CO HCPF Psychiatric Residential Treatment Facility and Out-of-state High Intensity Residential Treatment (OHIRT) Provider 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-04InstitutionalCertificationForm,locatedontheProviderFormswebpageundertheClaimFormsandAttachmentsdrop-downmenu,mustbecompletedandattachedtoallclaimssubmittedonthepaperUB-04.CompletedUB-04paperHealthFirstColoradoclaims,includinghardcopyMedicareclaims,shouldbemailedtothecorrectfiscalagentaddresslistedinAppendixA-ColoradoDepartmentofHealthCarePolicy&Financing,locatedontheBillingManualswebpageundertheAppendicesdrop-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.IfthePay-toNameandAddressisthesameasthereportedBillingProvider,thePay-toNameandAddressmustnotbesent.Entertheprovideroragencynameandcompletemailingaddressoftheproviderwhowillreceivepaymentfortheservices:

Street/PostOfficeboxCity

StateZipCode

Abbreviatethestateusingstandardpostofficeabbreviations.Enterthetelephonenumber.

3a.PatientControlNumber

Upto20characters:Letters,numbersorhyphens

OptionalEnterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).

3b.MedicalRecordNumber

17digits

OptionalEnterthenumberassignedtothemembertoassistinretrievalofmedicalrecords.

4.TypeofBill

3digits

RequiredForPRTForOHIRT,useTOB89X.Enterthethree(3)-digitnumberindicatingthespecifictypeofbill.Thethree(3)-digitcoderequiresone(1)digiteachinthefollowingsequences(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(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

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

Digits

RequiredFederalTaxNumbermustmatchtheoneassociatedwiththeprovider’senrolledNPInumber.

6.StatementcoversperiodFrom/Through

From:6digitsMMDDYYThrough:6digitsMMDDYY

RequiredEachdateofservicemustbebilledonaseparateline.RefertoFL45.Onpapersplitanentiremonthinto2claims.Thisformlocatormustreflectthebeginningandendingdatesofservice."From"dateistheactualstartdateofservices."From"datecannotbepriortothestartdatereportedontheinitialpriorauthorization,ifapplicable,oristhefirstdateofaninterimbill."Through"dateistheactualdischargedate,orfinaldateofaninterimbill."From"and"Through"datescannotexceedacalendarmonth(e.g.,bill01/15/10thru01/31/10and02/01/10thru02/15/10,not01/15/10thru02/15/10).Datesmustmatchthepriorauthorizationifapplicable.Ifmemberisadmittedanddischargedthesamedate,thatdatemustappearinbothfields.Detaildatesofservicemustbewithinthe"StatementCoversPeriod"dates.

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

RequiredEnterthefollowingtoidentifytheadmissionpriority:3-ElectiveThemember'sconditionpermitsadequatetimetoscheduletheavailabilityofaccommodations.

15.SourceofAdmission

1digit

RequiredEntertheappropriatecode.(TobeusedinconjunctionwithFL14,AdmissionType.)8-Court/LawEnforcement9-Informationnotavailable

16.DischargeHour

2digits

NotRequired

17.PatientDischargeStatus

2digits

RequiredValidstatuscodesforPRTFs/OHIRTsinclude:

01

DischargedtoHomeorSelfCare

05

Discharged/TransferredtoAnothertypeofinstitution

06

Discharged/TransferredtoorganizedHomeHealthCareProgram(HCBS)

07

LeftAgainstMedicalAdvice

09

AdmittedasanInpatienttoHospital

20

Expired

30

StillPatient

31

StillPatient-WaitingTransfertoLongTermPsychiatricHospital

32

StillPatient-WaitingPlacementbyDepartmentofSocialServices

ClaimswithMemberStatusof30,31or32willpayforeachdaybilledonthedetaillines,includingthethroughdateofserviceshownattheheader.Claimswithanyothermemberstatuswillnotpayforthethroughdateofserviceifitisbilledonadetailline.Whenamemberisdischarged,thedateofdischargeisnotcovered.

