Provider Manual. Billing and Payment

Transcription

1 Provider Manual Billing and Payment 8/31/2011

2 Billing and Payment This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente s billing and payment policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If, at any time, you have a question or concern about the information in this Manual, you can reach our Claims Customer Service Department by calling /31/2011

3 Table of Contents TABLE OF CONTENTS... 3 SECTION 5: BILLING AND PAYMENT /31/ WHOM TO CONTACT WITH 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 SUPPORTING DOCUMENTATION FOR PAPER CLAIMS WHERE TO MAIL/FAX PAPER CLAIMS ELECTRONIC DATA INTERCHANGE (EDI) ELECTRONIC CLAIMS FORMS SUPPORTING DOCUMENTATION FOR EDI CLAIMS TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS ELECTRONIC SUBMISSION PROCESS... 13

4 5.20 HIPAA REQUIREMENTS CLEAN CLAIMS CLAIMS SUBMISSION TIMEFRAMES CLAIMS PROCESSING TURN-AROUND TIME PROOF OF TIMELY CLAIMS SUBMISSION CLAIM ADJUSTMENTS/ CORRECTIONS Incorrect Claims Payments REJECTED CLAIMS DUE TO EDI CLAIMS ERROR FEDERAL TAX ID NUMBER CHANGES IN FEDERAL TAX ID NUMBER NATIONAL PROVIDER IDENTIFICATION (NPI) Member Claims Inquiries Visiting Members Coding for Claims Coding Standards Modifiers in CPT and HCPCS Modifier Review CODING & BILLING VALIDATION Coding Edit Rules Medical Claims Review Third Party Liability (TPL) Workers Compensation Third Party Administrator (TPA) PROVIDER CLAIMS APPEALS CMS-1500 (08/05) FIELD DESCRIPTIONS /31/2011 4

5 5.47 CMS-1450 (UB-04) FIELD DESCRIPTIONS BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES Capitation Payments Evaluation Management (E/M) Services Emergency Rooms Critical Care Services Observation Services Injection/ Immunizations Obstetrical Services Newborn Services Surgery Laboratory Procedures Radiology Services COORDINATION OF BENEFITS (COB) 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 /31/2011 5

6 The applicable Payor identified in your Agreement is responsible for payment of covered services in accordance with your Agreement and applicable law. It is your responsibility to submit itemized claims for services provided to Members in a complete and timely manner 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. Reimbursement based on a new or revised Resource Based Relative Value Scale (RBRVS) Fee Schedule will begin upon system implementation of the new fee schedule by the Health Plan. Health Plan agrees to implement any new or revised RBRVS Fee Schedule within 45 calendar days after the CMS RBRVS File Publish Date or CMS Implementation Date, whichever is later. 5.1 Whom to Contact with Questions The following information is provided as a quick reference to the Kaiser Permanente system. If you have questions or would like more information, contact the Network Development Provider Contracting Department at (303) Central Pre-authorization Department (303) FAX (303) 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 Referral Payment Department (303) 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 (303) To verify benefits or eligibility of a Kaiser Permanente member, contact this department. Providers can also find benefit information on the members Kaiser Permanente ID card. All copays or co-insurance that the member is responsible for should be collected at the time services are provided. The department also documents, reports and facilitates the response to member complaints. Denver/ Boulder Consultant Credentialing Requirements (303) 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. Southern Colorado Consultant Credentialing Requirements (719) /31/2011 6

7 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. 8/31/2011 7

8 5.2 Methods of Claims Filing Kaiser Permanente of Colorado accepts all claims submitted by mail or electronically. Kaiser Permanente of Colorado s Emdeon payor ID# Kaiser Permanente of Colorado s Relay Health payor ID# Rh003 Kaiser Permanente of Colorado s ENS payor ID# COKSR 5.3 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). Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 claim forms, unless you are contracted under a GLOBAL rate, in which case professional services should not be billed separately. Note: Effective October 2006, the center of Medicare & Medicaid Service (CMS) has revised the CMS form. The new CMS (08/05) version will accommodate the reporting of the National Provider Identifier (NPI). Kaiser Permanente began to accept the revised form on October 1, Kaiser Permanente will continue to accept CMS-1500 (12/90) version based on CMS guidelines for accepting this form. Kaiser Permanente will only accept (08/05) version of the CMS Record Authorization Number 5.5 One Member/ Provider per Claim Form 5.6 No Fault/ Workers The National Uniform Billing committee (NUBC) has approved the new UB-04 (CMS-1450) as the replacement for UB-92. Kaiser will begin to accept the New UB-04 on October 1, Kaiser Permanente will continue to accept UB92 form based on CMS guidelines. Kaiser Permanente will only accept UB-04 (CMS-1450). All services that require prior authorization must have an authorization number reflected on the claim form or a copy of the authorization form may be submitted with the claim. 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 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 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, 8/31/2011 8

