UB04 Billing Instructions, Exams of Nursing

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UB04 Billing Instructions

T h e U B 0 4 i s a f o r m t h a t i s u s e d t o b i l l i n s t i t u t i o n a l c l a i m s

f o r h o s p i t a l a n d s e l e c t r e s i d e n t i a l s e r v i c e s. T h i s m a n u a l

g i v e s d e t a i l e d l i n e b y l i n e i n s t r u c t i o n s o n h o w t o c o m p l e t e

t h e U B 0 4 c l a i m f o r m.

P a p e r U B 0 4 f o r m s s h o u l d h a v e a l l r e l e v a n t i n f o r m a t i o n

c o m p l e t e d p r i o r t o s e n d i n g t h e c l a i m s t o E a s t p o i n t e.

A l l U B 0 4 c l a i m s s u b m i t t e d v i a p a p e r a n d t h e P r o v i d e r P o r t a l

s h o u l d f o l l o w t h e i n s t r u c t i o n s i n t h i s m a n u a l.

 Do not total on the first page

 Staple or clip the 2 pages together, but do not staple more than once

 Indicate page X of 2 in line 23 of Field 42

 Total charges must be located at the bottom of Field 42 on the second page

 If reporting a TPL(third party liability) payment, indicate in field 54 on the first page

 On one copy of an attachment(EOB, EOMB, Consent forms, etc.) is required per claim

when applicable

 All attachments should be clearly marked with the beneficiary’s name and Medicaid ID

Electronic (Web Portal) Submissions of UB-04 Claims

This section gives instruction on how to navigate and utilize the UB-04 Claims Module within

the Partners BHM Alpha MCS Web Portal. To Navigate to the UB-04 claims entry module within the Alpha MCS system:

Login to the Alpha MCS Web Portal. On the Menu button, choose Claims:

After you click on “create” you will be able to create a new UB-04 claim. The next section will

provide detailed instructions and descriptions on the UB-04 Form. Please also see the attachments at the end of this guide for quick instructional tools that can also be utilized as a

reference guide and tool for the UB-04.

This section will give a detailed view of “box by box” view to help guide through the UB-04 claim form.

Box 1 – Billing Provider Site Information: (Required)This information should be auto-populated

from the Claims Management System. Paper formatted claim should have this information

entered prior to submission of claim. You will need to choose the site you are billing for if more

than one is available for choice in the drop down box.

Box 2 – Pay to Provider: (Not required)Only utilize if submitting a paper formatted UB04. This

box does not show up on the Alpha MCS UB-04 claim form.

Box 3a – Patient Control Number: (Optional)This number will be auto-populated when a

patient is entered through the search feature in box 8. Paper formatted claim should have the

Provider record number if known.

Box 3b – Medical Record Number: (Optional)This number will be auto-populated from the

Claims Management System once box 8 is completed. Paper formatted claim should have the Partners BHM record number if known.

Box 4 – Bill Type: (Required)The Type of bill code is comprised of three parts; a leading “0”, the

Facility Type Code, and the Bill Frequency Type Code. This field should be 4 digits when

completed. The first two digits following the zero indicate the type of facility. The final digit

indicates the type of bill. Below are all acceptable codes to bill to Partners BHM:

Inpatient Hospital Claims

0111 – Hospital Inpatient – Admit through Discharge 0112 – Hospital Inpatient – First Claim 0113 – Hospital Inpatient – Continuing Claim 0114 – Hospital Inpatient – Last Claim 0117 – Hospital Inpatient – Replacement Claim 0118 – Hospital Inpatient – Void Claim

Hospital Outpatient(Including Emergency Department) 0131 – Hospital Outpatient(including ED) – Admit through Discharge 0137 – Hospital Outpatient(including ED) – Replacement Claim 0138 – Hospital Outpatient(including ED) – Void Claim

Intermediate Care Facilities for Individuals with Intellectual disabilities (ICF/IID)

0651 – Intermediate Care – Admit through Discharge 0652 – Intermediate Care – First Claim 0653 – Intermediate Care – Continuing Claim 0654 – Intermediate Care – Last Claim 0657 – Intermediate Care – Replacement Claim 0658 – Intermediate Care – Void Claim

Psychiatric Residential Treatment Facilities (PRTF) 0891 – Residential – Admit through Discharge 0892 – Residential – First Claim 0893 – Residential – Continuing Claim 0894 – Residential – Last Claim 0897 – Residential – Replacement Claim 0898 – Residential – Void Claim

The Alpha MCS system is designed to treat each claim that is submitted as a “whole” claim. You can submit Bill types ending in 1 if the claim includes “all” dates of service including the date of discharge. This would include claims such as Hospital Outpatient or Inpatient Hospital. If you submit Interim bills, the “first claim” should be submitted with a bill type that ends in a “2”. Continuing interim claims should be submitted with a bill type that ends in a “3”. Interim Bills that are submitted for dates of service that include the date of discharge should be submitted with a bill type that ends with a “4”.

Box 5 – Federal Tax ID Number: (Not required)This is auto-populated from the Claims Management System. Paper formatted claims should have this information manually entered.

Box 6 – Statement Period From and Through Dates: (Required)Enter the eight digit beginning service date in the “From” box and the eight digit ending service date in the “Through” box. Dates are to be entered in the “mm/dd/yyyy” format. *Note if the claim submitted has a discharge date– the date of discharge is not billable for payment.

Box 7 – Reserved for local use. Do not submit information in this box.

Boxes 8-11 – This patient information is auto-populated from the Claims Management system when utilizing the patient search feature. Paper formatted claims should have this information entered exactly as it appears on the Recipients Medicaid Identification Card.