18-28.ConditionsCodes

2digits

Notrequired

29.AccidentState

2digits

Optional

31-34.OccurrenceCode/Date

2digitsand6digits

NotRequired

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

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

ForRanchoComaScorebillwithappropriatediagnosisforheadinjury.MedicareandTPL-RefertoA1-A3,B1-B3,andC1-C3above

42.RevenueCode

4digits

RequiredEntertherevenuecode0911.Arevenuecodemustappearonlyonceperdateofservice.Ifmorethanone(1)ofthesameserviceisprovidedonthesameday,combinetheunitsandchargesonone(1)lineaccordingly.

43.RevenuecodeDescription

Text

RequiredEntertherevenuecodedescriptionorabbreviateddescription.

44.HCPCS/Rates/HIPPSRateCodes

5digits

Notrequired

45.ServiceDate

6digits

ForspanbillsonlyEnterthedateofserviceusingMMDDYYformatforeachdetaillinecompleted.Eachdateofservicemustfallwithinthedatespanenteredinthe"StatementCoversPeriod"field(FL6).

46.ServiceUnits

3digits

RequiredEnteraunitvalueoneachlinecompleted.Usewholenumbersonly.Donotenterfractionsordecimalsanddonotshowadecimalpointfollowedbya0todesignatewholenumbers(e.g.,Donotenter1.0tosignifyone[1]unit).Forspanbills,theunitsofservicereflectonlythosevisits,milesortreatmentsprovidedondatesofserviceinFL45.

47.TotalCharges

9digits

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

48.Non-coveredCharges

Upto9digits

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

50.PayerName

1letterandtext

Enterthepaymentsourcecodefollowedbynameofeachpayerorganizationfromwhichtheprovidermightexpectpayment.Atleastone(1)linemustindicateHealthFirstColorado.

51.HealthPlanID

8digits

RequiredEntertheprovider'sHealthPlanIDforeachpayername.Entertheeight(8)-digitHealthFirstColoradoprovidernumberassignedtothebillingprovider.Paymentismadetotheenrolledprovideroragencythatisassignedthisnumber.

52.ReleaseofInformation

N/A

Submittedinformationisnotenteredintotheclaimprocessingsystem.

53.AssignmentofBenefits

N/A

Submittedinformationisnotenteredintotheclaimprocessingsystem.

54.PriorPayments

Upto9digits

Inpatient-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,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.

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

OptionalEntertheexactICD-10-CMdiagnosiscodecorrespondingtoadditionalconditionsthatco-existatthetimeofadmissionordevelopsubsequentlyandwhicheffectthetreatmentreceivedorthelengthofstay.Donotaddextrazerostothediagnosiscode.EnterapplicableICDindicatortoidentifywhichversionofICDcodesisbeingreported.

69.AdmittingDiagnosisCode

6digits

RequiredEntertheICD-10-CMdiagnosiscodeasstatedbythephysicianatthetimeofadmission.

70.PatientReasonDiagnosis

Submittedinformationisnotenteredintotheclaimprocessingsystem.

71.PPSCode

Submittedinformationisnotenteredintotheclaimprocessingsystem.

72.ExternalCauseofInjurycode(E-Code)

6digits

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

74.PrincipalProcedureCode/Date

7charactersand6digits

ConditionalEntertheICD-10-CMprocedurecodefortheprincipalprocedureperformedduringthisbillingperiodandthedateonwhichprocedurewasperformed.EnterthedateusingMMDDYYformat.Applythefollowingcriteriatodeterminetheprincipleprocedure:Theprincipalprocedureisnotperformedfordiagnosticorexploratorypurposes.Thiscodeisrelatedtodefinitivetreatment,andTheprincipalprocedureismostrelatedtotheprimarydiagnosis.

74A.OtherProcedureCode/Date

7charactersand6digits

ConditionalCompletewhenthereareadditionalsignificantprocedurecodes.EntertheICD-10-CMprocedurecodesidentifyingallsignificantproceduresotherthantheprincipleprocedureandthedatesonwhichtheprocedureswereperformed.Reportthosethataremostimportantfortheepisodeofcareandspecificallyanytherapeuticprocedurescloselyrelatedtotheprinciplediagnosis.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

OptionalSubmittedinformationisnotenteredintotheclaimprocessingsystem.

78-79.OtherID

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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