATTENDING PHYSICIAN / NPI / QUAL / ID 77 OPERATING PHYSICIAN / NPI/ QUAL/ ID OTHER PHYSICIAN/ NPI/ QUAL/ ID Required Required If Applicable INSTRUCTIONS/EXAMPLES Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology. Enter an ICD-9-CM E-code in this field (if applicable). Enter the ICD-9-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable). Enter other ICD-9-CM procedure CODE(S) and DATE(S) on all inpatient AND outpatient claims (in fields A through E ) for any additional surgical and/or obstetrical procedures which were performed (if applicable). Enter the National Provider Identifier (NPI) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services. Inpatient Claims Attending Physician Enter the full name (first and last name) of the physician who is responsible for the care of the patient. Outpatient Claims Referring Physician For ALL outpatient claims, enter the full name (first and last name) of the physician who referred the Member for the outpatient services billed on the claim. Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure. Required if Enter the National Provider Identifier (NPI) and name of any other physicians. Applicable 80 REMARKS Not Required Special annotations may be entered in this field. 81 CODE-CODE Not required Enter the code qualifier and additional code, such as martial status, taxonomy, or ethnicity codes, as may be appropriate. - FOR REFERENCE ONLY

46 KAISER PERMANENTE - FOR REFERENCE ONLY