CO HCPF Lactation Support Services Billing Manual — UB-04 Paper Claim Reference Table

LactationSupportServicesoutpatienthospitalpaperclaimsmustbesubmittedontheUB-04claimform.

Theinformationinthefollowingtableprovidesinstructionsforcompletingformlocators(FL)astheyappearonthepaperUB-04claimform.InstructionsforcompletingtheUB-04claimformarebasedonthecurrentNationalUniformBillingCommittee(NUBC)UB-04ReferenceManual.Unlessotherwisenoted,alldataformlocatorsontheUB-04havethesameattributes(specifications)forHealthFirstColoradoasthoseindicatedintheNUBCUB-04ReferenceManual.

AllcodevalueslistedintheNUBCUB-04ReferenceManualforeachformlocatormaynotbeusedforsubmittingpaperclaimstoHealthFirstColorado.TheappropriatecodevalueslistedinthismanualmustbeusedwhenbillingHealthFirstColorado.TheUB-04CertificationdocumentmustbecompletedandattachedtoallclaimssubmittedonthepaperUB-04.CompletedUB-04paperHealthFirstColoradoclaims,includinghardcopyMedicareclaims,shouldbemailedtothecorrectfiscalagentaddresslistedinAppendixA,undertheAppendicesdrop-downsectionontheBillingManualswebpage.

Donotsubmit"continuation"claims.Eachclaimformhasasetnumberofbillinglinesavailableforcompletion.Donotcrowdmorelinesontheform.Billinglinesinexcessofthedesignatednumberarenotprocessedoracknowledged.ClaimswithmorethanonepagemaybesubmittedthroughtheProviderWebPortal.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.Entertheprovideroragencynameandcompletemailingaddressoftheproviderwhoisbillingfortheservices:

Street

City

State

ZipCode

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

3a.PatientControlNumber

Upto20characters:Letters,numbersorhyphens

OptionalEnterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).

3b.MedicalRecordNumber

17digits

OptionalEnterthenumberassignedtothemembertoassistinretrievalofmedicalrecords.

4.TypeofBill

3digits

RequiredForPRTF,useTOB89X.Enterthethree-digitnumberindicatingthespecifictypeofbill.Thethree-digitcoderequiresonedigiteachinthefollowingsequences(Typeoffacility,Billclassification,andFrequency):

Digit1

TypeofFacility

1

Hospital

2

SkilledNursing

3

HomeHealthServices

4

ReligiousNon-MedicalHealthCareInstitution

6

IntermediateCare

7

Clinic(RuralHealth/FQHC/DialysisCenter)

8

SpecialFacility(Hospice,RTCs)

Digit2

BillClassification(ExceptClinics&SpecialFacilities):

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

HospitalBasedorIndependentRenalDialysisCenter

3

Freestanding

4

OutpatientRehabilitationFacility(ORF)

5

ComprehensiveOutpatientRehabilitationFacilities(CORFs)

6

CommunityMentalHealthCenter

Digit2

BillClassification(SpecialFacilitiesOnly):

1

Hospice(Non-HospitalBased)

2

Hospice(HospitalBased)

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,completeFL45(ServiceDate).Providersnotwishingtospanbillfollowingtheseguidelines,mustsubmitoneclaimperdateofservice."From"and"Through"datesmustbethesame.Alllineitementriesmustrepresentthesamedateofservice.

8a.PatientIdentifier

Text

Submittedinformationisnotenteredintotheclaimprocessingsystem.

8b.PatientName

Upto25characters,letters&spaces

RequiredEnterthemember'slastname,firstnameandmiddleinitial.

9a.PatientAddress-Street

CharactersLetters&numbers

RequiredEnterthemember'sstreet/postofficeboxasdeterminedatthetimeofadmission.

9b.PatientAddress-City

Text

RequiredEnterthemember'scityasdeterminedatthetimeofadmission

9c.PatientAddress-State

Text

RequiredEnterthemember'sstateasdeterminedatthetimeofadmission.

9d.PatientAddress-ZIP

Text

RequiredEnterthemember'szipcodeasdeterminedatthetimeofadmission.

