Highmark Blue Shield. Facility Billing Reference Manual

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Amberly Harmon
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1 Highmark Blue Shield Facility Billing eference Manual

3 The manual consists of each UB locator and any specific instructions as it relates to billing Highmark Blue Shield. A complete list of all locator values can be obtained through the NUBC (National Uniform Billing Committee) website at TABLE OF CONTENTS - LISTED ALPHABETICALLY DATA ELEMENT LOCATO(S) ACCIDENT STATE 29 ADMISSION HOU 3 ADMISSION/STAT OF CAE DATE 2 ADMITTING DGNOSIS CODE 69 ASSIGNMENT OF BENEFITS CETIFICATION INDICATO 53 A, B, C ATTENDING POVIDE NAME AND IDENTIFIES 76 BILLING POVIDE NAME, ADDESS AND TELEPHONE NUMBE 0 CODE - CODE FIELD 8 CONDITION CODES 8-28 DGNOSIS AND POCEDUE CODE QUALIFIE (ICD VESION 66 INDICATO) DISCHAGE HOU 6 DOCUMENT CONTOL NUMBE (DCN) 64 A, B, C EMPLOYE NAME (OF THE INSUED) 65 A, B, C ESTIMATED AMOUNT DUE - PAYE 55 A, B, C EXTENAL CAUSE OF INJUY (ECI) CODE 72 A, B, C FEDEAL TAX NUMBE 05 HCPCS/ACCOMMODATION ATES/HPS ATE CODES 44 HEALTH PLAN IDENTIFICATION NUMBE 5 A, B, C INSUED'S GOUP NAME 6 A, B, C INSUED'S GOUP NUMBE 62 A, B, C INSUED'S NAME 58 A, B, C INSUED'S UNIQUE IDENTIFIE 60 A, B, C MEDICAL/HEALTH ECOD NUMBE 03b NATIONAL POVIDE IDENTIFIE - BILLING POVIDE 56 NON-COVEED CHAGES 48 OCCUENCE CODES AND DATES 3-34, A& B OCCUENCE SPAN CODES AND DATES 35 A & B EATING PHYSICN NAME AND IDENTIFIES 77 OTHE (BILLING) POVIDE IDENTIFIE 57 OTHE DGNOSIS CODES 67 A - Q OTHE POCEDUE CODES AND DATES 74 A - E OTHE POVIDE (INDIVIDUAL) NAMES AND IDENTIFIES PATIENT ADDESS 09 PATIENT BITHDATE 0 PATIENT CONTOL NUMBE 03a PATIENT DISCHAGE STATUS 7 PATIENT NAME/IDENTIFIE 08

4 TABLE OF CONTENTS - LISTED ALPHABETICALLY DATA ELEMENT LOCATO(S) PATIENT SEX PATIENT'S EASON FO VISIT 70 A, B, C PATIENT'S ELATIONSH TO INSUED 59 A, B, C PAYE NAME 50 A, B, C PAY-TO NAME AND ADDESS 02 PINCAL DGNOSIS CODE (PDC) AND PESENT ON ADMISSION 67 INDICATO (POA) PINCAL POCEDUE CODE AND DATE 74 PIO PAYMENTS - PAYE 54 A, B, C PIOITY (TYPE) OF VISIT 4 POSPECTIVE PAYMENT SYSTEM (PPS) CODE 7 ELEASE OF INFOMATION CETIFICATION INDICATO 52 A, B, C EMAKS FIELD 80 ESEVED FO ASSIGNMENT BY THE NUBC 07 ESEVED FO ASSIGNMENT BY THE NUBC 30 ESEVED FO ASSIGNMENT BY THE NUBC 75 ESEVED FO ASSIGNMENT BY THE NUBC 73 ESEVED FO ASSIGNMENT BY THE NUBC 68 ESEVED FO ASSIGNMENT BY THE NUBC 37 ESEVED FO ASSIGNMENT BY THE NUBC 49 ESPONSIBLE PATY NAME AND ADDESS (CLAIM ADDESSEE) 38 EVENUE CODES 42 EVENUE DESCTION 43 SEVICE DATE 45 SEVICE UNITS 46 SOUCE OF EFEAL FO ADMISSION O VISIT 5 STATEMENT COVES PEIOD - FOM/THOUGH 06 TOTAL CHAGES 47 TEATMENT AUTHOIZATION CODE 63 A, B, C TYPE OF BILL 04 VALUE CODES AND AMOUNTS 39, 40, 4 A-D

