Claims Operations Guide for Providers

Transcription

1 San Francisco Health Plan Claims Operations Guide for Providers November 2017 San Francisco Health Plan 50 Beale Street 12 th Floor San Francisco, CA Telephone: (415) , Ext Fax: (415)

2 San Francisco Health Plan Claims Operations Guide for Providers January 2016 TABLE OF CONTENTS INTRODUCTION... 4 I. BILLING FOR MEDI-CAL... 4 II. AUTHORIZATION REQUIREMENTS... 4 III. CONTRACTS... 4 CLAIMS SUBMISSION AND PROCESSING... 5 AI. CLAIMS CONTACT INFORMATION... 6 AII. CLAIM SUBMISSIONS... 7 A. ELECTRONIC CLAIMS... 7 B. CHECKING CLAIM STATUS... 7 C. CORRECTED CLAIMS... 7 AIII. CLAIM TIMELINES... 7 A. BILLING LIMITS... 7 AIV. CLEAN CLAIMS... 8 A. OTHER CLAIM REQUIREMENTS... 8 AV. HEALTH INSURANCE CLAIM (CMS 1500) FORM INSTRUCTIONS... 8 AVI. HEALTH INSURANCE CLAIM FORM (UB04) INSTRUCTIONS AVII. OTHER INSURANCE/COORDINATION OF BENEFITS AVIII. THIRD PARTY LIABILITY CLAIMS CODING BI. OVERVIEW OF CODES BII. CPT CODES A. CONFLICTS WITH OTHER COMMON CORE DATA B. UNLISTED SERVICES AND PROCEDURES C. AGE PARAMETERS BIII. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES BIV. DIAGNOSIS CODES BV. MODIFIERS BVI. MULTIPLE PROCEDURES OR VISITS BVII. BY REPORT SERVICE/HCPCS CODES BVIII. NATIONAL DRUG CODES (NDC) AND UNIQUE PRODUCT NUMBERS (UPN) A. NATIONAL DRUG CODE (NDC): B. UNIQUE PRODUCT NUMBER (UPN): CLAIMS REQUIREMENTS AND POLICIES CI. PROFESSIONAL SERVICES A. GYNECOLOGICAL AND OB SERVICES B. ANESTHESIA CII. LABORATORY AND PATHOLOGY CIII. AMBULANCE TRANSPORT CIV. VISION SERVICES CV. INPATIENT SERVICES A. ADMISSION DATE B. MEMBERSHIP DATE C. BILLING D. COMPENSATION CONDITIONS CVI. FACILITY OUTPATIENT BILLING CVII. MEDICAL SUPPLY BILLING REQUIREMENTS CVIII. EMERGENCY ROOM SERVICES

3 CIX. IMMUNIZATIONS A. FEDERAL VACCINES FOR CHILDREN (VFC) B. NON VFC VACCINES CX. DUPLICATE BILLINGS CXI. SFHP COVERED BENEFITS, INCLUDING NON-SPECIALTY MENTAL HEALTH CXII. SERVICES COVERED BY OTHER ENTITIES CXIII. Family Planning, SENSITIVE SERVICES AND DIAGNOSIS CLAIM STATUS, RECONSIDERATIONS, RECOVERIES AND DENIALS DI. CLAIMS STATUS REQUESTS DII. NOTICE OF ACTION LETTERS FOR MEMBER DENIALS DIII. CLAIM RECOVERIES DIV. PROVIDER DISPUTE RESOLUTIONS (PDR) DV. BALANCE BILLING DVI. FRAUD, WASTE AND ABUSE a. Claims Department b. Compliance Department DVII. Contact Information

4 Introduction I. Billing for Medi-Cal San Francisco Health Plan (SFHP) primarily serves Medi-Cal Beneficiaries under a contract with the State of California. SFHP generally follows policies and procedures of the Medi-Cal program. Unless otherwise noted, SFHP s non-medi-cal lines of business also follow Medi-Cal policies and programs. Providers have access to SFHP policies and procedures in this manual. The Medi-Cal program manual may be found at the ACS (Affiliated Computer Services) manual on ACS is contracted by the State as the Medi-Cal fiscal Intermediary for the State Medi-Cal program. ACS processes and pays claims for Medi-Cal beneficiaries in Medi-Cal fee-for-service. San Francisco Health Plan is responsible to process and pay claims for its members. If you treat a member who is not a San Francisco Health Plan member, you must bill ACS or the member s Medi-Cal managed care plan for those services. This rule applies to members whose eligibility is through another county or who have an aid code not covered by San Francisco Health Plan. San Francisco Health Plan serves Medi-Cal, Healthy Workers HMO, and Healthy Kids HMO lines of business as well as acts as a third party administrator for Healthy San Francisco, a health access program. For more information on these programs, see the Network Operation Manual on our website, II. Authorization Requirements Any of the services or benefits outlined below are subject to prior authorization requirements. For the most up to date list of prior authorization requirements, please visit our website at or contact us at (415) extension III. Contracts Any service or benefit described in this manual is considered the general rule. The terms and conditions of your practice or medical group s responsibilities for claims to the extent they conflict with this manual shall be governed by your practice or medical group s contract with SFHP. For any questions or clarity about your contract, you can contact our Provider Relations department at extension

