UB-92 Billing Instructions

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1 August 26, 2005 UB-92 Billing Instructions 2005 Hospital Provider Workshop Conduent MS Medicaid Project Government Healthcare Solutions

2 Objective & Definition To explain how to complete a UB-92 claim form for Mississippi Medicaid Hospital Providers. The UB-92 is a billing form used by Mississippi Medicaid Hospital providers for inpatient, outpatient, and Medicare crossover claim types. 2

3 Sample of Inpatient UB-92 Claim 3

4 UB-92 Billing Instructions FIELD 1 PROVIDER NAME, ADDRESS REQUIRED; Minimum requirements & TELEPHONE NUMBER are the provider's name, address, city, state and zip code. FIELD 2 WORKER'S COMPENSATION RATIO NOT REQUIRED FIELD 3 Patient Control Number OPTIONAL; For your benefit to facilitate posting by provider. FIELD 4 Type of Bill REQUIRED; Enter the code indicating the specific type of bill (inpatient, outpatient. (SEE EXHIBIT C-1) 4

5 Exhibit C-1 *CODE. 1st Digit *CODE. 2nd Digit TYPE OF FACILITY - 1ST DIGIT *1 -Hospital BILL CLASSIFICATION -2ND DIGIT *1 -Inpatient (Including Medicare Part A) *2 -Inpatient (Medicare Part B only) *3 -Outpatient *4 -Other (for hospital referenced diagnostic services. Or home health not under plan of treatment.) *5 -Intermediate Care-Level I** *6 -Intermediate Care-Level II** *7 -Intermediate Care-Level III** *8 -Swingbeds *9 -Reserved for National Use 5

6 Exhibit C-1 Continued *CODE. 3rd Digit Example: Inpatient. Type of Bill (111) First Digit 1 Hospital Second Digit 1 Inpatient Third Digit 1 Admit Thru Discharge FREQUENCY - 3RD DIGIT *1 -Admit thru Discharge Claim *2 -Interim -First Claim *3 -Interim- Continuing Claim *4 -Interim -Last Claim *5 -Late Charge(s) Only Claim *6 -Adjustment of Prior Claim** *7 -Replacement of Prior Claim** *8 -Void Cancel of Prior Claim** *9 -Reserved for National Assignment ** Not allowed for hardcopy claims, only when submitting claims electronically 6

7 FIELD 5 FEDERAL TAX NUMBER NOT REQUIRED FIELD 6 STATEMENT COVERS PERIOD REQUIRED; The beginning and end service dates of the periods included on this bill (MM/DD/CCYY format). FIELD 7 COVERED DAYS REQUIRED; The total number of covered days. FIELD 8 NON-COVERED DAYS NOT REQUIRED FIELD 9 COINSURANCE DAYS NOT REQUIRED FIELD 10 LIFETIME RESERVE DAYS NOT REQUIRED FIELD 11 UNLABELED FIELD NOT REQUIRED FIELD 12 REQUIRED; Last name, first name PATIENT NAME and middle initial of the patient exactly as it appears in the Medicaid system. 7

8 FIELD 13 PATIENT ADDRESS REQUIRED; The full mailing address including street number and name or post office box number of RFD, city, state and zip code. FIELD 14 PATIENT BIRTHDATE REQUIRED; Enter the month, day, century, and year of birth. (MM/DD/CCYY format) FIELD 15 PATIENT SEX REQUIRED FIELD 16 PATIENT MARITAL STATUS NOT REQUIRED 8

9 FIELD 17 ADMISSION DATE REQUIRED FOR INPATIENT CLAIMS ONLY. FIELD 18 ADMISSION HOUR REQUIRED; Enter appropriate time. (SEE EXHIBIT C-2) FIELD 19 TYPE OF ADMISSION REQUIRED 1 Emergency 2 Urgent 3 Elective 4 - Newborn FIELD 20 SOURCE OF ADMISSION REQUIRED; Refer to UB-92 Billing Manual. 9

10 Exhibit C-2 CODE TIME AM 00 12:00-12:59 Midnight 01 01:00-01: :00-02: :00-03: :00-04: :00-05: :00-06: :00-07: :00-08: :00-09: :00-10: :00-11:59 CODE TIME PM 12 12:00-12:59 Noon 13 01:00-01: :00-02: :00-03: :00-04: :00-05: :00-06: :00-07: :00-08: :00-09: :00-10: :00-11:59 99 Hour Unknown 10

