Wis. ForwardHealth Online Handbook, Hospice, Topic #3450

Services

These instructions are for the completion of the UB-04 claim for ForwardHealth. For complete billing instructions, refer to the

National UB-04 Uniform Billing Manual prepared by the NUBC (National Uniform Billing Committee). The National UB-04

Uniform Billing Manual contains important coding information not available in these instructions. Providers may purchase the

National UB-04 Uniform Billing Manual by calling 312-422-3390 or by accessing the NUBC website.

Members enrolled in BadgerCare Plus or Medicaid receive a ForwardHealth identification card. Always verify a member's

enrollment before providing nonemergency services to determine if there are any limitations on covered services and to obtain the

correct spelling of the member's name.

Note: Every code used on this claim form, even if the code is entered in a non-required form locator, is required to be a valid

code. In addition, each provider is solely responsible for the truthfulness, accuracy, timeliness, and completeness of claims relating

to reimbursement for services submitted to ForwardHealth.

When submitting paper claims, if the member has any other health insurance (for example, commercial health insurance, Medicare,

Medicare Advantage Plans) sources, providers are required to complete and submit an Explanation of Medical Benefits form,

along with the completed paper claim.

Submit completed paper claims and the completed Explanation of Medical Benefits form, as applicable, to the following address:

ForwardHealth

Claims and Adjustments

313 Blettner Blvd

Madison WI 53784

Form Locator 1 — Provider Name, Address, and Telephone Number

Enter the name of the provider submitting the claim and the practice location address. The minimum requirement is the provider's

name, city, state, and ZIP+4 code. Do not enter a Post Office Box or ZIP+4 code associated with a PO Box. The name in Form

Locator 1 must correspond with the NPI (National Provider Identifier) in Form Locator 56.

Form Locator 2 — Pay-to Name, Address, and ID (not required)

Form Locator 3a — Pat. Cntl # (optional)

Providers may enter up to 20 characters of the patient's internal office account number. This number will appear on the RA

(Remittance Advice) and/or the 835 (835 Health Care Claim Payment/Advice) transaction.

Form Locator 3b — Med. Rec. # (optional)

Enter the number assigned to the patient's medical/health record by the provider. This number will appear on the RA and/or the

835 transaction.

Form Locator 4 — Type of Bill

Exclude the leading zero and enter the three-digit type of bill code. The first digit identifies the type of facility. The second digit

classifies the type of care. Hospice providers should use bill types 81X (non-hospital-based hospice) or 82X (hospital-based

hospice). The third digit ("X") indicates the billing frequency; providers should enter one of the following for "X":

• 1 = Admit through discharge claim.

• 2 = Interim — first claim.

• 3 = Interim — continuing claim.

• 4 = Interim — final claim.

Form Locator 5 — Fed. Tax No.

Data are required in this form locator for OCR (Optical Character Recognition) processing. Any information populated by a

provider's computer software is acceptable data for this form locator. If computer software does not automatically complete this

form locator, enter information such as the provider's federal tax identification number.

Form Locator 6 — Statement Covers Period (From - Through)

Enter both dates in MMDDYY format (for example, November 3, 2008, would be 110308). Providers should enter the first day

of the month (or the date of enrollment in hospice care) and the last day of the month (or the date of death or revocation of

hospice care) in Form Locator 6.

Form Locator 7 — Unlabeled Field (not required)

Form Locator 8 a–b — Patient Name

Enter the member's last name and first name, separated by a space or comma, in Form Locator 8b. Use Wisconsin's EVS

(Enrollment Verification System) to obtain the correct spelling of the member's name. If the name or spelling of the name on the

ForwardHealth card and the EVS do not match, use the spelling from the EVS.

Form Locator 9 a–e — Patient Address

Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is

acceptable data for this form locator (for example, "On file"). If computer software does not automatically complete this form

locator, enter information such as the member's complete address in field 9a.

Form Locator 10 — Birthdate

Enter the member's birth date in MMDDCCYY format (for example, September 25, 1975, would be 09251975).

Form Locator 11 — Sex (not required)

Form Locator 12 — Admission Date (not required)

Form Locator 13 — Admission Hr (not required)

Form Locator 14 — Priority (Type) of Admission or Visit

Enter the appropriate admission type for the services rendered. Refer to the UB-04 Billing Manual for more information.

Form Locator 15 — Point of Origin for Admission or Visit

Enter the code indicating the source of admission. Refer to the UB-04 Billing Manual for more information.

Form Locator 16 — DHR (not required)

Form Locator 17 — Patient Discharge Status

Enter the code indicating disposition or discharge status of the member at the end of service for the period covered on this claim.

Refer to the UB-04 Billing Manual for more information.

Form Locators 18–28 — Condition Codes (required, if applicable)

Enter the code(s) identifying a condition related to this claim, if appropriate. Refer to the UB-04 Billing Manual for more

information.

Form Locator 29 — ACDT State (not required)

Form Locator 30 — Unlabeled Field (not required)

Form Locators 31–34 — Occurrence Code and Date (required, if applicable)

If appropriate, enter the code and associated date defining a significant event relating to this claim that may affect payer

processing. All dates must be printed in the MMDDYY format. Refer to the UB-04 Billing Manual for more information.

Form Locators 35–36 — Occurrence Span Code (From - Through) (not required)

Form Locator 37 — Unlabeled Field (not required)

Form Locator 38 — Responsible Party Name and Address (not required)

Form Locators 39–41 a–d — Value Code and Amount (not required)

Form Locator 42 — Rev. Cd.