9e.PatientAddress-CountryCode

Digits

Optional

10.Birthdate

8digits(MMDDCCYY)

RequiredEnterthemember'sbirthdateusingtwodigitsforthemonth,twodigitsforthedate,andfourdigitsfortheyear(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

Required

Dialysismustusecode01.

18-28.ConditionsCodes

2digits

Conditional

Completewithasmanycodesnecessarytoidentifyconditionsrelatedtothisbill.

ConditionCodes06ESRDmember-First18monthsentitlement

Renaldialysissettings71Fullcareunit72Selfcareunit73Selfcaretraining74Homecare75Homecare-100percentreimbursement

29.AccidentState

2digits

Optional

31-34.OccurrenceCode/Date

2digits&6digits

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

DateofHospiceCertificationorRe-certification

40

ScheduledDateofAdmission(RTD)

50

MedicarePayDate

51

MedicareDenialDate

53

Nolongerused

55

InsurancePayDate

A3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerAindicatedinFL50

B3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerBindicatedinFL50

C3

BenefitsExhausted-IndicatethelastdateofservicethatbenefitsareavailableandafterwhichpaymentcanbemadebypayerCindicatedinFL50

*OtherPayeroccurrencecodes24and25mustbeusedwhenapplicable.Theclaimmustbesubmittedwiththethird-partyinformation.

35-36.OccurrenceSpanCodeFrom/Through

Digits

Leaveblank

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

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

42.RevenueCode

4digits

Required

Entertherevenuecodewhichidentifiesthespecificserviceprovided.Listrevenuecodesinascendingorder.ThesecodesarelistedinAppendixQ,undertheAppendicesdrop-downsectionontheBillingManualswebpage,forvaliddialysisrevenuecodes.

Arevenuecodemustappearonlyonceperdateofservice.*Ifmorethanoneofthesameserviceisprovidedonthesameday,combinetheunitsandchargesononelineaccordingly.

Completewithasmanycodesnecessarytoidentifyconditionsrelatedtothisbill.

43.RevenuecodeDescription

Text

RequiredEntertherevenuecodedescriptionorabbreviateddescription.WhenreportinganNDC:

EntertheNDCqualifierof"N4"inthefirsttwopositionsontheleftsideofthefield,immediatelyfollowedbythe11-digitNDCnumericcode

Enteronespaceforseparation.

F2-InternationalUnit

GR-Gram

ML-Milliliter

UN-Units

Enteroneperiodforseparation

Enterthequantity(numberofNDCunits).

Example:

42REV.CD.

43DESCRIPTION

0636

N467066000501ME.016

44.HCPCS/Rates/HIPPSRateCodes

5digits

Conditional

EnteronlytheHCPCScodeforeachdetailline.Useapprovedmodifierslistedinthissectionforhospitalbasedtransportationservices.

Completeforlaboratory,radiology,physicaltherapy,occupationaltherapyandhospitalbasedtransportation.WhenbillingHCPCScodes,theappropriaterevenuecodemustalsobebilled.

ServicesRequiringHCPCSAnatomicalLaboratory:BillwithTCmodifierHospitalBasedTransportationOutpatientLaboratory:UseonlyHCPCS80000s-89000s.OutpatientRadiologyServices

EnterHCPCSandrevenuecodesforeachradiologyline.TheonlyvalidmodifierforOPradiologyisTC.RefertotheannualHCPCSbulletinforinstructionsintheProviderServicesBulletinssectionofthewebsite.

Withtheexceptionofoutpatientlabandhospital-basedtransportation,outpatientradiologyservicescanbebilledwithotheroutpatientservices.

HCPCScodesmustbeidentifiedforthefollowingrevenuecodes:

030XLaboratory

032XRadiology-Diagnostic

033XRadiology-Therapeutic

034XNuclearMedicine

035XCTScan

040XOtherImagingServices

042XPhysicalTherapy

043XOccupationalTherapy

054XAmbulance

061XMRIandMRA

HCPCScodescannotberepeatedforthesamedateofservice.CombinetheunitsinFL46(Units)toreportmultipleservices.

45.ServiceDate

6digits

ForspanbillsonlyEnterthedateofserviceusingMMDDYYformatforeachdetaillinecompleted.