5 Section A CLAIMS SUBMISSION AND PROCESSING This section explains claims submission requirements and general claims processing information. 1. Claims Contact Information 2. Claims Submission Process 3. Claim Timelines 4. Clean Claims 5. Health Insurance Claim Form (CMS 1500) Instructions 6. Health Insurance Claim Form (UB04) Instructions 7. Other Health Insurance 8. Third Party Liability 5

6 AI. Claims Contact Information San Francisco Health Plan delegates authorization and claim processing to some of its medical groups. SFHP processes claims, in general, for the following medical groups: San Francisco Community Clinic Consortium, San Francisco Health Network (previously known as the Community Health Network) and UCSF Medical Group, see the grid below for more specific information. Any delegated medical group must submit encounter data to San Francisco Health Plan in lieu of claims. For more information on delegated responsibilities or encounter data please see the Network Operations Manual posted on our website at Patient s Medical Network BTP CCHCA CHN HILL KAISER NEMS NMS UCSF Who has financial risk? Shared by BTP & SFHP CCHCA CPG/DPH Shared by HILL & SFHP Kaiser NEMS Shared by NEMS & DPH (SFHN) SFHP Who processes claims? Professional: BTP Phone 1(415) Mail claims to: PO Box , SF, CA Facility & DME: SFHP Phone 1(415) x7115 Mail claims to: P.O. Box , SF, CA All claims: CCHCA Phone 1(415) x3207 Fax 1(415) Mail claims to: 445 Grant Ave Ste 700, SF, CA All claims: SFHP Phone 1(415) x7115 Mail claims to: P.O. Box , SF, CA Professional: HILL Phone 1(800) Mail claims to: PO Box 8001, Park Ridge, IL Facility & DME: SFHP Phone 1(415) x7115 Mail claims to: P.O. Box , SF, CA All claims: Kaiser Member Services 1(800) Mail claims to: 2425 Geary Blvd, SF, CA All claims: NEMS Phone 1(415) x5241 Mail claims to: 1520 Stockton Street, SF, CA All claims: NEMS Phone 1(415) x5241 Mail claims to: 1520 Stockton Street, SF, CA All claims: SFHP Phone 1(415) x7115 Mail claims to: P.O. Box , SF, CA Who makes UM decisions? All UM decisions: BTP Phone 1(415) Fax 1(415) All UM decisions: CCHCA Phone TPA UM Supervisor: 1(415) x3291 CCHCA Medical Director: 1(415) x2832 Fax 1(415) All UM decisions: SFHP Phone 1(415) x400 Outpatient Fax: 1(415) Inpatient Fax: 1(415) All UM decisions: HILL Phone 1(800) UM/Authorizations fax: 1(925) Inpatient Face Sheets: 1(925) All UM decisions: Kaiser Phone 1(415) Fax 1(415) All UM decisions: NEMS Phone 1(415) Fax 1(415) All UM decisions: NEMS Phone 1(415) Fax 1(415) All UM decisions: SFHP Phone 1(415) x400 Outpatient Fax: 1(415) Inpatient Fax: 1(415) Member Grievance Line 1(415) (415) (415) (415) (800) (415) (415) (415)

7 AII. Claim Submissions a. Electronic Claims SFHP prefers that claims be submitted electronically in a HIPAA compliant format. For information on file layouts, assistance on submitting electronic claims, or to obtain a copy of the SFHP 837 Companion guide, please contact the SFHP Information Technology Services Department at (415) or at production_services@sfhp.org. b. Checking Claim Status Providers may check claim status as well as eligibility and authorization status through the Provider Portal. The Provider Portal can be accessed on our website, Providers may also call SFHP s claim line at (415) ext AIII. c. Corrected Claims Claims denied or rejected for insufficient or incorrect claim data and/or for documentation, can be corrected and resubmitted for processing. For CMS 1500 forms, please write Corrected Claim on the top of the form itself or place a 7 for corrected claims in Box 22 of the form. For UB 04 forms, please indicate a corrected claim with the appropriate bill type, XXX7. To VOID an existing claim use an 8 in Box 22 of the CMS 1500 form or with the appropriate Bill Type, XXX8, on UB 04 forms. If you also include our original Claim ID in Box 22 after the resubmission code, it will help automate the replacement process in our system. Corrected claims are considered a new billing and therefore must meet the Claims Timelines listed below, as would an original claim. Claim Timelines SFHP complies with AB1455 timeline guidelines. SFHP shall reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but not later than 45 working days after the date of receipt of the complete claim, unless the complete claim or portion thereof is contested or denied. For more information of the requirements for a complete claim, see section AIV. The receipt date used for claims processing on claims submitted through the mail is the actual date the claim was received at SFHP. Electronic claims submitted after 5:00 pm are assigned to the following business day s receipt date. a. Billing Limits San Francisco Health Plan has billing limits based on Medi-Cal guidelines, as outlined below: Reimbursement 100% Percentage 75% % months 7 9 months months 0% Over 1 year 7