11 FIELD 21 DISCHARGE HOUR NOT REQUIRED FIELD 22 PATIENT STATUS CODES REQUIRED FOR INPATIENT CLAIMS ONLY. (SEE EXHIBIT C-3) FIELD 23 MEDICAL RECORD NUMBER NOT REQUIRED FIELD CONDITION CODES NOT REQUIRED 11

12 Exhibit C-3 01 Discharged to home or self care (routine discharge) 02 Discharged / transferred to another short-tern general hospital for inpatient care 03 Discharge / transferred to skilled nursing facility (SNF) 04 Discharge / transferred to an intermediate care facility (ICF) Discharge / transferred to another type of institution for inpatient care or referred for outpatient services to another institution Discharged / transferred to home under care of organized home health service organization 07 Left against medical advice or discontinued care 08 Discharged / transferred to home under care of a Home IVprovider 09 Admitted as an inpatient to this hospital Discharged to be defined at state level, if necessary 20 Expired Expired to be defined at state level, if necessary 30 Still a patient Still a patient to be defined at state level, if necessary 40 Expired at home (Medicare Hospice Claims Only) 41 Expired in a medical facility, e.g. Hospital, SNF, ICF or free standing hospice (Medicare Hospice Claims Only) 42 Expired place unknown Reserved for national assignment 12

13 FIELD 31 UNLABELED FIELD NOT REQUIRED FIELDS OCCURRENCE CODE AND DATE REQUIRED FIELD 36 FIELD 37A OCCURRENCE CODE SPAN AND DATE TRANSACTION CONTROL NUMBER (TCN) (SEE EXHIBIT C-4) NOT REQUIRED REQUIRED, IF APPLICABLE. Use 17-digit TCN to prove timely filing when claim is over 1 year from through date of service. 13

14 Exhibit C-4 Occurrence Codes C3 Benefits Exhausted 42 Actual date of discharge Scenario 1: Answer: Beneficiary has four days remaining for fiscal year Provider bills for dates of service 04/01/05 thru 04/12/05. This claim must be split billed for remaining inpatient days available. Field 6 (statement covered days) should contain 04/01/05-04/04/05. The bill type should indicate 112 (the first part of a split bill). Field 32 should contain occurrence code C3 and the last date of benefits were available (04/04/05). Field 33 should contain occurrence code 42 and actual date of discharge (04/12/05). 14

15 Exhibit C-4 Occurrence Codes C3 Benefits Exhausted 42 Actual date of discharge Scenario 2: Answer: A split bill is also required at Medicaid s fiscal year end (June 30), if the inpatient stay continues into the month of July. Provider bills claim for dates of service 06/25/04-07/05/04. The claim must be split billed and two claims will be submitted. Claim 1: Field 6 should be 06/25/04-06/30/04, with bill type of 112. Claim 2: Field 6 should be 07/01/04-07/05/04, with bill type

16 FIELD 38 RESPONSIBLE PARTY NAME AND NOT REQUIRED ADDRESS FIELDS VALUE CODES AND AMOUNT REQUIRED, IF APPLICABLE. (Must complete when revenue codes 38X-39X are billed. Blood value codes must include units used, replaced and not replaced.) FIELD 42 REVENUE CODES REQUIRED; A code, which identifies a specific accommodation, ancillary service or billing calculation. FIELD 43 REVENUE DESCRIPTION REQUIRED; A narrative description of the revenue codes included on this bill. Abbreviations may be used. 16

17 FIELD 44 HCPCS/RATES REQUIRED; Inpatient Accommodations must be entered in revenue code sequence. Dollar values reported in this field must include whole dollars, the decimal, and the cents. Outpatient Lab, X/ray and surgery services require a HCPCS code. FIELD 45 SERVICE DATES REQUIRED FIELD 46 UNITS OF SERVICE REQUIRED; Enter the total number of covered accommodation days, or ancillary units of service when appropriate. 17

18 FIELD 47 TOTAL CHARGES REQUIRED; Total charges pertaining to the related revenue code for the current billing period as entered in the "statement covers" period. FIELD 48 NON COVERED CHARGES REQUIRED, IF APPLICABLE FIELD 49 UNLABELED FIELD NOT REQUIRED FIELD 50 PAYER IDENTIFICATION REQUIRED; Enter payers in order of priority. FIELD 51 PROVIDER NUMBER REQUIRED; Enter the 8-digit Mississippi Medicaid provider number. 18

