UB-04 Workshop. Presented by: Xerox State Healthcare, LLC Provider Relations

Transcription

1 UB-04 Workshop Presented by: Xerox State Healthcare, LLC Provider Relations

2 Resources When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section

3 Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL BILLING INSTRUCTIONS REGISTERS AND SUPPLEMENTS:

4 Important Update Oct. 1, 2014 will be the compliance date for use of new codes that classify diseases and health problems. These code sets, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes. 4 November 20, 2013

5 Purpose of the Workshop Provide complete explanation of how to fill out the UB-04 paper claim form for: Claim Form Instructions Primary Medicaid Medicaid secondary to a Third Party Liability (TPL) HMO copayments Medicare replacement plans Additional information Medicare Crossovers Inpatient claims for Medicare Part B-only clients. Medicaid Tertiary 5

6 Claim Form Instructions

7 Where to get a copy of claim form instructions Click Forms, Publications, and Instructions under Provider Information

8 Where to get a copy of claim form instructions Scroll down Open file

9 Medicaid Primary Claim Forms

10 Medicaid Primary Outpatient Example Provider Name Street City, State Zip Patient Name 01/01/1931 F 01 01/14/ /14/ MRI Drugs/Detail Code A

11 Medicaid Primary Outpatient Example MEDICAID CONNIE CLIENT Billing NPI B3 332S00000X Qualifier Taxonomy 11

12 New Hospital Outpatient Payment Method for New Mexico Medicaid All General Acute Hospitals and Rehabilitation Hospitals must include a procedure code on every line item to receive payment. It is recommended that you bill all outpatient services for the same date of service on the same claim form all inclusive.

13 New Hospital Outpatient Payment Method for New Mexico Medicaid The following resources are available on the HSD/MAD website located at: Hospital Outpatient Payment Method FAQ Hospital Outpatient Payment Method Revenue Codes Hospital Outpatient Payment Method Procedure Codes Notice of Hospital Outpatient Prospective payment System Rates Explanation of Simulation Spreadsheet for Outpatient services

14 NCCI (National Corrective Coding Initiative) Is a CMS program that consists of coding policies and edits. Medicaid NCCI Edits consist of two types: (1) NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and (2) Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas). 14

15 NCCI (National Corrective Coding Initiative) RA EOB Codes: 6501 or Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service through Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit. Please visit the link below for any additional information: Topics/Data-and-Systems/National-Correct-Coding-Initiative.html 15

16 Medicaid Primary Federal Qualified Health Center (FQHC) Example Provider Name Street City, State Zip Patient Name 01/01/1931 F 01/14/ /14/ CLINIC VISIT

17 Medicaid Primary FQHC Example MEDICAID CONNIE CLIENT Billing NPI B3 332S00000X Qualifier Taxonomy

18 Medicaid Primary Inpatient Example Provider Name Required if pay to is Street different than physical City, State Zip address. 05/30/07 06/05/07 Patient Name /01/1931 F 05/30/07 01 Covered days are entered in FL 39 and FL Room and Board/Semi ICU/Medical ICU/Medical Pharmacy Drugs/Generic Med-Sur Supplies Laboratory or Lab

19 Medicaid Primary Inpatient Example MEDICAID CONNIE CLIENT Billing NPI Attending physician is only required on inpatient hospital services ATTENDING ALAN B3 332S00000X Qualifier Taxonomy 19

20 Medicaid Primary Long Term Care W/Covered and Non-Covered Days Example Provider Name Street City, State Zip 04/01/07 04/30/ /01/1931 F 01/01/ =covered days 81= non-covered days Covered and Non Covered Days are entered in FL 39 and FL Room and Board 27 8,

21 Medicaid Primary Long Term Care W/Covered and Non-Covered Days Example MEDICAID CONNIE CLIENT , Billing NPI Qualifier B3 332S00000X Taxonomy 21

22 Timely Filing

23 What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: The first digit indicates what the claim media is: Batch number 1= Debit 2= Credit 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim The last two digits of the year the claim was received The numeric day of the year. The claim number within the batch. 9 = Web portal claim entry This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87 th day of 2013, or March 28,

24 Timely Filing Denials Re-filing Claims and Submitting Adjustments UB Form: Put the TCN in Form Locator 64 Transaction Control Number (TCN) matching the appropriate payer line, using a paper form.

25 Timely Filing Denials Re-filing Claims and Submitting Adjustments UB-04 form: Put the TCN in block 64 on the paper form MEDICAID , CONNIE CLIENT B3 332S00000X 25

26 Medicaid Third Party Liability (TPL) Claim Forms

27 Third Party Liability (TPL) Tips TPL is commercial insurance TPL must be billed primary to Medicaid Medicaid does not consider Medicare TPL 27

28 TPL Tips When filling out a Medicaid claim where TPL is primary payer, be sure to fill in all required primary and secondary payer information. Always enter the amount the insurance has paid in Box 54 on the UB-04. If Medicaid requires a PA for the service, then a PA issued by Medicaid Utilization Review is always required when TPL is involved, no matter if TPL paid or denied the service. Attach the TPL EOB showing the payment/denial with the claim. Always include the explanation page of the EOB along with the page of the EOB that shows payment/denial. 28

29 Medicaid TPL Claim Example UNITEDHEALTHCARE COMMUNITY PLAN TPL Payment MEDICAID CONNIE CLIENT CONNIE CLIENT ABC, INC ATTENDING ALAN B3 332S00000X Qualifier Taxonomy 29