9 Compensation/ Other Accident 5.7 Record the Name of the Provider You Are Covering For 5.8 Submission of Multiple Page Claim 5.9 Entering Dates Workers Compensation, or Other Accident situations apply. 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. 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 Multiple Dates of Services and Place of Services 5.11 Surgical and/or Obstetrical procedures 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. 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) 5.12 Billing When an inpatient claim spans different years (for example, the patient was 8/31/2011 9

10 Inpatient Claims That Span Different Years 5.13 Supporting Documentation for Paper Claims 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 payment methodologies when processing these 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/Fax Paper Claims Paper claims are accepted; however EDI (electronic) submission is preferred. No handwritten claims are accepted. Paper claims are not accepted via fax due to HIPAA regulations. 8/31/

11 Mail all paper claims to: Denver / Boulder Region Kaiser Permanente of Colorado Claims Administration P.O. Box Denver, CO Southern Colorado Region Kaiser Permanente of Colorado P.O. Box Denver, CO /31/

12 5.15 Electronic Data Interchange (EDI) Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of claims. 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 Electronic Claims Forms 5.17 Supporting Documentation for EDI Claims 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, and to follow all claims completion instructions set forth in this Manual. 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). 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. 8/31/

13 5.18 To Initiate Electronic Claims Submissions 5.19 Electronic Submission Process Trading Partners or Trading Parties interested in implementing EDI transactions with Kaiser Permanente should contact Regional EDI Business Operations for information via 1 Providers EDI Responsibilities: Once a Provider has entered all of the required data elements (e.g., all of the required data for a particular claim) into a their claims processing system, the Provider then electronically sends all of this information to a Clearinghouse for further data sorting and distribution. 2 Clearinghouse s EDI Responsibilities: The Clearinghouse receives information electronically from a variety of Providers, which have chosen that particular Clearinghouse as their data sorter and distributor. The Clearinghouse batches all of the information it has received from the various Providers, sorts the information, and then electronically sends the information to the payer that the provider has identified in the transaction for processing. Data content required by HIPAA Transaction Implementation Guides is the responsibility of the Provider and the Clearinghouse. The Clearinghouse should ensure HIPAA Transaction Set Format compliance with HIPAA rules. In addition, Clearinghouses: Frequently supply the required PC software to enable direct data entry in the Provider s office. Edit the data which is electronically submitted to the Clearinghouse by the Provider s office, so that the data submission will be accepted by the appropriate payer for processing. Transmit the data to the correct payer in a format easily understood by the payer s computer system. Transmit electronic claim status reports from payers to Providers. 3 Kaiser Permanente s EDI Responsibilities: Kaiser Permanente receives EDI information after the Provider sends it to the Clearinghouse for distribution. The data is loaded into Kaiser Permanente s claims systems electronically and it is prepared for further processing. On the same day that Kaiser Permanente receives the EDI claims, Kaiser Permanente prepares an electronic acknowledgement which is transmitted back to the Clearinghouse. 8/31/

14 5.20 HIPAA Requirements 5.21 Clean Claims NOTE: If a Provider is not receiving Kaiser Permanente s electronic claim acknowledgement from the Clearinghouse, contact your billing service or the Clearinghouse and request that this be routinely forwarded to you. All electronic claim submissions must adhere to all HIPAA requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) 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 (08/05 or 12/90 based on CMS guidelines) 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. 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). 8/31/

