CO HCPF Dialysis Billing Manual — UB-04 Paper Claim Reference Table

TheinformationinthefollowingtableprovidesinstructionsforcompletingformlocatorsastheyappearonthepaperUB-04claimform.InstructionsforcompletingtheUB-04institutionalclaimformarebasedonthecurrentNationalUniformBillingCommittee(NUBC)UB-04ReferenceManual.Unlessotherwisenoted,alldataformlocatorsontheUB-04havethesameattributes(specifications)forHealthFirstColoradoasthoseindicatedintheNUBCUB-04ReferenceManual.

AllcodevalueslistedintheNUBCUB-04ReferenceManualforeachformlocatormaynotbeusedforsubmittingpaperclaimstoHealthFirstColorado.TheappropriatecodevalueslistedinthismanualmustbeusedwhenbillingHealthFirstColorado.

TheUB-04CertificationdocumentmustbecompletedandattachedtoallclaimssubmittedonthepaperUB-04.CompletedUB-04paperHealthFirstColoradoclaims,includinghardcopyMedicareclaims,shouldbemailedtothecorrectfiscalagentaddresslistedinAppendixAlocatedontheBillingManualswebpageundertheAppendicesdrop-down.

Donotsubmit"continuation"claims.Eachclaimformhasasetnumberofbillinglinesavailableforcompletion.Donotcrowdmorelinesontheform.

Billinglinesinexcessofthedesignatednumberarenotprocessedoracknowledged.Claimswithmorethanone(1)pagemaybesubmittedthroughtheProviderWebPortal.

Billwithadatespan(FromandTodatesofservice)onlyiftheservicewasprovidedeveryconsecutivedaywithinthespan.TheFromandTodatesmustbeinthesamemonth.

ThePaperClaimReferenceTablebelowliststherequired,optionalandconditionalformlocatorsforsubmittingthepaperUB-04claimformtoHealthFirstColorado.

FormLocatorandLabels

CompletionFormat

Instructions

1.BillingProviderName,Address,TelephoneNumber

Text

RequiredEntertheprovideroragencynameandcompletemailingaddressoftheproviderwhoisbillingfortheservices:

Street/PostOfficebox

City

State

ZipCode

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

2.Pay-toName,Address,City,State

Text

Requiredonlyifdifferentfromformlocator1.Entertheprovideroragencynameandcompletemailingaddressoftheproviderwhowillreceivepaymentfortheservices:

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

Street/PostOfficebox

City

State

ZipCode

3a.PatientControlNumber

Upto20characters:Letters,numbersorhyphens

OptionalEnterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).

3b.MedicalRecordNumber

17digits

OptionalEnterthenumberassignedtothemembertoassistinretrievalofmedicalrecords.

4.TypeofBill

3digits

RequiredForPsychiatricResidentialTreatmentFacility(PRTF),useTypeofBill(TOB)89X.Enterthethree(3)-digitnumberindicatingthespecifictypeofbill.Thethree(3)-digitcoderequiresone(1)digiteachinthefollowingsequences:Typeoffacility,BillclassificationandFrequency:

Digit1

TypeofFacility

1

Hospital

2

SkilledNursing

3

HomeHealthServices

4

ReligiousNon-MedicalHealthCareInstitution

6

IntermediateCare

7

Clinic(RuralHealth/FederallyQualifiedHealthCenter(FQHC)/DialysisCenter)

8

SpecialFacility(Hospice,ResidentialTreatmentCenters[RTCs])

Digit2

BillClassification(ExceptClinicsandSpecialFacilities):

1

Inpatient(IncludingMedicarePartA)

2

Inpatient(MedicarePartBonly)

3

Outpatient

4

Other(forhospitalreferenceddiagnosticservicesorhomehealthnotunderaplanoftreatment)

5

IntermediateCareLevelI

6

IntermediateCareLevelII

7

Sub-AcuteInpatient(RevenueCode019Xrequiredwiththisbilltype)

8

SwingBeds

9

Other

Digit2

BillClassification(ClinicsOnly):

1

RuralHealth/FQHC

2

Hospital-BasedorIndependentRenalDialysisCenter

3

Freestanding

4

OutpatientRehabilitationFacility(ORF)

5

ComprehensiveOutpatientRehabilitationFacilities(CORFs)

6

CommunityMentalHealthCenter

Digit2

BillClassification(SpecialFacilitiesOnly):

1

Hospice(Non-HospitalBased)

2

Hospice(Hospital-Based)

3

AmbulatorySurgeryCenter

4

FreestandingBirthingCenter

5

CriticalAccessHospital

6

ResidentialFacility

Digit3

Frequency:

0

Non-Payment/ZeroClaim

1

Admitthroughdischargeclaim

2

Interim-Firstclaim

3

Interim-Continuousclaim

4

Interim-Lastclaim

7

Replacementofpriorclaim

8

Voidofpriorclaim

5.FederalTaxNumber

None

Submittedinformationisnotenteredintotheclaimprocessingsystem.

