Transcript UB-04 Billing Instructions

Home Health UB-04
Claim form billing instructions for
Maricopa Care Advantage and University
Physicians Care Advantage
Overview
This step-by-step presentation is intended to provide
information to assist those who bill Maricopa Care
Advantage and University Physicians Care Advantage for
Medicare covered home health care services. The intent is
to help you to complete the UB-04 billing form correctly the
first time. This presentation is to be used in conjunction
with General Rules, your provider guidelines and
supplemental information.
Maricopa Care Advantage and University Physicians Care
Advantage reimburse for home health service at 100%
leaving no cross over for AHCCCS.
We hope you find this tutorial helpful
Claims Processing
 Paper claims submitted by mail go through UPHP’s Document
Management Imaging company, Avidity.
 Avidity processes hardcopy claims using Optical Character
Recognition (OCR) scanning.
 Please make sure your claim form meets OCR specifications. For
more information on specifications go to:
http://www.webopedia.com/TERM/O/optical_character_recognition.
html
 Use commercially available “red form” versions of the UB-04 CMS1450
Introducing the UB-04
 Not sure if you are using the correct form?
The bottom left corner will look like this.
Top section
Red = Required
Yellow = Optional
Box 1 - Required
Home Health
PO Box ###
Anytown, AZ 85###
Billing Provider Information
 Enter the name and address of the Home Health
agency requesting to be paid for services
rendered.
Box 3a - Required
X123400
Patient Account Number
 Enter your recipient account number here.
 This box allows up to twelve characters.
 UPHP will report this number in Remittance Advices to
provide cross reference between UPHP Claim Numbers
and the Provider Member Number.
Box 4 - Required
322
Type of Bill
 Enter the three-digit numeric code to identify the
type of claim you are billing.
 Bill Type 322 and 332 are RAP bills
 Bill Type 329 and 339 are FINAL or LUPA
(depending on how many visits occurred during the
60 day episode)
 Remember:
 5 or less visits – last bill is LUPA
 More than 5 visits – last bill is FINAL
Box 6 - Required
120110
120710
Statement Covers Period
 Enter the beginning and ending dates of services
covered by this claim.
 Please note - this box must list numeric dates of
service.
Box 8a-e - Required
Patient, Your
Recipient Name
 Enter the recipient’s name exactly as it is printed on
the Identification Card.
 Use the recipient’s last name first.
 Do not use nicknames.
Box 12 - Required
120110
Admission Date
 Enter the actual admission date, even if the recipient
was not eligible on that date.
Box 15 and 17 - Required
5
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30
Box 15 – Admit Source Code - Indicates the patient’s
point of origin for the admission. The HHA enters any
appropriate National Uniform Billing Committee (NUBC)
approved code.
Box 17- Discharge Status Code Indicates the patient’s
status as of the “through” date of the billing period.
Since the “through” date of the RAP will match the
“from” date, the patient will never be discharged as of
the “through” date. As a result only one patient status is
possible on RAPs, code 30 which represents that the
beneficiary is still a patient of the HHA.
Box 39-41 – Required
Value Codes and Amounts
 Value Code “61” = Location where service is
furnished
 HHAs report the MSA number or Core Based
Statistical Area (CBSA) number (or rural state code) of
the location where the home health is delivered.
Middle section
Red = Required
Box 42 - Required
421
424
571
Revenue Center Codes
 Enter the three-digit revenue center code
that most accurately describes the service
provided.
 Refer to the following page for a complete list
of revenue center codes.
0001
Revenue Center Codes
421
Physical therapy visit charge
424
Physical therapy evaluation/reevaluation
431
Occupational therapy visit
434
Occupational therapy evaluation/reevaluation
441
Speech language pathology visit
444
Speech language pathology evaluation/reevaluation
551
Skilled nursing visit charge
559
Other skilled nursing evaluation
561
Medical Social Services
571
Home health aide visit charge
0001
For total claim
Authorization is required for all home health services
Box 44 - Required
#####
HPPS Codes
 Required - On the 0023 revenue code
line, the HHA reports the HIPPS code
for which payment is being requested.
 HPPS code is required on both RAP
and Final/LUPA.
Box 45 - Required
Service Date
 Required - On the 0023 revenue code
line, the HHA reports the date of the first
billable service provided under the HIPPS
code reported on that line.
 Dates must match as indicated in box 6.