5 LOCATO EDIT GUIDELINES - EQUIEMENT INDICATO Your key to understanding the equirement Indicator... HHA/Hospice * * * * * * "HOSPITAL and " 'Inpatient' and 'Outpatient' claims for: >General hospital [acute care and all distinct units] >Physical rehabilitation hospital >Psychiatric hospital "NON-HOSPITAL " 'Inpatient' claims for: >Alcohol & Drug ehabilitation [AD] facility - Freestanding and Based >Veterans Administration [VA] hospital "NON-HOSPITAL " 'Outpatient' claims for: >Alcohol & Drug ehabilitation [AD] facility - Freestanding and Based >Ambulatory Surgery Center [ASC] >Dialysis facility - Freestanding and Based >Veterans Administration [VA] hospital "" >Freestanding Skilled Nursing Facility [] >-Based Skilled Nursing Facility "" >Freestanding Home Health Agency[HHA]/Hospice >-Based Home Health Agency[HHA]/Hospice KEY TO EQUIEMENT INCIDATO "" = equired "N" = Not equired or Not Applicable "" = If Applicable [required in certain instances]

7 LOCATO(S) Data Element: BILLING POVIDE NAME, ADDESS AND TELEPHONE NUMBE Minimum requirement is the provider's name, city, state and zip code. EQUIEMENT INDICATO LOCATO(S) 02 4 Data Element: PAY-TO NAME AND ADDESS 25 The address that the Provider submitting the bill intends payment to be sent IF DIFFEENT THAT FL0. EQUIEMENT INDICATO N N N N N N LOCATO(S) 03a Data Element: PATIENT CONTOL NUMBE 24 ecord the patient's unique alpha-numeric account number assigned by the provider. This number will appear on the remittance advice. EQUIEMENT INDICATO Page

8 LOCATO(S) 03b Data Element: MEDICAL/HEALTH ECOD NUMBE 24 The number assigned to the patient's medical/health record by the provider. EQUIEMENT INDICATO N N N N N N LOCATO(S) 04 Data Element: TYPE OF BILL 4 Each number of this four-digit code holds a specific meaning and is sequenced as follows: st digit - Leading 0 (do not include on electronic claims) 2nd digit - Type of Facility 3rd digit -Bill Classification 4th digit - Frequency EQUIEMENT INDICATO LOCATO(S) 05 Data Element: FEDEAL TAX NUMBE 2 4 upper 0 lower EQUIEMENT INDICATO Page 2

9 LOCATO(S) 06 2 Data Element: STATEMENT COVES PEIOD - FOM/THOUGH ecord the month, day and year for both dates. ecord the same date in both the "From" and "Through" fields when services are rendered on a single day. EQUIEMENT INDICATO LOCATO(S) 07 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC NOT USED 2 7 upper 8 lower EQUIEMENT INDICATO LOCATO(S) 08 2 subfields: a, b 2 Data Element: PATIENT NAME/IDENTIFIE 9a 29b NAME SHOULD BE EPOTED EXACTLY AS ON THE MEMBE'S ID CAD EQUIEMENT INDICATO Page 3

10 LOCATO(S) 09 Data Element: PATIENT ADDESS 5 subfields: a, b, c, d, e 40 a 30 b 2 c 9 d 2 e EQUIEMENT INDICATO LOCATO(S) 0 Data Element: PATIENT BITHDATE 8 Enter the month, day, and year of birth. The complete birth date must be entered for all claims. EQUIEMENT INDICATO LOCATO(S) Data Element: PATIENT SEX EQUIEMENT INDICATO Page 4

11 LOCATO(S) 2 Data Element: ADMISSION/STAT OF CAE DATE 6 EQUIEMENT INDICATO N N LOCATO(S) 3 Data Element: ADMISSION HOU 2 Alpha/Numeric The admission hour (service time) is required only on inpatient claims. EQUIEMENT INDICATO N N N N N N LOCATO(S) 4 Data Element: PIOITY (TYPE) OF VISIT FO COMPLETE CODE INFOMATION, PLEASE EFEENCE THE NATIONAL UNIFOM BILLING MANUAL EQUIEMENT INDICATO N N N Page 5