30 Medicaid HMO/PPO Copayment Claim Forms

31 HMO Co-Pay Tips Write HMO Co-pay Due on the claim. Attach the EOB. In the amount paid (field Box 54), enter the difference between the billed amount and the co-payment. Enter the co-payment amount in the est. amount due field (BOX 55). 31

32 HMO Co-pay Claim Example HMO COPAY ONLY Provider Name Required if pay to is Street different than physical City, State Zip address. 05/30/07 06/05/07 Patient Name /01/1931 F 05/30/07 01 Covered days are entered in FL Room and Board/Semi ICU/Medical ICU/Medical Pharmacy Drugs/Generic Med-Sur Supplies Laboratory or Lab

33 HMO Co-pay Claim Example Cop-pay/ Co-insurance/ Deductible UNITEDHEALTHCARE COMMUNITY PLAN MEDICAID TPL Payment CONNIE CLIENT ABC, INC. CONNIE CLIENT ATTENDING ALAN B3 332S00000X QUALIFIER TAXONOMY 33

34 Medicare Replacement Plan Claim Forms

35 Medicare Replacement Plan (MRP) Claim Tips Write Medicare Replacement Plan Only on the claim. Attach the EOB. In the amount paid field (BOX 54), enter the difference between the billed amount and the co-payment. Enter the co-payment amount in the est. amount due field (Box 55). 35

36 MRP Claim Example Medicare Replacement Plan Only Provider Name Required if pay to is Street different than physical City, State Zip address. 05/30/07 06/05/07 Patient Name /01/1931 F 05/30/ Room and Board/Semi ICU/Medical ICU/Medical Pharmacy Drugs/Generic Med-Sur Supplies Laboratory or Lab

37 MRP Claim Example Copay Due Total billed amount HUMANA MEDICAID CONNIE CLIENT CONNIE CLIENT ABC, INC Billed Copay = Paid amount value ATTENDING ALAN B3 332S00000X 37

38 Medicare Primary Claim Forms (Crossovers)

39 Medicare Primary Claims When billing for clients covered by Medicare for which Medicare has paid something on the claim and the claim DID NOT automatically crossover from Medicare to Xerox, submit those claims via paper to Xerox with the Medicare Explanation of Benefits (EOMB) attached. 39

40 Medicare Primary Claims When primary Medicare claims are submitted on paper: Fill out claim form exactly as the claim was submitted to Medicare (except for FQHCs.) Claim must match Medicare EOMB. Attach Medicare EOMB. Medicaid does not consider Medicare to be TPL. If any of the TPL information is filled in for a Medicare claim, the claim will deny as TPL indicated on claim so be certain that you do not fill in any of the TPL information blocks. 40

41 Medicare Primary Example MEDICARE MEDICAID CONNIE CLIENT CONNIE CLIENT A ATTENDING ALAN QUALIFIER B3 332S00000X TAXONOMY 41

42 Inpatient claims for Medicare Part B-only clients

43 Inpatient Claims for Medicare Part B-only clients Certain Medicaid/Medicare clients only have Medicare Part B coverage. Medicare may cross over the Part B claim with type of bill 121. This claim does not have an accommodation revenue code on it. The claim will deny and the provider will need to resubmit on paper and include the following four things on the claim: 43

44 Inpatient claims for Medicare Part Use type of bill 121. B-only clients Write Medicare Part B only on the claim form. Indicate Medicare paid amount in previous payment box (form locator 54). Attach a copy of the EOMB indicate Medicare paid amount in previous payment box (form locator 54). 44

45 Inpatient claims for Medicare Part Provider Name Required if pay to is Street different than physical City, State Zip address. 05/30/ /05/2007 Patient Name B-only clients MEDICARE PART B ONLY /01/1931 F 05/30/ Room and Board/Semi ICU/Medical ICU/Medical Pharmacy Drugs/Generic Med-Sur Supplies Laboratory or Lab

46 Inpatient claims for Medicare Part B-only clients MEDICARE TPL Payment amount MEDICAID CONNIE CLIENT CONNIE CLIENT Attending physician is only required on inpatient services ATTENDING ALAN B3 332S00000X QUALIFIER TAXONOMY 46

47 Medicaid Tertiary Claim Forms

48 Medicaid Tertiary Claims Submit a Medicaid tertiary claim as follows: Medicare primary TPL secondary Medicaid tertiary Fill out the information as you would for a Medicaid Secondary to a TPL claim and add a payer line for the Medicare information. Attach TPL EOB. Attach Medicare EOMB. 48

49 Medicaid Tertiary Claim Example MEDICARE UNITEDHEALTHCARE COMMUNITY PLAN MEDICAID CONNIE CLIENT CONNIE CLIENT ABC, INC CONNIE CLIENT ATTENDING ALAN QUALIFIER B3 332S00000X TAXONOMY 49

50 UB-04 Reminders

51 Did you remember? Ensure the line item charges are correct and match the total charge. If you re a for profit organization, make sure gross receipts tax is included in the line items, if required. Rev codes, diagnosis codes, etc., are entered correctly. 51

52 Did you remember? Date the claim. Include your NPI Billing number. Include all appropriate EOB s for TPL, HMO, Medicare, etc. Attach proof of timely filing/tcn if needed. 52

53 Resources When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section

54