15 The claim was submitted fraudulently. Must comply with coding standards (detailed in Sections 5.36 and 5.37 of this Manual). 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 5.22 Claims Submission Timeframes 5.23 Claims Processing Turn-Around Time 5.24 Timely Claims Submission 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). 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. Refer to Section 5.21 of this Manual for the definition of a clean claim. 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. 8/31/

16 5.25 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 5.22 of this Manual. Acceptable proof of timely filing may include the following documentation and/or situations: EDI Transmission reports (reports from a clearinghouse i.e. Emdeon, Relay Health, ENS) Remit notices Denial notices *Hand-written or typed documentation is not acceptable proof of timely filing Claim Adjustments/ Corrections 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. Correcting a previously submitted claim If your claim requires correction, you will receive a notice on the remit 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 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 8/31/

17 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 Explanation of Payment (EOP) 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 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. 8/31/

18 5.27 Incorrect Claims Payments For an Underpayment Error: Write or call Claims Customer Service ( ) 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 you will be added to/reflected in your next Kaiser Permanente reimbursement check Rejected Claims Due to EDI Claims Error 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 Evidence of Payment to your refund check, as well as a brief note explaining the error. NOTE: If Kaiser Permanente s Evidence of Payment 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. 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 Federal The Federal Tax ID Number as reported on any and all claim form(s) must 8/31/

19 Tax ID Number 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-9. 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 Add Technician P.O. Box Denver, CO /31/

20 5.30 Changes in Federal Tax ID Number 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. 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 Add Technician P.O. Box Denver, CO National Provider Identification (NPI) As of May 23, 2008, Kaiser Permanente will not be able to process electronic claims unless they contain the NPI. If you have already obtained your NPI numbers (both Individual Type 1 and/or Organization/Group Type 2), please notify Kaiser Permanente Provider Contracting & Network Management department. 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, coinsurance 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 unless explicitly stated otherwise in your Agreement Member Claims Inquiries 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. Members seeking information regarding claims should contact Kaiser Permanente Customer Service at Visiting Claims for members visiting from Kaiser Permanente regions other than Colorado should be submitted as you would normally and will be paid at the 8/31/

21 Members 5.35 Coding for Claims 5.36 Coding Standards same rates pursuant to your agreement. It is the contracted provider s responsibility to ensure that billing codes used on claims forms are current and accurate, that codes reflect the services provided, that coding is consistent with the encounter documentation and that coding is in compliance with Kaiser Permanente s coding standards. 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. A full explanation of coding standards is provided in Section 5.37 of this manual. Incorrect and invalid coding may result in delays in payment or denial of payment. Coding All fields should be completed using industry standard coding as outlined below. ICD-9 To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9 th 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 fivedigit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth digit for coding specificity. 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 8/31/

22 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 5.37 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 (2) 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 8/31/

23 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. 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 5.39 Coding & Billing Validation 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. 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. 8/31/

24 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. 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. 8/31/

25 5.40 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 (see Section 5.40) 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 will correct input codes with out without valid modifiers to more closely correspond to accepted coding practices by eliminating, replacing or 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 CodeReview. HCPCS codes related to CPT codes CodeReview 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 8/31/

26 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. 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. 8/31/

27 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) 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 Customer Service at Kaiser Permanente 8/31/

28 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.) Additional circumstances where coding edits are applied are detailed in Section 5.52 of this Manual. CodeReview 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. When a change is made to your submitted code(s), it will be noted in your remit. 8/31/

29 5.41 Medical Claims Review 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 Third Party Liability (TPL) 5.43 Workers Compensation 5.44 Third Party Administrator (TPA) 5.45 Provider Claims Appeals If you should be contacted regarding medical claims review, we expect you to respond within the timeframe specified in our request. Kaiser Permanente uses a vendor to identify third party liability (TPL). Providers should submit such claims directly to Kaiser Permanente. Our vendor will analyze our claims data to determine where TPL is applicable. Kaiser Permanente will pay the claims to the provider and request any overpayments from the third party that has the primary responsibility of the charges. Workers Compensation claims are not covered by Kaiser Permanente. We will deny all claims related to Workers Compensation. 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 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 questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax. 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. 8/31/