6.StatementcoversperiodFrom/Through

From:6digitsMMDDYYThrough:6digitsMMDDYY

RequiredThisformlocatormustreflectthebeginningandendingdatesofservice.Whenspanbillingformultipledatesofserviceandmultipleprocedures,completeformlocator45(ServiceDate).Providersnotwishingtospanbillfollowingtheseguidelinesmustsubmitone(1)claimperdateofservice."From"and"Through"datesmustbethesame.Allline-itementriesmustrepresentthesamedateofservice.

8a.PatientIdentifier

Text

Submittedinformationisnotenteredintotheclaimprocessingsystem.

8b.PatientName

Upto25characters,lettersandspaces

RequiredEnterthemember'slastname,firstnameandmiddleinitial.

9a.PatientAddress-Street

Characterslettersandnumbers

RequiredEnterthemember'sstreet/postofficeboxasdeterminedatthetimeofadmission.

9b.PatientAddress-City

Text

RequiredEnterthemember'scityasdeterminedatthetimeofadmission.

9c.PatientAddress-State

Text

RequiredEnterthemember'sstateasdeterminedatthetimeofadmission.

9d.PatientAddress-ZIP

Digits

RequiredEnterthemember'szipcodeasdeterminedatthetimeofadmission.

9e.PatientAddress-CountryCode

Digits

Optional

10.Birthdate

8digits(MMDDCCYY)

RequiredEnterthemember'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedate,andfour(4)digitsfortheyear(MMDDCCYYformat).Example:01012010forJanuary1,2010

11.PatientSex

1letter

RequiredEnteranM(male)orF(female)toindicatethemember'ssex.

12.AdmissionDate

6digits

NotRequired

13.AdmissionHour

6digits

Notrequired

14.AdmissionType

1digit

NotRequired

15.SourceofAdmission

1digit

Required

16.DischargeHour

2digits

NotRequired

17.PatientDischargeStatus

2digits

RequiredDialysismustusecode01.

18-28.ConditionsCodes

2digits

ConditionalCompletewithasmanycodesnecessarytoidentifyconditionsrelatedtothisbill.ConditionCodes06ESRDmember-First18monthsentitlementRenaldialysissettings71Fullcareunit72Self-careunit73Self-caretraining74Homecare75Homecare-100percentreimbursement

29.AccidentState

2digits

Optional

31-34.OccurrenceCode/Date

2digitsand6digits

ConditionalCompleteboththecodeanddateofoccurrence.Entertheappropriatecodeandthedateonwhichitoccurred.EnterthedateusingMMDDYYformat.OccurrenceCodes:

1

Accident/MedicalCoverage

2

AutoAccident-NoFaultLiability

3

Accident/TortLiability

4

Accident/EmploymentRelated

5

OtherAccident/NoMedicalCoverageorLiabilityCoverage

6

CrimeVictim

20

DateGuaranteeofPaymentBegan

24*

DateInsuranceDenied

25*

DateBenefitsTerminatedbyPrimaryPayer

26

DateSkilledNursingFacilityBedAvailable

27

DateofHospiceCertificationorRecertification

40

ScheduledDateofAdmission(RTD)

50

MedicarePayDate

51

MedicareDenialDate

53

Nolongerused

55

InsurancePayDate

A3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerAindicatedinformlocator50.

B3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerBindicatedinformlocator50.

C3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerCindicatedinformlocator50.

*OtherPayeroccurrencecodes24and25mustbeusedwhenapplicable.Theclaimmustbesubmittedwiththethird-partyinformation

35-36.OccurrenceSpanCodeFrom/Through

Digits

Leaveblank

38.ResponsiblePartyName/Address

None

Leaveblank

39-41.ValueCodesandAmounts

2charactersandupto9digits

ConditionalEnterappropriatecodesandrelateddollaramountstoidentifymonetarydataornumberofdaysusingwholenumbersnecessaryfortheprocessingofthisclaim.Neverenternegativeamounts.Codesmustbeinascendingorder.Ifavaluecodeisentered,adollaramountornumericvaluerelatedtothecodemustbeentered.MostCommonCodes:

01

SemiprivateRate(AccommodationRate)

06

MedicareBloodDeductible

14

NoFaultIncludingAuto/Other

15

Worker'sCompensation

31

MemberLiabilityAmount*

32

MultipleMemberAmbulanceTransport

37

PintsofBloodFurnished

38

BloodDeductiblePints

40

NewCoverageNotImplementedbyHMO

45

AccidentHourEnterthehourwhentheaccidentoccurredthatnecessitatedmedicaltreatment.Usethesamecodingusedinformlocator18(AdmissionHour).

