MO HealthNet Hospice Provider Manual § 4.5

Providers may bill MHD for hospice services electronically or by using the UB-04 claim form. Instructions on how to complete the UB-04 claim form are below.

The UB-04 claim form should be typed or legibly printed. It may be duplicated if the copy is legible. MHD claims should be mailed to:

Wipro Infocrossing

P.O. Box 5200

Jefferson City, MO 65102

NOTE: An asterisk (*) beside field numbers indicates required fields. These fields must be completed, or the claim is denied. Two (2) asterisks (**) beside the field number indicate a field is required in specific situations. All other fields should be completed as applicable.

Field Number | Field Name | Instructions for Completion

1* | Provider Name, Address, Telephone Number | Enter the provider name and address

2 | Unlabeled Field | Leave blank

3a | Patient Control Number | For the provider’s own information, a maximum of 20 alpha/numeric characters may be entered here

3b | Med Rec # | Leave blank

4* | Type of Bill | Enter the valid three (3)-digit code for hospice claims:; 811 – Freestanding; 821 – Provider affiliated

5 | Federal Tax Number | Enter the provider's federal tax number or leave blank

6* | Statement Covers Period (From and Through dates) | Indicate the beginning and ending dates in MMDDYY or MMDDYYYY numeric format. Only one calendar month of services may be shown on a claim. If all services billed are on a single day, enter that date as both ‘From’ and ‘Through.’

7 | Unlabeled Field | Leave blank

8a | Patient's Name - ID | Enter the patient's 8-digit MO HealthNet Identification Number (Designated Client Number (DCN)) or MO HealthNet Managed Care Identification Number. (Optional); NOTE: The MO HealthNet DCN or Managed Care identification number is required in Field 60 of this form.

8b* | Patient Name | Enter the patient's name in the following format: Last name, First name, and Middle Initial

9 | Patient Address | Enter the patient's full mailing address, including street number and name, post office box number or Rural Free Delivery (RFD), city, state and zip code

10 | Patient Birth Date | Enter the patient's date of birth in MMDDYY format

11 | Patient Sex | Enter the patient's sex, ‘M’ (male) or ‘F’ (female)

12 | Admission Date | Leave blank

13 | Admission Hour | Leave blank

14 | Admission Type | Leave blank

15 | Source of Admission (SRC) | Leave blank

16 | Discharge Hour | Leave blank

17* | Patient Status | Enter ‘50’ hospice home or ‘51’ hospice medical facility, which includes nursing facilities

18-24 | Condition Codes | ‘A1’ is the only valid value

25-28 | Condition Codes | Leave blank

29 | Accident State | Leave blank

30 | Unlabeled field | Leave blank

31-34** | Occurrence Code and Date | If one (1) or more of the following occurrence codes apply, enter the appropriate code(s) on the claim:; 01—Auto Accident; 02—No Fault; 03—Accident/Tort Liability; 04—Accident/Employment Related; 05—Other Accident; 06—Crime Victim

35-36 | Occurrence Span Codes and Dates | Leave blank

37 | Unlabeled field | Leave blank

38 | Responsible Party Name and Address | Leave blank

39-41 | Value Codes and Amounts | Leave blank

42* | Revenue Code | Enter the appropriate revenue code. Refer to Section 5.1 in this manual for a list of all hospice revenue codes.

43 | Revenue Description | Leave blank

44* | Healthcare Common Procedure Coding System/Rates/Health Insurance Premium Payments System code | Only enter the procedure code if billing for physician services.; Modifier 1 - Enter the applicable modifier, if any, corresponding to the service rendered.

45* | Service Date | Enter the date of service on each line billed in MMDDYY format.; When billing a revenue code for multiple days of service on a single line, enter the first day being billed.; NOTE: Each date on which continuous home care (revenue code 0652) is provided must be billed on a separate line. Charges for continuous home care for multiple days cannot be combined on one (1) line.

46* | Service Units | Enter the number of units for each revenue code billed. The last date of service is automatically calculated.; NOTE: Revenue code 0652 is billed by hourly units. Each line must include charges for only one (1) day.

47* | Total Charges | Enter the total charge for each line. After all charges are listed, skip a line and enter the total of all charges for this claim to correspond to revenue code 0001

48 | Non-covered Charges | Leave blank

49 | Unlabeled Field | Leave blank

50* | Payer Name | The primary payer is always listed first. If the patient has insurance, the insurance plan is the primary payer and ‘MO HealthNet’ is listed last.