30 5.46 CMS-1500 (08/05) FIELD DESCRIPTIONS 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. Note: The new CMS-1500 (08/05) form is revised to accommodate National Provider Identifiers (NPI). Kaiser currently accepts both forms. 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. 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 if Applicable 7 INSURED S ADDRESS Required if Applicable 8 PATIENT STATUS Required if Applicable 9 OTHER INSURED S NAME 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. Check the appropriate box for the patient s MARITAL STATUS, and check whether the patient is EMPLOYED or is a STUDENT. When additional insurance coverage exists, enter the last name, first name and middle initial of the insured. 8/31/

31 FIELD NUMBER 9a 9b FIELD NAME OTHER INSURED S POLICY OR GROUP NUMBER OTHER INSURED S DATE OF BIRTH/SEX REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if Applicable Required if Applicable INSTRUCTIONS/EXAMPLES 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 other insured s date of birth and sex. The date of birth must include the month, day, and FOUR DIGITS for year (MM/DD/YYYY). Example: 01/05/2006 9c EMPLOYER S NAME OR SCHOOL NAME Required if Applicable Enter the name of the other insured s EMPLOYER or SCHOOL NAME (if a student). 9d 10a-c INSURANCE PLAN NAME OR PROGRAM NAME IS PATIENT CONDITION RELATED TO Required if Applicable Required 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). Place (State) - enter the State postal code. 10d RESERVED FOR LOCAL USE Not Required Leave blank. 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). Example: 01/05/ b EMPLOYER S NAME OR SCHOOL NAME Not Required Enter the name of the employer or school (if a student), if applicable. 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. 8/31/

32 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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/ NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required if Applicable 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 8/31/

33 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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 Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization. 19 RESERVED FOR LOCAL USE Required if Applicable If you are covering for another physician, enter the name of the physician (for whom you are covering) in this field. If a non-contracting Provider/Provider will be covering for you in your absence, please notify that individual of this requirement. 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 4 diagnostic codes, in PRIORITY order (primary, secondary condition). 22 MEDICAID RESUBMISSION Not Required 23 PRIOR AUTHORIZATION NUMBER Required if Applicable Enter the prior authorization number for those procedures requiring prior approval. 24a-g 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. 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 8/31/

34 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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 SUPPLIES: CPT/HCPCS, MODIFIER Required Enter the CPT/HCPCS codes and MODIFIERS (if 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 8/31/

35 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES (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 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 8/31/

36 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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). 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. 8/31/

37 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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. 8/31/

38 8/31/

39 5.47 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 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 14 outpatient care, enter the 2-digit code for the hour during which the member was admitted or seen. 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 (DHR) Applicable 17 PATIENT STATUS Required Enter the discharge status code CONDITION CODES Required if Applicable 29 ACCIDENT (ACDT) STATE Not Required 30 BLANK Not Required Leave blank. Enter the two-digit code for the hour during which the member was discharged. Enter any applicable codes which identify conditions relating to the claim that may affect claims processing. Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment. 8/31/

40 FIELD NUMBER FIELD NAME OCCURRENCE CODES AND DATES OCCURRENCE SPAN CODES AND DATES REQUIRED FIELDS FOR CLAIM SUBMISSIONS 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 45 Not Required Enter the revenue description. Required For ALL outpatient claims, enter BOTH a revenue code in Field 42 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field. 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. 8/31/

41 FIELD NUMBER FIELD NAME 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 (NPI). IDENTIFIER (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. Required 69 ADMITTING DIAGNOSIS 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. 8/31/

42 FIELD NUMBER 70 (a-c) FIELD NAME REASON FOR VISIT (PATIENT REASON DX) REQUIRED FIELDS FOR CLAIM SUBMISSIONS Not Required 71 PPS CODE Required if Applicable INSTRUCTIONS/EXAMPLES Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration. Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology. 72 EXTERNAL CAUSE OF Required if Enter an ICD-9-CM E-code in this field (if applicable). 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. Required 76 ATTENDING PHYSICIAN / NPI / QUAL / ID 77 OPERATING PHYSICIAN / NPI/ QUAL/ ID OTHER PHYSICIAN/ NPI/ QUAL/ ID Required If Applicable Required if 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. 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. 8/31/

43 8/31/