49

HematocritReading-EPORelated

58

ArterialBloodGas(PO2/PA2)

68

Erythropoietin(EPO)-Drug

80

CoveredDays

81

Non-CoveredDays

D6

TimeonMachine

Enterthedeductibleamountappliedbyindicatedpayer:A1DeductiblePayerAB1DeductiblePayerBC1DeductiblePayerC

Entertheamountappliedtomember'sco-insurancebyindicatedpayer:A2CoinsurancePayerAB2CoinsurancePayerBC2CoinsurancePayerC

Entertheamountpaidbyindicatedpayer:A3EstimatedResponsibilityPayerAB3EstimatedResponsibilityPayerBC3EstimatedResponsibilityPayerC

42.RevenueCode

4digits

RequiredEntertherevenuecodethatidentifiesthespecificserviceprovided.Listrevenuecodesinascendingorder.RefertoAppendixQontheBillingManualswebpageundertheAppendicesdrop-downforvaliddialysisrevenuecodes.Arevenuecodemustappearonlyonceperdateofservice.*Ifmorethanone(1)ofthesameservicesisprovidedonthesameday,combinetheunitsandchargesonone(1)lineaccordingly.Completewithasmanycodesasnecessarytoidentifyconditionsrelatedtothisbill.

43.RevenueCodeDescription

Text

RequiredEntertherevenuecodedescriptionorabbreviateddescription.WhenreportingaNationalDrugCode(NDC):

EntertheNDCqualifierof"N4"inthefirsttwo(2)positionsontheleftsideofthefield,immediatelyfollowedbythe11-digitNDCnumericcode.

Enterone(1)spaceforseparation.

F2-InternationalUnit

GR-Gram

ML-Milliliter

UN-Units

Enterone(1)periodforseparation.

Enterthequantity(numberofNDCunits).

Example:

42REV.CD.

43DESCRIPTION

0636

N467066000501ME.016

44.HCPCS/Rates/HealthInsuranceProspectivePaymentSystem(HIPPS)RateCodes

5digits

ConditionalEnteronlytheHCPCScodeforeachdetailline.Useapprovedmodifierslistedinthissectionforhospital-basedtransportationservices.Completeforlaboratory,radiology,physicaltherapy,occupationaltherapyandhospital-basedtransportation.WhenbillingHCPCScodes,theappropriaterevenuecodemustalsobebilled.ServicesRequiringHCPCSAnatomicalLaboratory:BillwithTCmodifierHospital-BasedTransportationOutpatientLaboratory:UseonlyHCPCS80000s-89000s.OutpatientRadiologyServicesEnterHCPCSandrevenuecodesforeachradiologyline.TheonlyvalidmodifierforoutpatientradiologyisTC.RefertotheannualHCPCSbulletinforinstructions,locatedontheBulletinswebpage.Withtheexceptionofoutpatientlabandhospital-basedtransportation,outpatientradiologyservicescanbebilledwithotheroutpatientservices.HCPCScodesmustbeidentifiedforthefollowingrevenuecodes:

030XLaboratory

032XRadiology-Diagnostic

033XRadiology-Therapeutic

034XNuclearMedicine

035XCTScan

040XOtherImagingServices

042XPhysicalTherapy

043XOccupationalTherapy

054XAmbulance

061XMRIandMRA

HCPCScodescannotberepeatedforthesamedateofservice.Combinetheunitsinformlocator46(Units)toreportmultipleservices.

45.ServiceDate

6digits

Forspanbillsonly:EnterthedateofserviceusingMMDDYYformatforeachdetaillinecompleted.Eachdateofservicemustfallwithinthedatespanenteredinthe"StatementCoversPeriod"field(formlocator6).

46.ServiceUnits

3digits

RequiredEnteraunitvalueoneachlinecompleted.Usewholenumbersonly.Donotenterfractionsordecimalsanddonotshowadecimalpointfollowedbya0todesignatewholenumbers(e.g.,Donotenter1.0tosignifyone[1]unit).Forspanbills,theunitsofservicereflectonlythosevisits,milesortreatmentsprovidedondatesofserviceinformlocator45.