Eachdateofservicemustfallwithinthedatespanenteredinthe"StatementCoversPeriod"field(FL6).

46.ServiceUnits

3digits

RequiredEnteraunitvalueoneachlinecompleted.Usewholenumbersonly.Donotenterfractionsordecimalsanddonotshowadecimalpointfollowedbya0todesignatewholenumbers(e.g.,Donotenter1.0tosignifyoneunit).

Forspanbills,theunitsofservicereflectonlythosevisits,milesortreatmentsprovidedondatesofserviceinFL45.

47.TotalCharges

9digits

Required

Enterthetotalchargeforeachlineitem.Calculatethetotalchargeasthenumberofunitsmultipliedbytheunitcharge.DonotsubtractMedicareorthird-partypaymentsfromlinechargeentries.Donotenternegativeamounts.Agrandtotalonline23isrequiredforallcharges.

48.Non-coveredCharges

Upto9digits

Conditional

EnterincurredchargesthatarenotpayablebyHealthFirstColorado.

Non-coveredchargesmustbeenteredinbothFL47(TotalCharges)andFL48(Non-CoveredCharges.)Eachcolumnrequiresagrandtotalonline23.

Non-coveredchargescannotbebilledforoutpatienthospitallaboratoryorhospitalbasedtransportationservices.

50.PayerName

1letterandtext

Required

Enterthepaymentsourcecodefollowedbynameofeachpayerorganizationfromwhichtheprovidermightexpectpayment.AtleastonelinemustindicateHealthFirstColorado.

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

ConditionalCompletewhentheservicerequiresaPAR.EntertheauthorizationnumberinthisFLifaPARisrequiredandhasbeenapprovedforservices.

64.DocumentControlNumber

None

Conditional

65.EmployerName

Text

ConditionalCompletewhenthereisthirdpartycoverage.EnterthenameoftheemployerthatprovideshealthcarecoveragefortheindividualidentifiedinFL58(InsuredName).

66.DiagnosisVersionQualifier

Submittedinformationisnotenteredintotheclaimprocessingsystem.EnterapplicableICDindicatortoidentifywhichversionofICDcodesisbeingreported.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

Conditional

EntertheICD-10-CMprocedurecodefortheprincipalprocedureperformedduringthisbillingperiodandthedateonwhichprocedurewasperformed.EnterthedateusingMMDDYYformat.Applythefollowingcriteriatodeterminetheprincipalprocedure:

Theprincipalprocedureisnotperformedfordiagnosticorexploratorypurposes.Thiscodeisrelatedtodefinitivetreatment,and

Theprincipalprocedureismostrelatedtotheprimarydiagnosis.

74A.OtherProcedureCode/Date

7charactersand6digits

Conditional

Completewhenthereareadditionalsignificantprocedurecodes.

Entertheprocedurecodesidentifyingallsignificantproceduresotherthantheprincipalprocedureandthedatesonwhichtheprocedureswereperformed.Reportthosethataremostimportantfortheepisodeofcareandspecificallyanytherapeuticprocedurescloselyrelatedtotheprincipaldiagnosis.EnterthedateusingMMDDYYformat.

76.AttendingNPI-Required

NPI-10digits

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

77.OperatingNPI

NotrequiredSubmittedinformationisnotenteredintotheclaimprocessingsystem.

78-79.OtherID

NPI-10digits

Conditional

CompletewhenattendingphysicianisnotthePCPortoidentifyadditionalphysicians.

Ordering,PrescribingorReferringNPI-whenapplicable

NPI-Enteruptotwo10-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

Optional

Completeboththequalifierandthetaxonomycodeforthebillingproviderinfield81CC-a.

Field81CC-amustbebilledwithqualifierB3forthetaxonomycodetobecapturedintheclaimsprocessingsystem.IfB3ismissing,notaxonomycodewillbecapturedintheclaimsprocessingsystem.Onlyonetaxonomycodecanbecapturedfromfield81CC.Ifmorethanonetaxonomycodeisprovided,onlythefirstinstanceofB3andtaxonomycodewillbecapturedintheclaimsprocessingsystem.

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