8 AIV. The original claim should be billed to SFHP as soon as possible from the date of service However, the original clean claim must be received at SFHP within 6 months of the date services were rendered to avoid a reduction in payment. After six months from the service date, there is a payment reduction as defined by Medi-Cal regulations as shown in the graph above. Claims received after 365 days from the Date of Service or the primary payer paid date will be denied for timely filing. This requirement is referred to as the One- Year Billing Limit. Again, a corrected claim will be handled the same as an original claim and will be subject to the timelines noted in the diagram above. Clean Claims SFHP will process a clean and complete claim that is submitted in a timely manner for medically necessary and covered services by a participating provider group in accordance with the agreement between SFHP and the provider group for the applicable benefit program. A clean claim is defined as a fully completed claim that contains all the required data necessary (including any essential documentation) for accurate adjudication. For a list of the required fields by form see the following two sections, AV and AVI. AV. a. Other Claim Requirements Multiple page paper claims: In order for SFHP to convert these claims successfully into a useable electronic format we ask that our Providers do not place a TOTAL CHARGES amount on the claims pages unless it is the last page of the claim; and then that should be for the total for all pages. NDC/UPN: Include whenever applicable. NDC codes are required per Medi-Cal guidelines. Quantities: A quantity for each service rendered is required. Please enter quantities as a single digit (e.g., 1 not 01, 001 or 010 ). Please do not use decimals or partial units, like.4. Attachments: Individual claim forms are separated. Each claim is processed separately. Do not staple original claims together. Stapling original claims together indicates the second claim is an attachment, not an original claim to be processed separately. Professional/Facility Services: Do not bill both hospital professional and facility services on the same form. If this procedure is not followed, services billed on an incorrect form will be denied. Authorizations: Prior authorization of services is required for some procedures; see for the most up-to-date list of prior authorization requirements. All out-of-network referrals (e.g., a CHN member consulting with a UCSF specialist) and inpatient admissions require prior authorizations. Referrals within a member's medical group do not require prior authorization. Please be sure to include a prior authorization number when applicable. Health Insurance Claim (CMS 1500) Form Instructions The most current and standard Center of Medicaid and Medicare Services (CMS) 1500 form must be used to bill SFHP for medical services. The form is used by Physicians and Allied Health Professionals to submit claims for medical services. All items must be completed unless otherwise noted in these instructions. A CMS 1500 form with field descriptions and instructions is shown below. 8

9 In order to maintain the highest level of data integrity, SFHP will not add or change any information on a submitted claim (electronic or paper), therefore, the entire claim may be rejected if any of the required data elements are missing or invalid. To submit a corrected claim, see AII. CMS 1500 Field Required Field? Description and Requirements 1 Optional Type of Insurance 1a Required Insured's SFHP ID Number - Enter the member's 11-digit SFHP number as it appears on the ID card. When submitting a claim for a newborn infant for the month of birth or the following month, enter the mother s ID number in this field. Do not use the SSN number when billing services. If you do not know the patient's SFHP ID, you can log onto our Provider Portal to look up the patient's ID, see section DVI for more instructions on the Provider Portal. 2 Required Patient's Name - Enter the member s name as is indicated on the ID card. When submitting claims for a newborn infant using the mother s ID number, enter the infant s name in Box 2. Services rendered to an infant may only be billed with the mother s ID for the month of birth and the month after. Enter Newborn using Mother s ID / (twin a) or (twin b) in the Reserved for Local Use field (Box 19). 3 Required Patient's Birthdate - Enter member's date of birth for all claims, including Newborn claims. 4 If Applicable Insured's Name - Not required unless billing for an infant using the Mother s ID. See #2 above. 5 Required Patient's Address/Telephone - Enter member s complete address and telephone number. 6 If Applicable Patient's Relationship to Insured - Only Self or Child are applicable. 7 Optional Insured's Address 8 Optional Reserved For NUCC Use 9 Optional Other Insured's Name 9a Optional Other Insured's Policy/Group Number 9b-c Optional Reserved for NUCC use 9d Optional Insurance Plan/Program Name 10a-c Optional Patient's Condition Related to employment, auto accident/place, other accident. 10d Optional Claim codes (designated by NUCC) 11 Optional Insured s policy group or FECA number 11a Optional Insured's Date of Birth/Sex 9

10 CMS 1500 Field Required Field? Description and Requirements 11b Optional Other claim ID (designated by NUCC) 11c If Applicable Insurance Plan Name or Program Name - For Medicare/Medi-Cal crossover claims. Enter the Medicare Carrier Code. 11d Required Is there another health benefit plan? Enter an X if recipient has other health coverage. Medi-Cal policy requires that, with certain exceptions, providers must bill the recipient s other health insurance coverage prior to billing Medi-Cal. If the Other Health Coverage has paid, enter the amount in the upper right side of this field, do not enter a decimal point or dollar sign. 12 Optional Patients of Authorized Person s Signature 13 Optional Insured's or Authorized Person's Signature 14 Required Date of Current - Illness (First Symptom) or Injury or Pregnancy (LMP) - Enter the date of onset of the member's illness, the date of accident/injury or the date of the last menstrual period. 15 Optional Other Date 16 Optional Dates Patient Unable to Work in Current Occupation 17 If Applicable Name of Referring Provider or Other Source - Enter the full name of the Referring Provider. Data in this field must be indented. The space to the left of the vertical dotted line must remain blank. A referring/ordering provider is one who requests services for a member, such as provider consultation, diagnostic laboratory or radiological tests, physical or other therapies, pharmaceuticals or durable medical equipment. 17a If Applicable Unlabeled 17b If Applicable NPI - Enter Referring Provider's NPI number. 18 If Applicable Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank. 19 If Applicable Reserved for Local Use - Use this area for procedures that require additional information, justification or an Emergency Certification Statement. This section may be used for an unlisted procedure code when explanation is required and clinical review is required. If modifier -99 multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be listed. Claims for By Report codes and complicated procedures should be detailed in this section if space permits. All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section. Anesthesia start and stop times. 10