47.TotalCharges

9digits

RequiredEnterthetotalchargeforeachlineitem.Calculatethetotalchargeasthenumberofunitsmultipliedbytheunitcharge.DonotsubtractMedicareorthird-partypaymentsfromlinechargeentries.Donotenternegativeamounts.Agrandtotalonline23isrequiredforallcharges.

48.Non-coveredCharges

Upto9digits

ConditionalEnterincurredchargesthatarenotpayablebyHealthFirstColorado.Non-coveredchargesmustbeenteredinbothformlocator47(TotalCharges)andformlocator48(Non-CoveredCharges).Eachcolumnrequiresagrandtotalonline23.Non-coveredchargescannotbebilledforoutpatienthospitallaboratoryorhospital-basedtransportationservices.

50.PayerName

1letterandtext

RequiredEnterthepaymentsourcecodefollowedbynameofeachpayerorganizationfromwhichtheprovidermightexpectpayment.Atleastone(1)linemustindicateHealthFirstColorado.

SourcePaymentCodes

B

Workmen'sCompensation

C

Medicare

D

HealthFirstColorado

E

OtherFederalProgram

F

InsuranceCompany

G

BlueCross,includingFederalEmployeeProgram

I

Other

LineA

PrimaryPayer

LineB

SecondaryPayer

LineC

TertiaryPayer

51.HealthPlanID

10digits

RequiredEntertheNPInumberassignedtothebillingprovider.Paymentismadetotheenrolledprovideroragencythatisassignedthisnumber.

52.ReleaseofInformation

N/A

Submittedinformationisnotenteredintotheclaimprocessingsystem.

53.AssignmentofBenefits

N/A

Submittedinformationisnotenteredintotheclaimprocessingsystem.

54.PriorPayments

Upto9digits

ConditionalCompletewhenthereareMedicareorthird-partypayments.Enterthirdpartyand/orMedicarepayments.

55.EstimatedAmountDue

Upto9digits

ConditionalCompletewhenthereareMedicareorthird-partypayments.EnterthenetamountduefromHealthFirstColoradoafterproviderhasreceivedotherthirdparty,Medicareormemberliabilityamount.MedicareCrossoversEnterthesumoftheMedicarecoinsuranceplusMedicaredeductiblelessthird-partypaymentsandmemberpayments.

56.NationalProviderIdentifier(NPI)

10digits

RequiredEnterthebillingprovider's10-digitNationalProviderIdentifier(NPI).

57.OtherProviderID

OptionalSubmittedinformationisnotenteredintotheclaimprocessingsystem.

58.Insured'sName

Upto30characters

RequiredEnterthemember'snameontheHealthFirstColoradoline.OtherInsurance/MedicareCompleteadditionallineswhenthereisthirdpartycoverage.Enterthepolicyholder'slastname,firstnameandmiddleinitial.

60.Insured'sUniqueID

Upto20characters

RequiredEntertheinsured'suniqueidentificationnumberassignedbythepayerorganizationexactlyasitappearsonthehealthinsurancecard.Includeletterprefixesorsuffixesshownonthecard.

61.InsuranceGroupName

14letters

ConditionalCompletewhenthereisthirdpartycoverage.Enterthenameofthegrouporplanprovidingtheinsurancetotheinsuredexactlyasitappearsonthehealthinsurancecard.

62.InsuranceGroupNumber

17digits

ConditionalCompletewhenthereisthirdpartycoverage.Entertheidentificationnumber,controlnumberorcodeassignedbythecarrierorfundadministratoridentifyingthegroupunderwhichtheindividualiscarried.

63.TreatmentAuthorizationCode

Upto18characters

ConditionalCompletewhentheservicerequiresaPriorAuthorizationRequest(PAR).EntertheauthorizationnumberinthisformlocatorifaPARisrequiredandhasbeenapprovedforservices.

64.DocumentControlNumber

none

Conditional

65.EmployerName

Text

ConditionalCompletewhenthereisthirdpartycoverage.Enterthenameoftheemployerthatprovideshealthcarecoveragefortheindividualidentifiedinformlocator58(InsuredName).