51 | Health Plan ID | Leave blank

52 | Release of Information Certification Indicator | Leave blank

53 | Assignment of Benefits Certification of Indicator | Leave blank

54** | Prior Payments | Indicate the amount the hospice has received toward payment of this bill from a health insurance company. Payments must correspond with the payer information entered in Field 50.

55 | Estimated Amount Due | Leave blank

56 | National Provider Identifier (NPI) | Enter the provider's 10-digit NPI number

57* | Other Provider ID | Enter the provider's nine (9)-digit MO HealthNet Provider Identifier

58** | Insured's Name | Complete if the insured’s name is different from the patient's name

59 | Patient’s Relationship to Insured | Leave blank

60* | Insured's Unique ID | Enter the patient's eight (8)-digit MO HealthNet or MO HealthNet Managed Care Identification Number. If insurance was indicated in Field 50, enter the insurance number to correspond to the order shown in Field 50.

61** | Insurance Group Name | If insurance is shown in Field 50, state the name of the group or plan through which the insurance is provided to the insured

62** | Insurance Group Number | If insurance is shown in Field 50, state the number assigned by the insurance company to identify the group under which the individual is covered

63 | Treatment Authorization Codes | Leave blank

64** | Document Control Number | If the current claim exceeds the timely filing limit of one (1) year from the ‘Through' date, but was originally submitted timely and denied, the provider may enter the 13-digit Internal Control Number (ICN) from the Remittance Advice that documents that the claim was previously filed and denied within the one (1) year limit

65 | Employer Name | If the patient is employed, the employer's name may be entered here

66 | Diagnosis & Procedure Code Qualifier | Leave blank

67* | Principal Diagnosis Code | Enter the complete ICD diagnosis code for the condition for which the services were provided.; Remember to code to the highest level of specificity shown in the current version of the ICD diagnosis code book.

67 A-D** | Other Diagnosis Codes | Enter any additional diagnosis codes that have an effect on the treatment received

67 E-Q | Other Diagnosis Codes | Leave blank

68 | Unlabeled Field | Leave blank

69 | Admitting Diagnosis | Leave blank

70 | Patient's Reason for Visit | Leave blank

71 | Prospective Payment system (PPS) Code | Leave blank

72 | External Cause of Injury Code (E Code) | Leave blank

73 | Unlabeled Field | Leave blank

74** | Principal Procedure Code and Date | If billing for physician services and a surgical procedure was performed, enter the Current Procedural Terminology (CPT) code. The date on which the procedure was performed must be indicated.

74 A-E** | Other Procedure Codes and; Dates | If billing for physician services and more than one (1) surgical procedure was performed, state the additional procedure codes and dates performed

75 | Unlabeled field | Leave blank

76* | Attending Provider Name and Identifiers | Enter the attending physician's name, last name first. (Optional); Use the appropriate qualifier when entering the Missouri (or state) license number, MO HealthNet Provider Identifier or Unique Personal Identification Number (UPIN).; The appropriate qualifier is:; 0B – State License Number; 1G – Provider UPIN Number; G2 – MO HealthNet Provider Identifier

77 | Operating Provider Name and Identifiers | Enter the operating physician's name, last name first. (Optional); Use the appropriate qualifier when entering the Missouri (or state) license number, MO HealthNet Provider Identifier or Unique Personal Identification Number (UPIN).; The appropriate qualifier is:; 0B – State License Number; 1G – Provider UPIN Number; G2 – MO HealthNet Provider Identifier

78-79** | Other Provider Name and Identifiers | Enter the physician's name, last name first. (Optional); Use the appropriate qualifier when entering the Missouri (or state) license number, MO HealthNet Provider Identifier or Unique Personal Identification Number (UPIN).; The appropriate qualifier is:; 0B – State License Number; 1G – Provider UPIN Number; G2 – MO HealthNet Provider Identifier

80 | Remarks | Use this field to draw attention to attachments such as operative notes, Third Party Liability (TPL) denial, Medicare Part B only, etc.

81CC | Code-Code Field | Enter the taxonomy qualifier and corresponding 10-digit Provider Taxonomy code for the NPI number reported in Field 56.; The appropriate qualifier is B3 – Healthcare Provider Taxonomy code

NOTE: An asterisk (*) beside field numbers indicates required fields. These fields must be completed, or the claim is denied. Two (2) asterisks (**) beside the field number indicate a field is required in specific situations. All other fields should be completed as applicable.