11 CMS 1500 Field Required Field? Description and Requirements Itemization of miscellaneous supplies, etc. 20 If Applicable Outside Lab? If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory. 21 If Applicable Diagnosis or Nature of Illness or Injury - Enter all letters and/or numbers of the ICD-9-CM or ICD-10, effective 10/1/2015, code for each diagnosis, including fourth and fifth digits if present. The first diagnosis listed in section 21.1 indicates the primary reason for the service provided. Once ICD-10 is implemented, SFHP will require that the ICD indicator be set to zero when using ICD-10 codes. 22 Optional Resubmission Code/Original Ref. No. 23 If Applicable Prior Authorization Number - Enter prior authorization or referral number. Shaded Section Above 24 If Applicable Use this area for and NDC/UPN information. These must be included, if applicable. 24A Required Dates of Service - Enter the date the service was rendered in the from and to boxes in the MMDDYY format. If services were provided on only one date, they will be indicated only in the from column. If the services were provided on multiple dates (i.e., DME rental, hemodialysis management, radiation therapy, etc.), the range of dates and number of services should be indicated. To date should never be greater than the date the claim is received by the Health Plan. 11

12 CMS 1500 Field Required Field? Description and Requirements 24B Required Place of Service - Enter one code indicating where the service was rendered School 04 - Homeless Shelter 05 - Indian Health Service Free-Standing Facility 06 - Indian Health Service Provider-Based Facility 07 - Tribal 638 Free-Standing Facility 08 - Tribal 638 Provider Based-Facility 11 - Office Visit 12 - Home 13 - Assisted Living 14 - Group Home 15 - Mobile Unit 19 Off Campus Outpatient Hospital 20 - Urgent Care Facility 21 - Inpatient Hospital 22 On Campus - Outpatient Hospital 23 - Emergency Room 24 - Ambulatory Surgical Center 25 - Birthing Center 26 - Military Treatment Facility 31 - Skilled Nursing Facility 32 - Nursing Facility 33 - Custodial Care Facility 34 - Hospice 41 - Ambulance - Land 42 - Ambulance - Air or Water 50 - Federally Qualified Health Center 51 - Inpatient Psychiatric Facility 52 - Psychiatric Facility Partial Hospitalization 53 - Community Mental Health Center 54 - Intermediate Care Facility 55 - Residential Substance Abuse Treatment Facility 56 - Psychiatric Residential Treatment Center 60 - Mass Immunization Center 61 - Comprehensive Inpatient Rehab Facility 62 - Comprehensive Outpatient Rehab Facility 65 - End Stage Renal Disease Treatment Facility 71 - State or Local Public Health Clinic 72 - Rural Health Clinic 81 - Independent Laboratory 99 - Other Unlisted Facility 12

13 CMS 1500 Field Required Field? Description and Requirements 24C If Applicable Emergency Code: Enter an X or Y when billing for emergency services, or the claim may be reduced or denied. 24D Required Procedures, Services or Supplies/Modifier - Enter the applicable CPT and/or HCPCS National codes in this section. Modifiers, when applicable, are listed to the right of the primary code under the column marked modifier. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the fivedigit medical supply code. 24E Required Diagnosis Pointer - Enter the diagnosis code letter from box 21 that applies to the procedure code indicated in 24D. 24F Required Charges - Enter the charge for service in dollar amount format. If the item is a taxable medical supply, include the applicable state and county sales tax. 24G Required Days or Units - Enter the number of medical visits or procedures, units of anesthesia time, oxygen volume, items or units of service, etc. Do not enter a decimal point or leading zeroes. Do not leave blank as units should be at least 1. For more information on billing requirements of specific services, see section C. 24H If Applicable EPSDT Family Plan - Enter code 1 or 2 if the services rendered are related to family planning (FP). Enter code 3 if the services rendered are Child Health and Disability Prevention (CHDP) screening related 24I Optional ID Qualifier for Rending Provider 24J If Applicable Rendering Provider ID #/ NPI - Enter the NPI for a rendering provider (unshaded area), if the provider is billing under a group NPI. 25 Required Federal Tax ID Number - Enter the Federal Tax ID for the billing provider. (Note: if vendor tax ID # is shared between two or more individual vendors, the provider must submit claims using a SFHPissued 3-digit suffix addition to the Tax ID number). 26 Optional Patient's Account Number -Enter the patient s medical record number or account number in this field. This number will be reflected on Remittance Advice (RA), if populated. 27 Optional Accept Assignment? 28 Required Total Charge -Enter the total for all services in dollar and cents. Do not include decimals. Do not leave blank. 29 If Applicable Amount Paid - Enter the amount of payment received from the Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals. 30 If Applicable Balance Due - Enter the difference between the Total Charges and the Amount Paid in full dollar amount and cents. Do not enter decimals. 31 Required Signature of Physician or Supplier Including Degrees or Credentials 13