Box 12 – Admission Date: (Required)Enter the eight digit date of admission. Dates are to be entered in the “mm/dd/yyyy” format.

Box 13 – Admission Hour: (Required if applicable)Enter the physical time of admission if applicable – required for Hospital claims.

51 – Discharged/transferred to hospice – medical facility(inpatient only)

61 – Discharged/transferred within this institution to a hospital based Medicare approved swing bed. 62 – Discharged/transferred to an inpatient rehab facility, including distinct part units of a Hospital 63 – Discharged/transferred to a Long Term Care Hospital(LTCH) 64 – Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare 65 – Discharged/transferred to a psychiatric hospital or psychiatric distinct-part unit of a hospital 66 – Discharged/transferred to a Critical Access Hospital (CAH) 70 – Discharged/transferred to another type of health care institution not defined elsewhere in the code list

Box 18-28 – Condition Codes : Not required unless applicable for the service.

Box 29-Accident State: Not Required.

Box 31-34, a-b – Occurrence Codes: Not required unless applicable for the service

Box 35-36 – Occurrence Span codes and dates: Not required

Box 38 – Insured Name and Address: (Required)This information will auto-populate from the Partners BHM Claim Management System

Box 39-41; a-d – Value codes and amounts: (Optional)Use these locators to indicate codes and amounts essential to the proper adjudication of the submitted claim. Each form locator contains a three digit field in which to key the indicator code, and a larger free text field in which to designate an applicable amount.

Patient Responsibility – Key “31” in the code box of this field to identify the value code as patient liability. Key the amount of patient minimal liability due in the Amt. box.

Covered Days – Key “80” in the code box and the number of covered days in the amount.

Non-Covered Days – Key “81” for the code and the number of non-covered days as the amount.

Share of Cost – Key “23” to show a payment that is a share of cost͘

Box 42 – Revenue Code: (Required)For General Hospitals, please use the appropriate revenue code(s) in a 4 digit format with a leading zero. Ex. 0100 not 100. Only claims with appropriate diagnostic ranges of 290-319 will be paid.

Inpatient Hospital/Residential/ICF: Paid on a state negotiated per diem all inclusive basis Codes: 0100,0101,0113,0114,0116,0120,0123,

Emergency Department: Paid at 80% of the Medicaid approved RCC: Codes: 0450-0459(labs are paid at 100% of the DMA approved rate)

Note for ED services, Revenue Codes for ancillaries may be billed in addition to the ED charge. RC 0253 (take home medications) are non-covered services.

Hospital Outpatient Claims: Codes: 0901,0903,0905,0906,0907,0912,0913,0914,0915,0916,0918,

Intermediate Care Facilities Claims(ICF/IID): Code: 0100

Psychiatric Residential Treatment Facility: Code: 0911

Long term Residential: Code: 0902 (H0019)(H2020)

Therapeutic Leave Code: 0183

Box 43 – Description: (Required)This will be auto-populated based upon choice of Revenue Code

Box 44 – HCPCS/HIPPS Code: (Required if applicable)This field is used to report the appropriate HCPCS codes for ancillary services, the accommodation rate for bills for inpatient services, and the Health Insurance Prospective Payment System rate codes for specific patient groups that are the basis for payment under a PPS(prospective payment system)

For all other types of facilities: When billing Therapeutic leave for the following residential services: *H *S *H Use the HCPCS Code indicated on the authorization letter for Therapeutic Leave.

ICF/IID – Does not require a HCPCS code be entered for Therapeutic Leave

Box 59a-c – Patient Relationship: (Required)Identify the relationship of the patient to the primary insurance policyholder using the following two digit codes:

01 – Spouse 18 – Self 19 – Child 20 – Employee 21 – Unknown 53 – Life Partner G8 – Other Relationship

**Note – This is the relationship of the patient to the policy holder, so if the patient’s parents are the policy holders, the subsequent relationship would be “19 – Child”

Box 60a-c – Insured ID Number: (Required)Enter the number assigned by the primary health plan to identify the specific policy of the insured.

Box 61a-c – Group Name: (Only required when patient has other insurance coverage)

Box 62a-c – Insured Group Number: (Only required when patient has other insurance coverage)

Box 63a-c – Treatment Auth Codes: (Not required)

Box 64A – Document Control Number: If the bill type indicates a replacement or voided claim, enter the Partners BHM Claim Header ID of the original submitted claim in this field. You will find the claim number on your Remittance Advice.

Box 65a-c – Employer Name: (Not required)

Box 66 – Principal Diagnosis Code: (Required)Enter the Primary ICD-9 Diagnosis Code in this box marked with an asterisk.

Box 67 – (additional diagnosis fields) Secondary Diagnosis Codes: (Optional)Enter secondary diagnosis code(s) as applicable

Box 69 – Admitting Diagnosis Code (Inpatient/Residential Claims only): Enter the diagnosis code describing the patient’s diagnosis at the time of admission

Box 70 – 72: (Not required)

Box 74a-e – Principal Procedure Codes (Optional and only for Hospital claims)

Box 76 – Attending NPI: (Required if applicable) (Clinician/Physician/Agency) that actually delivered the service.

Box 77-79 – (Not required)

Box 80 – Remarks Field: (Not required) Can be used to put free text for remarks or comments

Box 81CCa – Taxonomy Code: ( Required)Enter your taxonomy code in box 81CCa of the UB-04. The value B3 will be hard coded into the first field. This identified the value to be entered as th e Provider’s Taxonomy Code͘ Enter the taxonomy code in the box to the right of where “B3” is located.

Once you have completed all required fields, you can choose to save or submit your claim. If all fields are accurate and complete, you may choose to submit your claim. If you still have items that need addressing and you do not want to submit yet but rather want to “save” so that you can work on later, you may choose to Save.