12 LOCATO(S) 5 Data Element: SOUCE OF EFEAL FO ADMISSION O VISIT FO COMPLETE CODE INFOMATION, PLEASE EFEENCE THE NATIONAL UNIFOM BILLING MANUAL EQUIEMENT INDICATO * * *Optional but recommended N LOCATO(S) 6 Data Element: DISCHAGE HOU 2 Alpha/Numeric EQUIEMENT INDICATO N N N N LOCATO(S) 7 Data Element: PATIENT DISCHAGE STATUS 2 FO COMPLETE CODE INFOMATION, PLEASE EFEENCE THE NATIONAL UNIFOM BILLING MANUAL EQUIEMENT INDICATO Page 6

13 LOCATO(S) 8-28 Data Element: CONDITION CODES 2 each FO COMPLETE CODE INFOMATION, PLEASE EFEENCE THE NATIONAL UNIFOM BILLING MANUAL EQUIEMENT INDICATO LOCATO(S) 29 Data Element: ACCIDENT STATE 2 EQUIEMENT INDICATO N N N N N N LOCATO(S) 30 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 2 3 EQUIEMENT INDICATO Page 7

14 LOCATO(S) 3-34, A& B 4 code 2 code Data Element: OCCUENCE CODES AND DATES 2 code FO COMPLETE CODE INFOMATION, PLEASE EFEENCE THE NATIONAL UNIFOM BILLING MANUAL EQUIEMENT INDICATO LOCATO(S) 35 A & B Data Element: OCCUENCE SPAN CODES AND DATES 4 date 2 date 6 date EQUIEMENT INDICATO LOCATO(S) 37 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 2 8 EQUIEMENT INDICATO Page 8

15 LOCATO(S) 38 Data Element: ESPONSIBLE PATY NAME AND ADDESS (CLAIM ADDESSEE) 5 40 EQUIEMENT INDICATO N N N N N N LOCATO(S) 39, 40, 4 A-D 3 code 3 amt 4 code 4 amt Data Element: VALUE CODES AND AMOUNTS 2 code 9 amt Only use value codes when reporting other insurance on paper submitted claims. If submitting secodary or tertiary claims electronically, report the appropriate CAS Codes. Covered Days, Non-Covered Days, Co-Insurance Days, Lifetime eserve Days are now reported using the appropriate Value Code. EQUIEMENT INDICATO Page 9

16 LOCATO(S) 42 Data Element: EVENUE CODES 23 4 For inpatient claims, record the accommodation revenue code(s) first, then record the ancillary code(s). There are no restrictions on the number of accommodation revenue codes for inpatient claims. For inpatient claims, do not record duplicate accommodations revenue codes unless the room rate differs for the same accommodations category. For outpatient claims, do not record duplicate ancillary revenue codes unless HCPCS codes are present and the HCPCS are different or if the HCPCS Codes are the same but the associated charge per unit is different. When reporting multiple surgical procedures on an outpatient claim, report a separate service line for each service. Each line must include the HCPCS Code for the procedure preferred. EQUIEMENT INDICATO LOCATO(S) 43 Data Element: EVENUE DESCTION EQUIEMENT INDICATO *N *N *N *N * NOTE: this data element is required only for paper submitted claims. *N *N Page 0

17 LOCATO(S) Numeric (rate) Alpha/numeric (HCPCS/HPS) Data Element: HCPCS/ACCOMMODATION ATES/HPS ATE CODES OUTPATIENT BILLS For outpatient clinical diagnostic laboratory, surgery, radiology, other diagnostic, prosthetic/orthotic and therapeutic services, enter the HCPCS code describing the service. Various CPT and HCPCS codes may require the use of modifiers to improve the accuracy of coding. Consequently, reimbursement, coding consistency, editing, and proper payment will benefit from the reporting of modifiers. Facilities should not report a separate HCPCS (fivedigit code) instead of the modifier. eport the applicable Health Insurance Prospective Payment System (HPS) rate code on FreedomBlue claims for Skilled Nursing, Home Health and Inpatient ehabilitation Services. EQUIEMENT INDICATO * ** * * ate Only ** HCPCS only LOCATO(S) 45 Data Element: SEVICE DATE (service date) (creation date) 6 (service date) 6 (creation date) EQUIEMENT INDICATO N N N Page

18 LOCATO(S) 46 Data Element: SEVICE UNITS 22 7 EQUIEMENT INDICATO LOCATO(S) 47 Data Element: TOTAL CHAGES 23 9 (7 dollar 2 cents) EQUIEMENT INDICATO LOCATO(S) 48 Data Element: NON-COVEED CHAGES 23 9 (7 dollar 2 cents) equired if needed to report line specific non-covered charge amount. EQUIEMENT INDICATO N N N Page 2