Box 46 - Required
6
7
3
Service Units
 Enter the number of days or units for each
related revenue center code listed.
 One visit equals one unit of service.
 One supply item equals one unit of service.
Box 47 - Required
22 30 Total Charges
151 00  Enter the total usual and customary charge
5700
for each related revenue center code listed.
 Do not list credits.
 Do not use dashes.
Total - Required
230 30
Total
 Enter the total charge amount for all services listed in
column 47.
 Each claim form is a separate document, and is to be
totaled as such.
Bottom section
Red = Required
Yellow = Optional
Box 50 - Optional
Primary payer
Secondary payer
Tertiary payer
Payer Name
 Enter the name and identification number, if
available, of each payer who may have full or
partial responsibility for the charges incurred by the
recipient and from which the provider might expect
some reimbursement. If there are no other payers,
UPHP should be the only entry.
Box 54 - Optional
Prior Payments
 Enter the total amount paid by other third party
resource’s.
 Do not list write-off’s.
 Do not include how much MCA or UPCA previously
paid.
 Correspond the placement as outlined in box 50
instructions.
Box 56 - Required
###########
National Provider Identifier (NPI)
 Enter the ten-digit NPI of the Home Health
agency billing for services rendered.
Box 57 - Required
######
Provider Number
 Enter the six digit Medicare Oscar provider number
of the Home Health agency billing for services
rendered.
 Do not list other payer provider numbers.
 Correspond the placement number as outlined in
box 50 instructions.
Box 60 - Required
XX###X#X
Insured’s Unique Identifier
 Enter the patient ID# related to the payer(s) in Field
50. AHCCCS ID must be listed last. If you have
questions about eligibility or the ID#, contact UPHP
Customer Care Department at (800) 582-8686 or
visit: http://www.upcareaz.com http://www.mcareaz.com
 Please note - UPCA and MCA members have a
preceding “M” in front of the AHCCCS ID. I.E.
MA12345678
Box 63 - Required
07JK08AA41GBMDCDLG
Treatment Authorization
 Required - The HHA enters the claim-OASIS matching
key output by the Grouper software. This data element
links the RAP record to the specific OASIS assessment
used to produce the HIPPS code.
Box 66 - Required
7993
Diagnosis Code
 Enter the recipient’s diagnosis/condition.
 The diagnosis code must be the reason chiefly
responsible for the service being provided as
shown in medical records.
 You may enter up to five codes if necessary by
listing them in box 67 - 67D.
 The diagnosis codes must be carried out to its
highest degree of specificity.
 Do not use the decimal point.
Box 76 - Required
##########
######
Attending Provider Name and Identifiers
 Required - The HHA enters the name and provider
identifier of the attending physician that has signed the
plan of care.
Home Health
PO Box ###
Anytown, AZ 85###
X123400
322
120110 120710
Patient, Your
120110
5
30
C
61
46060.00
E
O
M
270
424
559
#####
#####
#####
6
7
3
22 30
151 00
57 00
X
P
A
L
M
E
P
T
0001
UPI MCR HMO
E
D
230 30
##########
######
E
MA12345678
10KI10KI11FXGJIZH
7993
##########
NC
L
##########
######
######
Where to mail your claim
 Mail your UB-04 claim form to:
Maricopa Care Advantage (MCA)
PO Box 37169, Phoenix, AZ 85069
University Physician Care Advantage (UPCA)
PO Box 35699, Phoenix, AZ 85069
References
http://www.cms.gov/manuals/download
s/clm104c10.pdf
 The Medicare Claims Processing Manual
(Chapter 10 – Home Health Agency Billing is
available on line at the above web address
Definitions and References
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Admission Date - For HH PPS, date of first service
of episode or first service in a period of continuous
care (multiple episodes) placed in the
Admission/Start of Care Date field on the
institutional claim.
Claim - Second of two transactions at opening and
closing of HH PPS episode to receive one of two
split percentage payments.
CMS - The Center for Medicare & Medicaid
Services, the Federal Agency administering the
Medicare program and the Federal portions of
Medicaid and the Child Health program.
DME - Durable Medical Equipment. Billed by
revenue codes and/or HCPCS. Paid by CMS
according to a CMS DME fee schedule accessible on
the CMS Web site.
DME- MAC - DME Medicare Administrative
Contractor - 4 Medicare contractors nationally
processing DME on professional claim formats.
