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

Theinformationinthefollowingtableprovidesinstructionsforcompletingformlocators(FL)astheyappearonthepaperUB-04claimform.InstructionsforcompletingtheUB-04claimformarebasedonthecurrentNationalUniformBillingCommittee(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,optionaland/orconditionalformlocatorsforsubmittingthepaperUB-04claimformtoHealthFirstColoradofornursingfacilityservices.

FormLocatorandLabels

CompletionFormat

Instructions

1.BillingProviderName,Address,TelephoneNumber

Text

RequiredEntertheprovideroragencynameandcompletemailingaddressoftheproviderwhoisbillingfortheservices:

Street

City

State

ZipCode

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

2.Pay-toName,Address,City,State

Text

RequiredonlyifdifferentfromFL1.Entertheprovideroragencynameandcompletemailingaddressoftheproviderwhowillreceivepaymentfortheservices:

Street/PostOfficeboxCity

StateZipCode

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

3a.PatientControlNumber

Upto20characters:Letters,numbersorhyphens

OptionalEnterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).

3b.MedicalRecordNumber

17digits

OptionalEnterthenumberassignedtothemembertoassistinretrievalofmedicalrecords.

4.TypeofBill

3digits

RequiredUsethefollowingcoderangeforHospice:811-815fornon-hospital-basedHospiceservices821-825forhospital-basedHospiceservicesThethree(3)-digitcoderequiresone(1)digitfromeachofthesequences(Typeoffacility,Billclassification,andFrequency).Enterthethree(3)-digitnumberindicatingthespecifictypeofbill.Thethree(3)-digitcoderequiresone(1)digiteachinthefollowingsequences:Digit1TypeofFacility:8-SpecialFacility(Hospice)Digit2BillClassification(SpecialfacilitiesOnly):1-Hospice(Non-HospitalBased)2-Hospice(HospitalBased)Digit3Frequency:0-Non-Payment/ZeroClaim1-AdmitThroughDischargeClaim2-Interim-FirstClaim3-Interim-ContinuousClaim4-Interim-LastClaim5-LateCharge(s)OnlyClaim

5.FederalTaxNumber

None

Submittedinformationisnotenteredintotheclaimprocessingsystem.

6.StatementcoversperiodFrom/Through

From:6digitsMMDDYYThrough:6digitsMMDDYY

Required"From"dateistheactualstartdateofservices."From"datecannotbepriortothestartdatereportedontheinitialpriorauthorization,ifapplicable,oristhefirstdateofaninterimbill."Through"dateistheactualdischargedate,orfinaldateofaninterimbill."From"and"Through"datescannotexceedacalendarmonth(e.g.,bill01/15/18thru01/31/18and02/01/18thru02/15/18,not01/15/18thru02/15/18).Matchdatestothepriorauthorizationifapplicable.Ifthememberisadmittedanddischargedonthesamedate,thatdateappearsinbothformlocators.Detaildatesofservicemustbewithinthe"StatementCoversPeriod"dates.

8a.PatientIdentifier

Text

RequiredEntertheHealthFirstColoradoIDnumberforthemember.

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

RequiredEnterthedatecareoriginallystartedfromanyfundingsource(e.g.,Medicare,HealthFirstColorado,ThirdPartyResource,etc.).

13.AdmissionHour

6digits

NotRequired

14.AdmissionType

1digit

NotRequired

15.SourceofAdmission

1digit

Required

16.DischargeHour

2digits

NotRequired

17.PatientDischargeStatus

2digits

RequiredEntermemberstatusasongoingmember(code30)orasofdischargedate.Agenciesarelimitedtothefollowingcodes:

01

DischargedtoHome

02

DischargedtoHospital

03

Discharged/TransferredtoSNF

04

Discharged/TransferredtoAnothertypeofinstitution

06

Discharged/TransferredtoorganizedHomeHealthCareProgram(HCBS)

07

LeftAgainstMedicalAdvice

20

Deceased/Expired(notforHospiceuse)

30

Stillapatient(ongoing)

40*

Expiredathome

41*

Expiredinhospital,SNF,ICF,orfreestandinghospice

42*

Expired-placeunknown

50

DischargedtoHospice-Home

51

Hospice-MedicalFacility

*Hospiceuseonly

18-28.ConditionsCodes

2digits

RequiredZ4necessaryforpaperclaims.Enterthecodethatmatchestheprogramandthepriorauthorization.