19 LOCATO(S) 49 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 23 2 EQUIEMENT INDICATO LOCATO(S) 50 A, B, C Data Element: PAYE NAME 3 23 EQUIEMENT INDICATO LOCATO(S) 5 A, B, C 3 Data Element: HEALTH PLAN IDENTIFICATION NUMBE 5 Until a Helath Plan Identification Number has been assigned, report NAIC 5477C. EQUIEMENT INDICATO N N N N N N Page 3

20 LOCATO(S) 52 A, B, C Data Element: ELEASE OF INFOMATION CETIFICATION INDICATO 3 EQUIEMENT INDICATO LOCATO(S) 53 A, B, C Data Element: ASSIGNMENT OF BENEFITS CETIFICATION INDICATO 3 EQUIEMENT INDICATO LOCATO(S) 54 A, B, C Data Element: PIO PAYMENTS - PAYE 3 0 (8 dollar 2 cents) The A, B and C indicators refer to the payers described in locator 50. Enter the amount paid by the primary payer (line A, B and C). DO NOT INCLUDE CONTACTUAL ADJUSTMENT.. EQUIEMENT INDICATO Page 4

21 LOCATO(S) 55 A, B, C 3 Data Element: ESTIMATED AMOUNT DUE - PAYE 0 8 dollar 2 cent) Optional for use on claims in conjunction with locator 54. EQUIEMENT INDICATO LOCATO(S) 56 5 Data Element: NATIONAL POVIDE IDENTIFIE - BILLING POVIDE equired for provider on or after the mandated HAA National Provider Identifier (NPI) implementation date. EQUIEMENT INDICATO LOCATO(S) 57 3 Data Element: OTHE (BILLING) POVIDE IDENTIFIE 5 eport Highmark Provider Number. equired for providers until mandated NPI implementation date. EQUIEMENT INDICATO Page 5

22 LOCATO(S) 58 A, B, C Data Element: INSUED'S NAME 3 25 EQUIEMENT INDICATO LOCATO(S) 59 A, B, C Data Element: PATIENT'S ELATIONSH TO INSUED 3 2 EQUIEMENT INDICATO LOCATO(S) 60 A, B, C 3 Data Element: INSUED'S UNIQUE IDENTIFIE 20 EQUIEMENT INDICATO Page 6

23 LOCATO(S) 6 A, B, C Data Element: INSUED'S GOUP NAME 3 4 ecord the insured's group name in locator 6 A, B and C that relates to the payer's name in locator 50 A, B and C. EQUIEMENT INDICATO LOCATO(S) 62 A, B, C 3 Data Element: INSUED'S GOUP NUMBE 7 Enter the insured's group number in locater 62 A, B and C that relates to the payer's name in locator 50 A, B and C. EQUIEMENT INDICATO LOCATO(S) 63 A, B, C 3 Data Element: TEATMENT AUTHOIZATION CODE 30 EQUIEMENT INDICATO N N N N N N Page 7

24 LOCATO(S) 64 A, B, C 3 Data Element: DOCUMENT CONTOL NUMBE (DCN) 26 eport original claim number when submitting an adjusted bill EQUIEMENT INDICATO LOCATO(S) 65 A, B, C 3 Data Element: EMPLOYE NAME (OF THE INSUED) 25 EQUIEMENT INDICATO N N N N N N LOCATO(S) 66 Data Element: DGNOSIS AND POCEDUE CODE QUALIFIE (ICD VESION INDICATO) EQUIEMENT INDICATO N N N N N N Page 8

25 LOCATO(S) 67 Data Element: PINCAL DGNOSIS CODE (PDC) AND PESENT ON ADMISSION INDICATO (POA) POA ia not required at this time but may be in the future. -7 (PDC) 8 (POA) EQUIEMENT INDICATO LOCATO(S) 67 A - Q 7 Data Element: OTHE DGNOSIS CODES 2-7 (DC) 8 (POA) EQUIEMENT INDICATO LOCATO(S) 68 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 2 8 (line ) 9 (line 2) EQUIEMENT INDICATO Page 9