14 CMS 1500 Field Required Field? Description and Requirements - The claims must be signed and dated by the provider or a representative assigned by the provider in black pen. An original signature is required. Stamps, initials or facsimiles are not acceptable. 32 Required Service Facility Location Information - Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number of the facility where services were rendered, if other than home or office. 32a Required Service Facility Location Information - Enter the NPI of the facility where the services were rendered. 32b If Applicable Service Facility Location Information - Enter the Medi-Cal provider number for an atypical service facility. 33 Required Billing Provider Info & Phone # (Pay-To) - Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number. 33a Required Enter the billing provider s NPI. 33b Required Used for atypical providers only. Enter the Medi-Cal provider number for the billing provider. AVI. Health Insurance Claim Form (UB04) Instructions The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Community-Based Adult Services). Claims not submitted on red and white claim forms will not be adjudicated. They will be returned to the originating service provider. A UB04 form with field descriptions and instructions is shown below. In order to maintain the highest level of data integrity, SFHP will not add or change any information on a submitted claim (electronic or paper), therefore, the entire claim may be rejected if any of the required data elements are missing or invalid. To submit a corrected claim, see AII. UB-04 Field Required Field? Inpatient Outpatient Description and Requirements 1 Required Required Rendering Provider Name and Address - Enter the provider name, address and zip code and telephone number this section. 2 Required Required Pay - To Provider Name and Address - Enter the provider name, address and zip code and telephone number this section. 14

15 UB-04 Field Required Field? Inpatient Outpatient Description and Requirements 3a Optional Optional Patient Control Number - This number is reflected on the Explanation of Benefits for reconciling payments if populated. 3b Optional Optional Medical Record Number - Not required. This number will not be reflected on RA if populated. 4 Required Required Type of Bill - Enter the appropriate four-character type of bill code as specified in the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual. 5 Required Required Federal Tax Number - Enter the Federal Tax ID for the billing facility. (Note: If vendor tax ID # is shared between two or more individual vendors, the provider must submit claims using a SFHP-issued 3-digit suffix addition to the Tax ID number). 6 Required Required Statement Covers Period - Enter the From and Through dates of services covered on the claim if claim is for inpatient services. 7 Optional Optional Future Use 8a Optional Optional Patient Name - Enter patient s name in 8b. 8b Required Required Patient Name - Enter patient s last name, first name and middle initial if known. When submitting claim for a newborn using the mother s ID, enter the infant s name in box 8b. If the infant is unnamed, write the mother s last name followed by baby boy or baby girl. If billing for multiple births, use twin A, twin B, etc. on separate claim forms. 9 Optional Optional Patient Address 10 Required Required Patient Birthdate - Enter the patient s date of birth in an eight digit format, Month, Date, Year (MMDDYYYY) format. 11 Required Required Patient Sex - Use the capital letter M for male, or F for female. 12 Required Required Admission Date - Enter in a six-digit format (MMDDYY), enter the date of hospital admission. 13 Required Required Admission Hour - Enter hour of patient's admission. 14 Required Required Admission/Visit Type - Enter the numeric code indicating the necessity for admission to the hospital. 1 - Emergency 2 - Elective 15

16 UB-04 Field Required Field? Inpatient Outpatient Description and Requirements 15 If Applicable If Applicable Admission Source - If the patient was transferred from another facility, enter the numeric code indicating the source of transfer. 1 - Non-Healthcare Facility Point of Origin 2 Clinic 4 - Transfer from a Hospital (Different Facility) 5 - Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) 6 - Transfer from Another Healthcare Facility 7 - Emergency Room 8 - Court/Law Enforcement 9 - Information Not Available B - Transfer from Another Healthcare Facility C - Readmission to the same Home Health Agency D - Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in a separate claim to the payer E - Transfer from Ambulatory Surgery Center F - Transfer from Hospice and is under a hospice plan of care or enrolled in a hospice program 16 Required n/a Discharge Hour - Enter the discharge hour. For Inpatient only. 17 Required Required Patient Discharge Status Optional Optional Condition Codes - Enter the Medi-Cal codes used to identify the condition relating to this bill and affect payer processing. Condition Codes covered by SFHP: 80 - Other Coverage 81 - Emergency Certification A1 - CHDP Screening Related A3 - Family Planning/Sterilization A4 - Family Planning/Other 29 If Applicable If Applicable Accident State - If visit or stay is related to an accident, enter in which state the accident occurred. 30 n/a n/a Future Use If Applicable If Applicable Occurrence Codes and Dates - Enter the codes and associated dates that define the significant event related to the claim. Occurrence Codes covered by SFHP: 01 - Auto Accident 02 - No Fault Insurance Involvement - Including Auto Accident/Other 03 - Accident/Tort Liability 04 - Employment Related 16

17 UB-04 Field Inpatient Required Field? Outpatient Description and Requirements 05 - Other Accident 06 - Crime Victim Optional Optional Occurrence Span Codes and Dates 37 Optional Optional Internal Control Number/Document Control Number 38 If Applicable If Applicable Responsible Party Name and Address - Enter the name and address of the party responsible for payment if different from name in box Optional Optional Value Codes and Amounts 42 Required Required Revenue Code - For inpatient billing, enter the four-digit revenue code for the services provided, e.g. room and board, obstetrics, etc. 43 Required Required Revenue Description - Identify the description of the particular revenue code in box 42 or HCPCS code in box 44. Include NDC/UPN Codes here, when applicable. 44 Required Required HCPCS/Rates - Enter the applicable HCPCS codes and modifiers. For outpatient billing do not bill a combination of HCPCS and Revenue codes on the same claim form. When billing for professional services, use CMS 1500 form. 45 Required Required Service Date - Enter the service date in MMDDYY format for outpatient billing. 46 Required Required Units of Service -Enter the actual number of times a single procedure or item was performed or provided for the date of service. 47 Required Required Total Charges (By Rev. Code) 48 Optional Optional Non-Covered Charges 49 n/a n/a Future Use 50 Required Required Payer Identification (Name) - Enter San Francisco Health Plan and the corresponding medical group that the member belongs to. 51 Optional Optional Health Plan ID 52 Optional Optional Release of Info Certification 53 Optional Optional Assignment of Benefit Certification 54 If Applicable If Applicable Prior Payments - Enter any prior payments received from Other Coverage in full dollar amount. 55 Optional Optional Estimated Amount Due 56 Required Required NPI - Enter NPI number. 57 Optional Optional Other Provider IDs 58 If Applicable If Applicable Insured's Name - Enter the mother s name if billing for an infant using the mother s ID. If any other circumstance, leave blank. 17