Enter the appropriate four-digit revenue code as defined by the NUBC that identifies a specific accommodation or ancillary

service.

Form Locator 43 — Description (not required)

Form Locator 44 — HCPCS/Rate/HIPPS Code

Enter the appropriate HCPCS (Healthcare Common Procedure Coding System) code that corresponds to the revenue code

listed in Form Locator 42.

Form Locator 45 — Serv. Date

Enter the single "from" DOS (date of service) in MMDDYY format in this form locator.

Form Locator 46 — Serv. Units

Enter the number of covered accommodation days or ancillary units of service for each line item.

Units are measured in days for revenue codes "0169," "0651," "0655," and "0656" and in hours for revenue code "0652."

Form Locator 47 — Total Charges (by Accommodation/Ancillary Code Category)

Enter the usual and customary charges for each line item.

Form Locator 48 — Non-covered Charges (not required)

Form Locator 49 — Unlabeled Field

Enter the "to" DOS in DD format. A range of consecutive dates may be indicated only if the revenue code, the procedure code

(and modifiers, if applicable), the service units, and the charge were identical for each date within the range.

Detail Line 23

PAGE ___ OF ___

Enter the current page number in the first blank and the total number of pages in the second blank. This information must be

included for both single- and multiple-page claims.

CREATION DATE (not required)

TOTALS

Enter the sum of all charges for the claim in this field. If submitting a multiple-page claim, enter the total charge for the claim

(for example, the sum of all details from all pages of the claim) only on the last page of the claim.

Form Locator 50 A–C — Payer Name

Enter all health insurance payers here. Enter "T19" for Medicaid and the name of the commercial health insurance, if applicable. If

submitting a multiple-page claim, enter health insurance payers only on the first page of the claim.

Form Locator 51 A–C — Health Plan ID (not required)

Form Locator 52 A–C — Rel. Info (not required)

Form Locator 53 A–C — Asg. Ben. (not required)

Form Locator 54 A–C — Prior Payments (not required)

This information is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example,

commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate

Explanation of Medical Benefits form for each other payer listed in Form Locator 50 A-C as an attachment(s) to their completed

claim.

Form Locator 55 A–C — Est. Amount Due (not required)

Form Locator 56 — NPI

Enter the provider's NPI. The NPI in Form Locator 56 should correspond with the name in Form Locator 1.

Form Locator 57 — Other Provider ID (not required)

Form Locator 58 A–C — Insured's Name

Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is

acceptable data for this form locator (for example, "Same"). If computer software does not automatically complete this form

locator, enter information such as the member's last name, first name, and middle initial.

Form Locator 59 A–C — P. Rel (not required)

Form Locator 60 A–C — Insured's Unique ID

Enter the member identification number. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to

obtain the correct member ID.

Form Locator 61 A–C — Group Name (not required)

Form Locator 62 A–C — Insurance Group No. (not required)

Form Locator 63 A–C — Treatment Authorization Codes (not required)

Form Locator 64 A–C — Document Control Number (not required)

Form Locator 65 A–C — Employer Name (not required)

Form Locator 66 — Dx (not required)

Form Locator 67 — Principal Diagnosis Code and Present on Admission Indicator

Enter the valid, most specific ICD (International Classification of Diseases) code describing the principal diagnosis (for example,

the condition established after study to be chiefly responsible for causing the admission or other health care episode). Do not enter

manifestation codes as the principal diagnosis; code the underlying disease first. The principal diagnosis may not include External

Cause of Morbidity codes.

Form Locators 67A–Q — Other Diagnosis Codes and Present on Admission Indicator

Enter valid, most specific ICD diagnosis codes corresponding to additional conditions that coexist at the time of admission, or

develop subsequently, and that have an effect on the treatment received or the length of stay. Diagnoses that relate to an earlier

episode and have no bearing on this episode are to be excluded. Providers should prioritize diagnosis codes as relevant to this

claim.

Form Locator 68 — Unlabeled Field (not required)

Form Locator 69 — Admit Dx (not required)

Form Locator 70 — Patient Reason Dx (not required)

Form Locator 71 — PPS Code (not required)

Form Locator 72 — ECI (not required)

Form Locator 73 — Unlabeled Field (not required)

Form Locator 74 — Principal Procedure Code and Date (not required)

Form Locator 74 a-e — Other Procedure Code and Date (not required)

Form Locator 75 — Unlabeled Field (not required)

Form Locator 76 — Attending

Enter the attending provider's NPI.

Form Locator 77 — Operating (not required)

Form Locators 78 and 79 — Other Provider Name and Identifiers

Enter the referring provider's NPI, followed by DN in the qualifier field and the last and first names of the provider in the

appropriate fields. If a rendering provider is required on the claim, enter the rendering provider's NPI, followed by 82 in the

qualifier field and the last and first names of the provider in the appropriate fields.

Form Locator 80 — Remarks (not required)

Commercial Health Insurance Billing Information

This information is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example,

commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate

Explanation of Medical Benefits form for each other payer listed in Form Locator 50 A-C as an attachment(s) to their completed

claim.

Form Locator 81 a–d — CC

If the billing provider's NPI was indicated in Form Locator 56, enter the qualifier B3 in the first field to the right of the form

locator, followed by the appropriate 10-digit provider taxonomy code on file with ForwardHealth in the second field.

Note: Providers should use qualifier PXC when submitting an electronic claim using the 837I (837 Health Care Claim:

Institutional) transaction. For further instructions, refer to the companion guide for the 837I transaction.