ConditionCodes(asapplicable)

04

HMOMedicareenrollee

07

Treatmentofnon-terminalcondition/hospicepatient

17

Patientover100yearsold

39

Privateroommedicallynecessary

29.AccidentState

2digits

NotRequired

31-34.OccurrenceCode/Date

2digitsand6digits

RequiredEntertheappropriatecodeandthedateonwhichitoccurred.EnterthedateusingMMDDYYformat.OccurrenceCodes

27

DateHospicePlanEstablished

42

DateofDischarge(HospiceBenefitTermination)

35-36.OccurrenceSpanCodeFrom/Through

Digits

NotRequired

38.ResponsiblePartyName/Address

None

Leaveblank

39-41.ValueCodesandAmounts

2charactersandupto9digits

ConditionalEnterappropriatecodesandrelateddollaramountstoidentifymonetarydataornumberofdaysusingwholenumbers,necessaryfortheprocessingofthisclaim.Neverenternegativeamounts.Codesmustbeinascendingorder.Ifavaluecodeisentered,adollaramountornumericvaluerelatedtothecodemustalwaysbeentered.MostCommonCodes:

01

semiprivaterate(AccommodationRate)

06

Medicareblooddeductible

14

Nofaultincludingauto/other

15

Worker'sCompensation

30

Preadmissiontesting

31

MemberLiabilityAmount*

32

MultipleMemberAmbulanceTransport

37

PintsofBloodFurnished

38

BloodDeductiblePints

40

NewCoverageNotImplementedbyHMO

45

AccidentHourEnterthehourwhentheaccidentoccurredthatnecessitatedmedicaltreatment.UsethesamecodingusedinFL18(AdmissionHour).

49

HematocritReading-EPORelated

58

ArterialBloodGas(PO2/PA2)

68

EPO-Drug

80

CoveredDays

81

Non-CoveredDays

Enterthedeductibleamountappliedbyindicatedpayer:DeductiblePayerAB1DeductiblePayerBC1DeductiblePayerC

Entertheamountappliedtomember'sco-insurancebyindicatedpayer:A2CoinsurancePayerAB2CoinsurancePayerBC2CoinsurancePayerC

Entertheamountpaidbyindicatedpayer:A3EstimatedResponsibilityPayerAB3EstimatedResponsibilityPayerBC3EstimatedResponsibilityPayerC

MedicareandTPLseeA1-A3,B1-B3andC1-C3above.*MemberLiabilityAmountispaymentmadebythememberforcare.ThisamountisdeterminedbytheCountyIncomeMaintenanceTechnicians.Thismemberliabilityamountmustbeappliedtothemember'scareatthebeginningofeachmonthusingcode31.Whenreportingthememberliabilityamountfortheentiremonth,regardlessofthenumberofdaysinthatmonth,applythetotalmemberliabilityamount.Whenreportingmemberliabilityamountforlessthanone(1)fullmonthofcare,usetheperdiemcalculationtocalculatethecorrectamount.Theperdiemcalculationisthenumberofdaysinthefacility,excludingthedateofdischarge,timesthefacility'sperdiemrate.Tocalculatepatientliability:

CalculatetheHealthFirstColoradoamountbymultiplyingthenumberofdaysforpaymenttimestheperdiemamount.

IftheHealthFirstColoradoamountexceedsthepatientliability,thepartialmonth'spatientliabilityremainsthesameastheregularpatientliabilityamount.

IfthepatientliabilityismorethantheHealthFirstColoradoamount,thepartialmonth'spatientliabilityisthesameastheHealthFirstColoradoamount.Theexcessofthepatientliabilityoverthepartialmonth'spatientliabilitybelongstotheresidentand,ifithasalreadybeenpaidtothefacility,shallberefundedtotheresident.

WhenmemberhasMedicare"PartBonly"coverage,andtheproviderisbillingfortheHealthFirstColoradoAccommodationPerDiemandthepayersourcecodeisH,enterthe"PartBonly"ancillaryservicespaymentinthisformlocatorontheMedicareline.

42.RevenueCode

4digits

RequiredIfbillingfornursingfacilityperdiemcharges(RevenueCode0659or0651),thenursingfacilityprovidernumbermustbeenteredinFL78(OtherPhys.ID)RefertotheRevenueCodingtable.

43.RevenuecodeDescription

Text

RequiredEntertherevenuecodedescriptionorabbreviateddescription.

44.HCPCS/Rates/HIPPSRateCodes

5digits

NotRequired

45.ServiceDate

6digits

RequiredForspanbillsonly.EnterthedateofserviceusingMMDDYYformatforeachdetaillinecompleted.EachdateofservicemustfallwithinthedatespanenteredinFL6(StatementCoversPeriod).

46.ServiceUnits

3digits

RequiredEnteraunitvalueoneachlinecompleted.Usewholenumbersonly.Donotenterfractionsordecimalsanddonotshowadecimalpointfollowedbya0todesignatewholenumbers.Example:Donotenter1.0tosignifyone(1)unit.Forspanbills,theunitsofservicereflectonlythosevisits,milesortreatmentsprovidedondatesofserviceinFL45.

47.TotalCharges

9digits

RequiredEnterthetotalchargeforeachrevenuecode.ForMedicarePartBclaims,enterthetotalancillarychargesbilledtoMedicare.Agrandtotalonline23isrequiredforallcharges.