18 UB-04 Field Required Field? Inpatient Outpatient Description and Requirements 59 If Applicable If Applicable Patient's Relation to Insured -Enter 03 (child) if billing for an infant using the mother s Identification Number. 60 Required Required Insured's Unique ID - Enter the patient s 11-digit SFHP ID number as it appears in the member s ID card. Enter the mother s ID number in this section for a newborn infant for the month of birth and the month after only. Do not use the SSN or CIN. 61 Optional Optional Insured Group Name 62 Optional Optional Insured Group Number 63 If Applicable If Applicable Treatment Authorization Code - Enter any authorizations numbers in this section. It is not necessary to attach a copy of the authorization to the claim. Member information from the authorization must match the claim. 64 Optional Optional Document Control Number 65 Optional Optional Employer Name 66 Required Required Diagnosis/Procedure Code Qualifier use 9 for ICD-9 codes, and 0 for ICD-10 codes 67 Required Required Principal Diagnosis Code/ Other Diagnosis Codes - Enter all letters and/or numbers of the ICD-9 CM or ICD-10 CM, which were effective 10/1/2015, code for the primary diagnosis. 68 If Applicable If Applicable Other Diagnosis Codes - Enter all letters and/or numbers of the secondary ICD-9 CM oricd-10, effective 10/1/2015. code. Do not enter a decimal point when entering the code. 69 If Applicable If Applicable Admitting Diagnosis Code 70 Optional Optional Patient's Reason for Visit Code 71 Optional Optional PPS Code 72 Optional Optional External Cause of Injury Code 73 Optional Optional Future Use 74 If Applicable If Applicable Principal Procedure Code/Date 75 n/a n/a Future Use 76 If Applicable If Applicable Attending Name/ ID-Qualifier 1G 77 If Applicable If Applicable Operating ID If Applicable If Applicable Other ID 80 If Applicable If Applicable Remarks 81CC Optional Optional Code - Code Field/Qualifiers. 18

19 AVII. Other Insurance/Coordination of Benefits Some SFHP members have other health coverage (OHC) in addition to their SFHP coverage. Specific rules govern how benefits must be coordinated in these cases. For information on member eligibility and program descriptions, please see the Network Operation Manual on State and Federal laws require that all available health coverage be exhausted before billing Medi-Cal. Thus, when a SFHP member has other health coverage and has Medi-Cal, SFHP will always be the payer of last resort. Other Health Coverage includes any non Medi-Cal health coverage that provides or pays for health care services. This can include: Commercial Health Plans (individual and group policies) Prepaid Health Plans Health Maintenance Organizations (HMO) Employee benefit plans Union Plans Tri-Care, Champ VA TPL Third Party Liability Medicare, including Medicare Part D plans, Medicare supplemental plans and Medicare Advantage (PPO, HMO and Fee for Service) plans. When a SFHP member also has OHC, s/he must treat the other insurance plan as the primary insurance company and access services under the company s rules of coverage. SFHP is not liable for the cost of services for members with OHC who do not obtain the services in accordance with the rules of their primary insurance. If a member elects to seek services outside of the framework of his or her primary insurance, the member is responsible for the cost. If other insurance is primary and SFHP does not pay as primary, procedures which normally require prior authorization will not be required except for the following services: admission for skilled nursing facilities, long term care facilities and inpatient admissions. To coordinate benefits for a patient who has dual coverage, you must bill the primary insurance first. If there is any balance remaining after payment is received from the primary insurer, you should submit a claim to San Francisco Health Plan or the appropriate Medical Group responsible along with the Explanation of Benefits (EOB) from the primary payer. If your claim is denied for no EOB, you may resubmit the claim; see section AII for more information. San Francisco Health Plan reimburses Medicare and Medi-Cal eligible providers for applicable deductible and coinsurance, if the collective payment of Medicare and Medi-Cal does not exceed Medi-Cal s reimbursement rates. For members with Medicare and Medi-Cal coverage, please submit the following: For UB-04 claims, please submit the Medicare National Standard Remittance Advice. For CMS-1500 claims, please submit the Medicare Remittance Notice (MRN). When a SFHP members primary insurance has co-payments and/or deductibles, the member cannot be asked to pay, as long as he or she is obtaining benefits within the rules of the primary insurance. The exceptions to this are: 1) Healthy Workers HMO with timely filing; and 2) When the member has Medicare Part D. 19