26 LOCATO(S) 69 Data Element: ADMITTING DGNOSIS CODE 7 ICD-9 Code describing patients diagnosis at time of admission. equired when claim involves an inpatient admission. EQUIEMENT INDICATO N N LOCATO(S) 70 A, B, C FIELD 3 SUBFIELDS Data Element: PATIENT'S EASON FO VISIT 7 ICD-CM diagnosis describing the patient's reason for visit at the time of outpatient registration. equired when claim involves visit. EQUIEMENT INDICATO N N N LOCATO(S) 7 Data Element: POSPECTIVE PAYMENT SYSTEM (PPS) CODE 4 EQUIEMENT INDICATO N N N N N N Page 20

27 LOCATO(S) 72 A, B, C Data Element: EXTENAL CAUSE OF INJUY (ECI) CODE 3-7 (PDC) 8 (POA) EQUIEMENT INDICATO N N N N N N LOCATO(S) 73 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 9 EQUIEMENT INDICATO LOCATO(S) 74 code date Data Element: PINCAL POCEDUE CODE AND DATE 7 code 6 date The use of ICD-9-CM procedure codes are restricted to the reporting of inpatient procedures by hospitals. equired on Inpatient claims when a procedure was performed. EQUIEMENT INDICATO N N N Page 2

28 LOCATO(S) 74 A - E 5 code 5 date Data Element: OTHE POCEDUE CODES AND DATES 7 code 6 date The use of ICD-9-CM procedure codes are restricted to the reporting of inpatient procedures by hospitals. equired on Inpatient claims when additional procedures must be reported. EQUIEMENT INDICATO N N N LOCATO(S) 75 Data Element: ESEVED FO ASSIGNMENT BY THE NUBC 4 4 EQUIEMENT INDICATO Page 22

29 LOCATO(S) Data Element: ATTENDING POVIDE NAME AND IDENTIFIES Attending plysician required on inpatient claims. Until the mandated HAA implementation date for the National Provider Identifier (NPI), Highmark will accept NPI or UPIN. eport the appropriate qualifier identifying the number being reported. OB - State License Number IG - Provider UPIN Number G2 - Provider Commercial Number EI - Employer's Identification Number SY - Social Security Number LINE 22 LINE 2 28 EQUIEMENT INDICATO Page 23

30 LOCATO(S) 77 Data Element: EATING PHYSICN NAME AND IDENTIFIES 5 2 Until the mandated HAA implementation date for the National Provider Identifier (NPI), Highmark will accept NPI or UPIN. eport the appropriate qualifier identifying the number being reported. OB - State License Number IG - Provider UPIN Number G2 - Provider Commercial Number EI - Employer's Identification Number SY - Social Security Number LINE 22 LINE 2 28 Operating physician required on inpatient claims when revenue code equals , , or and a principal procedure code is reported. Operating physician required on outpatient claims when revenue code equals , , or and HCPCS Codes equals EQUIEMENT INDICATO LOCATO(S) Data Element: OTHE POVIDE (INDIVIDUAL) NAMES AND IDENTIFIES 6 2 LINE 24 LINE 2 28 EQUIEMENT INDICATO Page 24

31 LOCATO(S) 80 Data Element: EMAKS FIELD 4 LNE 9 LINE EQUIEMENT INDICATO LOCATO(S) 8 (CODE QUALIFIE) (CODE) (NUMBE O VALUE) Data Element: CODE - CODE FIELD 4 (CODE QUALIFIE) 4 (CODE) 4 (NUMBE O VALUE) 2 (CODE QUALIFIE) 0 (CODE) 2 (NUMBE O VALUE) This field may be used to report additional codes related to a form locater (overflow). NOTE: TAXONOMY NUMBE NOT EQUIED BUT ENCOUAGED FO PE ENUMEATION AND PAYMENT OF CLAIMS. USE QUALIFIE B3 WHEN EPOTING TAXONOMY. Code List Qualifiers: A - Condition Code A2 - Occurrence Codes A3 - Occurrence Span Codes A4 - Value Codes B3 - Taxonomy Codes EQUIEMENT INDICATO Page 25

* Specific codes required (refer to UB-04 manual) Required. Optional. Required if applicable. Not required. Field No. Field Name Instructions

* Specific codes required (refer to UB-04 manual) Required. Optional. Required if applicable. Not required. Field No. Field Name Instructions equired ptional A equired if applicable N P 01 Billing provider name, address and telephone number (phone # and fax # desirable) The name and service location of the provider submitting the bill. Enter