48.Non-coveredCharges

Upto9digits

conditionalEnterincurredchargesthatarenotpayablebyHealthFirstColorado.Non-coveredchargesmustbeenteredinbothFL47(TotalCharges)andFL48(Non-CoveredCharges.)Eachcolumnrequiresagrandtotal.

50.PayerName

1letterandtext

Enterthepaymentsourcecodefollowedbynameofeachpayerorganizationfromwhichtheprovidermightexpectpayment.Atleastone(1)linemustindicateHealthFirstColorado.

SourcePaymentCodes

B

Workmen'sCompensation

C

Medicare

D

HealthFirstColorado

E

OtherFederalProgram

F

InsuranceCompany

G

BlueCross,includingFederalEmployeeProgram

H

Other-Inpatient(PartBOnly)

I

Other

LineA

PrimaryPayer

LineB

SecondaryPayer

LineC

TertiaryPayer

51.HealthPlanID

10digits

RequiredEntertheprovider'sHealthPlanIDforeachpayername.EntertheHealthFirstColoradonumberassignedtothebillingprovider.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

NotRequired

58.Insured'sName

Upto30characters

RequiredEnterthemember'snameontheHealthFirstColoradoline.OtherInsurance/MedicareCompleteadditionallineswhenthereisthirdpartycoverage.Enterthepolicyholder'slastname,firstname,andmiddleinitial.

60.Insured'sUniqueID

Upto20characters

RequiredEntertheinsured'suniqueidentificationnumberassignedbythepayerorganizationexactlyasitappearsonthehealthinsurancecard.Includeletterprefixesorsuffixesshownonthecard.

61.InsuranceGroupName

14letters

ConditionalCompletewhenthereisthirdpartycoverage.Enterthenameofthegrouporplanprovidingtheinsurancetotheinsuredexactlyasitappearsonthehealthinsurancecard.

62.InsuranceGroupNumber

17digits

ConditionalCompletewhenthereisthirdpartycoverage.Entertheidentificationnumber,controlnumber,orcodeassignedbythecarrierorfundadministratoridentifyingthegroupunderwhichtheindividualiscarried.

63.TreatmentAuthorizationCode

Upto18characters

ConditionalCompletewhentheservicerequiresaPAR.EntertheauthorizationnumberinthisFLifaPARisrequiredandhasbeenapprovedforservices.ASsofMarch1,2017,PETI/IMEsrequireaPAR.

64.DocumentControlNumber

None

Conditional

65.EmployerName

Text

ConditionalCompletewhenthereisthirdpartycoverage.EnterthenameoftheemployerthatprovideshealthcarecoveragefortheindividualidentifiedinFL58(InsuredName).

66.DiagnosisVersionQualifier

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

67.PrincipalDiagnosisCode

Upto6digits

RequiredEntertheexactICD-10-CMdiagnosiscodedescribingtheprincipaldiagnosisthatexistsatthetimeofadmissionordevelopssubsequentlyandaffectsthelengthofstay.Donotaddextrazerostothediagnosiscode.

67A.-67Q.-OtherDiagnosis

6digits

OptionalCompletewhenthereareadditionalconditionsthataffecttreatment.

69.AdmittingDiagnosisCode

6digits

RequiredEntertheICD-10-CMdiagnosiscodeasstatedbythephysicianatthetimeofadmission.

70.PatientReasonDiagnosis

NotRequired

71.PPSCode

NotRequired

72.ExternalCauseofInjurycode(E-Code)

6digits

OptionalEntertheICD-10-CMdiagnosiscodefortheexternalcauseofaninjury,poisoning,oradverseeffect.Thiscodemustbeginwithan"E".

74.PrincipalProcedureCode/Date

7charactersand6digits

ConditionalCompletewhenthereareadditionalsignificantprocedurecodes.EntertheICD10CMprocedurecodesidentifyingallsignificantproceduresotherthantheprincipalprocedureandthedatesonwhichtheprocedureswereperformed.Reportthosethataremostimportantfortheepisodeofcareandspecificallyanytherapeuticprocedurescloselyrelatedtotheprincipaldiagnosis.EnterthedateusingMMDDYYformat.

74A.OtherProcedureCode/Date

7charactersand6digits

NotRequired

76.AttendingNPI-RequiredAttendingLast/FirstName

NPI-10digitsText

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

77.OperatingNPI

OptionalSubmittedinformationisnotenteredintotheclaimprocessingsystem.

78-79.OtherIDNPI-Conditional

NPI-10digits

ConditionalCompletewhenattendingphysicianisnotthePCPortoidentifyadditionalphysicians.Ordering,Prescribing,orReferringNPI-whenapplicableNPI-Enteruptotwo(2)10-digitNPInumbers,whenapplicable.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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