19 FIELD 52 RELEASE OF INFORMATION NOT REQUIRED FIELD 53 ASSIGNMENT OF BENEFITS NOT REQUIRED CERTIFICATION INDICATOR FIELD 54 PRIOR PAYMENTS REQUIRED, IF APPLICABLE. The amount received toward payment of this bill prior to the billing date by the indicated payer. Medicare payments should never be reflected in this field, refer to February 2005 bulletin, page 2. FIELD 55 ESTIMATED AMOUNT DUE NOT REQUIRED 19

20 FIELD 56 UNLABELED FIELD NOT REQUIRED FIELD 57 UNLABELED FIELD NOT REQUIRED FIELD 58 INSURED NAME REQUIRED; Enter the insured's last name, first name, and middle initial. Name must correspond with the name in the Medicaid system. If the patient is covered by insurance other than Medicaid: Enter the name of the individual in whose name the insurance is carried, as qualified below by payer organization. FIELD 59 PATIENT S RELATIONSHIP TO INSURED NOT REQUIRED 20

21 FIELD 60 IDENTIFICATION NUMBER 9-DIGIT MEDICAID IDENTIFICATION NUMBER FIELD 61 INSURED GROUP NAME REQUIRED, IF APPLICABLE. FIELD 62 INSURANCE GROUP NAME REQUIRED, IF APPLICABLE. FIELD 63 TREATMENT AUTHORIZATION REQUIRED, IF APPLICABLE. CODES FIELD 64 EMPLOYMENT STATUS REQUIRED, IF APPLICABLE. (Y/N are the required indicators) FIELD 65 EMPLOYER NAME REQUIRED, IF APPLICABLE. FIELD 66 EMPLOYER LOCATION REQUIRED, IF APPLICABLE. FIELD 67 PRINCIPAL DIAGNOSIS CODE REQUIRED; Enter the ICD-9-CM for the principal diagnosis. 21

22 FIELDS OTHER DIAGNOSIS CODES REQUIRED, IF APPLICABLE. Enter any other ICD-9 diagnosis codes that relates to the billing period. FIELD 76 ADMITTING DIAGNOSIS REQUIRED, IF APPLICABLE. Enter ICD-9 diagnosis code provided at time of admission as stated by the physician. FIELD 77 EXTERNAL CAUSE OF INJURY NOT REQUIRED CODE FIELD 78 UNLABELED FIELD NOT REQUIRED 22

23 FIELD 79 PROCEDURE CODING REQUIRED; enter a 9. METHOD USED FIELD 80 PRINCIPAL PROCEDURE CODE AND DATE REQUIRED, IF APPLICABLE. If operating room is used, enter the appropriate ICD-9-CM surgical procedure code and date using the MM/DD/CCYY format. FIELD 81 OTHER PROCEDURE CODES AND REQUIRED, IF APPLICABLE DATES FIELD 82 ATTENDING PHYSICIAN REQUIRED; In this field, we can accept the 8-digit Medicaid provider number or state abbreviation and license number. 23

24 FIELD 83 OTHER PHYSICIAN ID REQUIRED, IF APPLICABLE. FIELD 84 REMARKS OPTIONAL FIELD 85 PROVIDER REPRESENTATIVE SIGNATURE REQUIRED; A true signature stamp can be used, guidelines listed in April 2005 bulletin, page 7. FIELD 86 DATE BILL SUBMITTED REQUIRED; Enter the date the hospital submits the claim to the fiscal agent in MM/DD/CCYY format. 24

25 Helpful Hints Bill types 117, 137, 118, and 138 can only be used when submitting claims electronically, never hardcopy. If submitting hardcopy, a paper adjustment/void form must be used. Medicare Crossovers can never be adjusted, they can only be voided. Once voided, a corrected claim should be resubmitted within 180-days from Medicare s paid date. When completing a UB-92 as a crossover, no Medicare payment should be annotated in prior payments, block 54. This is keyed from the EOMB by data entry. Block 54 is for other (TPL) third party liability payments ONLY. 25

26 UB-92 Billing Manual To receive a copy of the UB-92 Billing Manual, contact the American Hospital Association at or visit the following websites: May 9, 2017 Conduent Internal Use Only 26

Subject: Updated UB-04 Paper Claim Form Requirements

INDIANA HEALTH COVERAGE PROGRAMS P R O V I D E R B U L L E T I N B T 2 0 0 7 0 2 J A N U A R Y 3 0, 2 0 0 7 To: All Providers Subject: Updated UB-04 Paper Claim Form Requirements Overview The following