66.DiagnosisVersionQualifier

Submittedinformationisnotenteredintotheclaimprocessingsystem.EnterapplicableInternationalClassificationofDiseases(ICD)indicatortoidentifywhichversionofICDcodesisbeingreported.0ICD-10-CM(DOS10/1/15andafter)

67.PrincipalDiagnosisCode

Upto6digits

Notrequired

67A.-67Q.-OtherDiagnosis

6digits

OptionalEntertheexactdiagnosiscodecorrespondingtoadditionalconditionsthatco-existatthetimeofadmissionordevelopsubsequentlyandwhicheffectthetreatmentreceivedorthelengthofstay.Donotaddextrazerostothediagnosiscode.

69.AdmittingDiagnosisCode

6digits

Notrequired

70.PatientReasonDiagnosis

Submittedinformationisnotenteredintotheclaimprocessingsystem.

71.PPSCode

Submittedinformationisnotenteredintotheclaimprocessingsystem.

72.ExternalCauseofInjurycode(E-Code)

6digits

OptionalEnterthediagnosiscodefortheexternalcauseofaninjury,poisoningoradverseeffect.Thiscodemustbeginwithan"E."

74.PrincipalProcedureCode/Date

7charactersand6digits

ConditionalEntertheICD-10-CMprocedurecodefortheprincipalprocedureperformedduringthisbillingperiodandthedateonwhichprocedurewasperformed.EnterthedateusingMMDDYYformat.Applythefollowingcriteriatodeterminetheprincipalprocedure:Theprincipalprocedureisnotperformedfordiagnosticorexploratorypurposes.Thiscodeisrelatedtodefinitivetreatment.Theprincipalprocedureismostrelatedtotheprimarydiagnosis.

74A.OtherProcedureCode/Date

7charactersand6digits

ConditionalCompletewhenthereareadditionalsignificantprocedurecodes.Entertheprocedurecodesidentifyingallsignificantproceduresotherthantheprincipalprocedureandthedatesonwhichtheprocedureswereperformed.Reportthosethataremostimportantfortheepisodeofcareandspecificallyanytherapeuticprocedurescloselyrelatedtotheprincipaldiagnosis.EnterthedateusingMMDDYYformat.

76.AttendingNPI-Required

NPI-10digits

HealthFirstColoradoIDRequiredNPI-Enterthe10-digitNPInumberassignedtothephysicianhavingprimaryresponsibilityforthemember'smedicalcareandtreatment.Thisnumberisobtainedfromthephysicianandcannotbeaclinicorgroupnumber.(IftheattendingphysicianisnotenrolledinHealthFirstColorado,orifthememberleavestheERbeforebeingseenbyaphysician,thehospitalmayentertheirindividualnumbers.)HospitalsandFQHCsmayenterthemember'sregularphysician's10-digitNPIintheAttendingPhysicianIDformlocatorifthelocumtenensphysicianisnotenrolledinHealthFirstColorado.QUAL-Enter"1D"forHealthFirstColoradoEntertheattendingphysician'slastandfirstname.Thisformlocatormustbecompletedforallservices.

77.OperatingNPI

NotrequiredSubmittedinformationisnotenteredintotheclaimprocessingsystem.

78-79.OtherID

NPI-10digits

ConditionalCompletewhenattendingphysicianisnotthePrimaryCareProvider(PCP)ortoidentifyadditionalphysicians.Ordering,Prescribing,orReferringProviderNPI-whenapplicableNPI-Enteruptotwo(2)10-digitNPInumberswhenapplicable.Thisformlocatoridentifiesphysiciansotherthantheattendingphysician.IftheattendingphysicianisnotthePCPorifaclinicisaPCPagent,enterthePCPNPInumberasthereferringphysician.ThenameoftheHealthFirstColoradomember'sPCPappearsontheeligibilityverification.RevieweitherforeligibilityorPCP.HealthFirstColoradodoesnotrequirethatthePCPnumberappearmorethanonceoneachclaimsubmitted.Theattendingphysician'slastandfirstnameareoptional.

80.Remarks

Text

Enterspecificadditionalinformationnecessarytoprocesstheclaimorfulfillreportingrequirements.

81.Code-QUAL/CODE/VALUE(a-d)

Qualifier:2digitsTaxonomyCode:10digits

OptionalCompleteboththequalifierandthetaxonomycodeforthebillingproviderinfield81CC-a.Field81CC-amustbebilledwithqualifierB3forthetaxonomycodetobecapturedintheclaimsprocessingsystem.IfB3ismissing,notaxonomycodewillbecapturedintheclaimsprocessingsystem.Onlyone(1)taxonomycodecanbecapturedfromfield81CC.Ifmorethanone(1)taxonomycodeisprovided,onlythefirstinstanceofB3andtaxonomycodewillbecapturedintheclaimsprocessingsystem.

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