20 AVIII. Third Party Liability If a member is injured through the act or omission of another person (a third party), SFHP will, with respect to services required as a result of that injury, provide covered services to its members, but the member shall agree to the following: Agrees to reimburse SFHP the reasonable cash value of benefits provided as reflected by the physician's usual and customary charges and as allowed by law, immediately upon collection of damages by the member, whether by action at law, settlement, or otherwise Provides SFHP with a lien, in an amount equal to the value of benefits provided by SFHP, as reflected by an amount not to exceed eighty (80) per cent of the provider's usual and customary charges or the amount actually paid by SFHP. The lien may be filed with the third party, the third party's agent, or the court All liens filed by SFHP for the recovery of payments made by SFHP on behalf of a member entitled to medical services under the Plan shall be in accordance with Civil Code section 3040 For Medi-Cal members, the State Department of Health Care Services (DHCS), and not SFHP, has the right to recovery and can ask a third party for money related to services obtained from SFHP. For more information on Medi-Cal Third Party Liability and Recovery, see 20

21 Section B CLAIMS CODING In the Claims Coding Section you will find coding requirements to assist you in billing correctly for services rendered to SFHP members. 1. Overview of Codes 2. Procedure Codes 3. Healthcare Common Procedure Coding System (HCPCS) Codes 4. Diagnosis Codes 5. Modifiers 6. Multiple Procedures or Visits 7. By Report Procedures 8. National Drug Codes (NDC)and Unique Product Numbers (UPN) 21

22 B. CLAIMS CODING BI. Overview of Codes San Francisco Health Plan uses Medi-Cal billing guidelines in addition to Optum coding books application for claim activities. Additional coding information and updates can be found on the AMA website at The following most current procedure codes valid on the date of service must be used for a claim to be processed: Professional charges HIPAA compliant HCPCS Level 1 (CPT) & level 2 Inpatient hospital/facility/institutional charges UB04 revenue codes Outpatient hospital/facility charges HCPCS Level 1 & 2 codes HCPCS Level 3 codes until retired by DHCS Professional and institutional charges must be submitted as separate claims. If submitted on the same claim, one or the other type of charges will not be considered for payment. For example, if professional charges (CPT codes) are included on an institutional claim for an inpatient stay, then these charges will be automatically bundled under the per-diem payment. The following includes special instructions regarding the use of various codes for different types of services. CPT codes, rather than HCPCS codes, should be used as first line coding when an appropriate code exists. Professional CPT-4 HCPCS I HCPCS II HCPCS III Inpatient Revenue Codes Professional Services Physician Services Non-physician procedures and services California only Inpatient facility services BII. CPT Codes Report ambulatory surgery, outpatient department visits, diagnostic testing and ancillary services using CPT, HCPCS Level II and III codes. Claims submitted with invalid, incorrect or missing procedure codes will be denied. Procedure CPT or HCPCS Surgery Radiology Pathology & Laboratory Medicine Evaluation & Management Anesthesia

23 a. Conflicts with Other Common Core Data Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not be made for claims where CPT procedure codes conflict with common core data, such as: Patient age/gender Diagnosis Place of service Provider specialty b. Unlisted Services and Procedures Claims for services submitted with unlisted CPT procedure codes (XXX99) require the following: Invoices of other pertinent information for DME, etc. Medical records for surgical procedures Documentation/Remarks or itemization of supplies Authorization c. Age Parameters Claims are processed according to the following age parameters as defined by Medi-Cal. Age range Classification up to 17 years Pediatric (infant, children and adolescent) patients 18 years and older Adult patients BIII. Healthcare Common Procedure Coding System (HCPCS) Codes The Healthcare Common Procedure Coding System (HCPCS) is a national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to process Medicare and Medicaid (Medi-Cal) claims on a national basis. HCPCS is a three-level coding system that incorporates Physicians Current Procedural Terminology (CPT-4), National and Local codes. The HCPCS coding format for Level I is five-digit numeric. The format for Level II and III is an alpha character followed by four numeric digits. The full range of codes for each level is as follows: Level I is thru and thru 99999; Level II is A0000 thru V9999. The existence of a specific Level II HCPCS code for a particular item or service is not a guarantee that the item or service is covered by SFHP. Refer to the section in the Medi-Cal Provider Manual specific to the service rendered for Medi-Cal reimbursable Level II. BIV. Diagnosis Codes SFHP requires a valid diagnosis code with each claim. Claims submitted with invalid, incorrect or missing diagnosis codes will be denied. Diagnoses and procedures for inpatient admission and outpatient services should be coded using the International Classification of Diseases (ICD-9/10-CM or ICD-9/10-PCS). For sick visits, use the appropriate 23

24 diagnosis code(s) for which the patient presented. Please provide the most specific ICD-9/10 code, down to the sixth-character level if appropriate. Use V codes, the supplementary classification of factors influencing health status in accordance with ICD-9- CM V-code reporting guidelines. Use E codes, the supplementary classification of causes of injury and poisoning in accordance with ICD-9- CM E code reporting guidelines. CMS requires all entities to use ICD-10 diagnosis codes for any dates of service on or after October 1, Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not made for claims where Diagnosis procedure codes conflict with common core data, such as: Patient age/gender CPT code Place of service Provider specialty BV. Modifiers Modifiers are "the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance, but not changed in its definition or code. Although many procedure codes require a modifier, some procedures do not need further clarification via a modifier. The inappropriate use of a modifier may result in the claim being denied. We follow current approved HIPAA compliant modifiers and consult Medi-Cal guidelines for appropriate coding. BVI. Multiple Procedures or Visits In general, only one visit or consultation per specialty is reimbursed for the same date of service. When two or more visits/consultations are billed for the same date of service, remarks should be made and they will be reviewed for individual consideration. Please ensure to use the appropriate member ID, rendering physician NPI (s), dates of service, service code(s) and modifiers when billing for more than one service on the same date of service. Multiple surgery procedure codes (CPT ) for the same patient, for the same date of service, are required to be coded following Medi-Cal guidelines.. When a service is legitimately rendered more than once on the same date of the service (before and after X-rays, glucose tolerance testing, ova and parasite tests, etc.), providers must include documentation with the claim explaining why the service was rendered more than once. This information may be entered in the Reserved for Local Use field (Box 19) or on an attachment to the claim. When billing electronically, enter the statement in the Remarks area. Include the rendering physicians NPI number in box 24I. A statement indicating, this service is not a duplicate is not sufficient to clarify why the service was rendered more than once. 24