Episode - 60-day unit of payment for HH PPS.
FI – Fiscal Intermediary (intermediary)
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Grouper - A software module that “groups”
information for payment classification; for HH PPS,
data from the OASIS assessment tool is grouped to
form HHRGs and output HIPPS codes.
Specifications for the HH PPS Grouper are posted
on the CMS Web site, and the Grouper module is
also built into PPS-compatible versions of HAVEN
software, software publicly available automating the
OASIS assessment tool.
HCPCS Code(s) - Healthcare Common Procedure
Coding System. Coding for services or items used in
the HCPCS/ Accommodation Rates/HIPPS Rate
Codes field on institutional claim formats. A list of
HCPCS is accessible on the CMS Web site.
HH - Home Health
HHA(s) - Home Health Agency(ies)
(H)HRG - Home Health Resource Group. One of
HH episode payment rates.
HIPPS - Health Insurance Prospective Payment
System. Procedural coding used in the HCPCS/
Accommodation Rates/HIPPS Rate Codes field on
institutional claim formats in association with
certain CMS prospective payment systems
Glossary and Acronym List
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Inquiry System (HIQH/ELGH) - An online
transaction providing information on HH PPS
episodes for specific Medicare beneficiaries for
HHAs and hospices. Like the HIQA/ELGA eligibility
inquiry system, this system is based on batch claim
data available in the Common Working File, a
component of Medicare claims processing systems,
available to providers via their Medicare contractor.
Line Item - Service or item-specific detail of claim.
Contains repeated entries of revenue code, HCPCS
code, service units and charge data.
LUPA - Low Utilization Payment Adjustment. An
episode of 4 or less visits paid by national
standardized per visit rates instead of case-mix
groups.
MAC – Medicare Administrative Contractor
National Standard Per Visit Rates - National
rates for each 6 home health disciplines based on
historical claims data. Used in payment of LUPAs
and calculation of outliers.
No-RAP LUPAs - A billing scenario in which only a
claim, not a RAP, is submitted for an episode by an
HHA because the HHA is aware from the outset
that the episode will be four visits or less.
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OASIS - Outcome Assessment Information Set.
The HH assessment instrument required by CMS.
Outlier - An addition to a full episode payment in
cases where costs of services delivered are
estimated to exceed a fixed loss threshold. Pricer
computes HH PPS outliers as part of Medicare
claims payment for all non-LUPA episodes.
Patient Status Code – a code in the Patient
Discharge Status field on institutional claims which
describes patient status at discharge/end of period.
PEP - Partial Episode Payment (adjustment). A
reduced episode payment that may be made based
on the number of service days in an episode
(always less than 60 days, employed in cases of
transfers or discharges with readmissions).
POC - Plan of care. Medicare HH services for
homebound beneficiaries must have a physicianestablished plan.
P/O(S) - Prosthetics and orthotics. The (S) is used
to also include the supplies and other items
associated with the prosthetics and orthotics.
PPS - Prospective Payment System. Medicare
payment for medical care based on pre-determined
payment rates or periods, linked to the anticipated
intensity of services delivered and/or beneficiary
condition.
Glossary and Acronym List
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Pricer - Software modules in Medicare claims
processing systems, specific to certain benefits,
used in pricing claims, most often under
prospective payment systems.
RAP - Request for Anticipated Payment. First of
two transactions at opening and closing of HH PPS
episode to receive one of two split percentage
payments. Note although the RAP is submitted on
an institutional claim format, it is not a claim
according to Medicare statutes. It is not subject to
the payment floor, among other differences from
claims.
Revenue Code - Four position payment codes for
services or items placed in the Revenue Codes field
on institutional claim formats. Note that a new
revenue code 0023 will be used on a distinct line
item when billing episode payments. (HIPPS code
in HCPCS field, separate line items for visits and
supplies follow on claim). An “x” in the last digit of
revenue codes means that value can vary from 0-9.
RHHI - Regional Home Health Intermediary. Four
FIs nationally designated to process Medicare home
health and hospice claims.
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TOB - Type of Bill (i.e., 32X, 34X). Coding
representing the nature of each institutional claim
(i.e., type of benefit, such as homebound home
health; payment source, such as specific Medicare
trust fund; and frequency of bill, such as initial or
cancellation) - an “x” in the last digit of numeric
three digit TOB means that value can be from 0-9.