25 For more information on duplicate billing, see section CX. BVII. By Report Service/HCPCS Codes This section includes information about By Report procedures, attachments and documentation. The following applicable information must be included in either Box19 of the CMS 1500, Box 84 on the UB04 form or provided as an attachment to the claim form: Invoice should include item description, manufacturer name, model number, catalog number, manufacturer suggested retail price (MSRP), if applicable. Operative report, operating time or procedure report including a description of the actual procedure performed and the results of the procedure. Number, size and location of lesions (if applicable). Time involved, the nature and purpose of the procedure or service and how it relates to the diagnosis. Description of and justification for any special features, custom modifications, etc. The reason a listed code was not used. Itemization of miscellaneous supply codes, etc. BVIII. National Drug Codes (NDC) and Unique Product Numbers (UPN) a. National Drug Code (NDC): The Federal Deficit Reduction Act of 2005 (DRA) requires Medi-Cal to collect rebates from drug manufacturers for physician-administered drugs. The collection of rebates is accomplished with the inclusion of National Drug Codes (NDCs) on claims submitted by providers. Effective for claims with dates of service on or after April 1, 2009, providers must use NDC for physicianadministered drugs, in conjunction with the customary Healthcare Common Procedure Coding System (HCPCS) Level I, II or III code, on all Medi-Cal claims. Claims will be denied if providers do not submit claims with a valid NDC paired with the appropriate HCPCS code as mandated by the NDC reporting requirement. Physician-administered drugs include any covered outpatient drug billed by a provider other than a pharmacy. This includes (but is not limited to) the following provider types: Physicians Clinics Hospitals The NDC reporting requirement applies to claims submitted using the following formats: 837 electronic transactions for Institutional and Professional claims CMS 1500 and UB-04 paper claims 25

26 b. Unique Product Number (UPN): There are codes that require a UPN, see Medi-Cal guidelines for the list of those codes, Claims must be billed with a HCPC and correct UPN for reimbursement. 26

27 Section C CLAIMS REQUIREMENTS AND POLICIES This section was developed to assist you in understanding key claim requirements and policies. CI. CII. CIII. CIV. CV. CVI. CVII. CVIII. CIX. CX. CXI. CXII. CXIII. Professional Services Laboratory and Pathology Ambulance Services Vision Services Inpatient Services Facility Outpatient Billing Medical Supply Billing Requirements Emergency Room Services Immunizations Duplicate Billings SFHP Covered Benefits, including Non-Specialty Mental Health Services Covered by Other Entities Family Planning, Sensitive Services and Diagnosis 27

28 CI. Professional Services SFHP reimburses providers for professional services. Professional services should be obtained within the member s network. Most professional services rendered outside of the member s network require priorauthorization. Emergency services, Family Planning and Sensitive Services do not require prior authorization. Professional services should be billed on a CMS 1500 claim form and should be submitted to the Member s Medical group or SFHP as referenced in Section A1 of this claims manual. a. Gynecological and OB Services SFHP members may access obstetric and gynecological services directly from an OB/GYN specialist or family practitioner within the member s network. This includes all services provided by a network OB/GYN, including prenatal and Comprehensive Perinatal Services Program (CPSP) services. The Comprehensive Perinatal Services Program (CPSP) offers a wide range of services to pregnant Medi-Cal SFHP members from the date of conception through 60 days after the month of delivery. Member and provider participation is voluntary. CPSP codes can be used by CPSP certified providers only. CPSP frequency limits apply. All visits over the allowed number of visits are subject to authorization. SFHP does not allow Global Billing for Obstetrical Services. OB services should be billed on a per-visit basis. Additional information regarding CPSP, obstetric and gynecological billing can be found at b. Anesthesia SFHP reimburses anesthesia services to providers for induction of general or regional anesthesia and supportive services associated with the provision of optimal anesthesia care for medical or surgical procedures. SFHP reimburses anesthesia services using the Anesthesia Unit System. SFHP requires the following for Anesthesia billing: Services are reimbursed using the surgical CPT code or anesthesia codes. Complete the CMS 1500 form using the surgical anesthesia services CPT code representing the major procedure performed with the appropriate HCPCS anesthesia modifier. If an unlisted (not otherwise specified) CPT code is used, submit documentation of the operative procedure with the claim. Services are reimbursed by determining the sum of the allowable base and time units. o Base values as defined by the American Society of Anesthesiologists (ASA); SFHP automatically assigns base values from Medi-Cal fee schedule. A time unit of fifteen (15) minutes or a portion thereof. Each 15-minute increment equals one unit. o Anesthesia time starts when the anesthetist begins to prepare the patient for induction and ends when the patient can be safely placed under post-operative supervision 28