NTT Data, Inc. updated Billspecs & Billing Setup

Transcription

1 Software Versions: NS652p3 INSTALLATION NOTES BILLSPECS & BILLING SETUP These installation notes highlight the pieces that need to be set up for paper and electronic billing to work successfully using the supplied bill specifications. It is assumed that all the regular data has been set up correctly, i.e. values have been entered into the facility profiles, payor profiles, etc. Failure to do this may ultimately lead to billing problems - you can t print a field that hasn t been entered! These notes concentrate on the special fields or data elements that must be set up for the various general and state specific billing procedures to work correctly. For specific instructions regarding the creation of charges to a particular payor/state entity, please refer to the payor/state plan setup document for the entity that you are setting up. For example, to set up a payor/plan for billing Maryland Medicaid, please refer to the mcdmd.doc (or mcdmd.pdf) plan setup document. BILL SPECIFICATION INSTALLATION Bill Specifications are installed onto a system using the Install option available from the Profiles/Payors/Bill Specifications menu. The installer is responsible for setting up the bill specifications a client needs for everyday billing. From then on, it will become the client s responsibility to maintain these bill specifications from facility to facility and to upgrade them for new releases. Page 1

2 Table of Contents Software Versions: NS652p INSTALLATION NOTES BILLSPECS & BILLING SETUP... 1 BILL SPECIFICATIONS... 4 General (Not State Specific) Type Billspecs /ANSI Professional Billing for Medicare B Therapy /ANSI Professional Billing for Medicare B Professional Services... 5 UB & ANSI Type Billspecs... 6 UB/ANSI Billing for Commercial UB/ANSI Billing for Medicare Secondary UB/ANSI Billing for Medicare A No Pay UB/ANSI Billing for Medicare B Legacy Flat File Version 6 Billing for Medicare State Medicaids Alabama Medicaid Alaska Medicaid Arizona Medicaid Evercare Select California Medicaid Colorado Medicaid Connecticut Medicaid Delaware Medicaid District Of Columbia Medicaid Florida Medicaid Georgia Medicaid Hawaii Medicaid Idaho Medicaid Illinois Medicaid Indiana Medicaid Iowa Heath Link Iowa Medicaid Louisiana Medicaid Maine Medicaid Maryland Medicaid Massachusetts Medicaid Massachusetts Rehab Medicaid Michigan Medicaid Minnesota Medicaid Mississippi Medicaid Missouri Medicaid Montana Medicaid Nebraska Medicaid Nevada Medicaid New Hampshire Medicaid New Jersey Medicaid FFS New Jersey Medicaid Managed Long Term Services And Supports (MLTSS) New Mexico Medicaid New York Medicaid North Carolina Medicaid North Dakota Medicaid Ohio Medicaid Ohio MyCareOhio Page 2

3 Oklahoma Medicaid Oregon Medicaid Pennsylvania Medicaid Rhode Island Medicaid South Carolina Medicaid South Dakota Medicaid Tennessee Medicaid Texas Medicaid Fee For Service (FFS) Texas Medicaid STAR+PLUS Utah Medicaid Virginia Medicaid Washington Medicaid West Virginia Medicaid Wisconsin Medicaid Medicare A/B MAC s Cahaba GBA CGS Administrators First Coast Service Options, Inc National Government Services Noridian Administrative Services (EDI Support Services) Novitas Solutions (formerly Highmark Medicare Services) Palmetto GBA WPS Medicare Commercial Payors Blue Cross Blue Shield of Michigan Medicare Replacement Plans Page 3

4 BILL SPECIFICATIONS General (Not State Specific) 1500 Type Billspecs Medicaid 1500 Gross (02/12) Medicaid 1500 Net (02/12) Medicare (02/12) Commercial 1500 Gross (02/12) Commercial 1500 Net (02/12) All other custom state and federal 1500 billspecs These bill specifications are used for 1500 paper billing. Note: Each individual billspec has a Column Offset field which can be used to move the billspec the specified number of characters to the right of the page. This can eliminate having to edit all the fields on a billspec to move them over for certain printers. Accident Codes On 08/05 forms, if you want the accident code fields to show you must enter the values that you want on a per bill basis using the edit bill data function. For box 10b yes enter X in User defined billing field #1, for box 10b no enter X in User defined billing field #2, for box 10c yes enter X in User defined billing field #3, for box 10c no enter X in User defined billing field #4, for box 14 date of accident enter the date (in mm/dd/yyyy format) in User defined billing field #5. Note, these fields are disabled in the default Medicaid billspec, to use them change them from literals to database fields. On 02/12 forms edit the field labeled 1500 Field Locator and select one of the 10B fields. Maximum Services Per Claim On an ANSI Professional billspec there is a maximum of 50 detail lines allowed per claim according to the national guidelines. For a "1500"/Professional billspec if the required maximum is entered in the "Max Anc/Acc Seq #" field and this limit is exceeded it will split the claim segments up into service line groups that match this number. For example, if we had a 55 line bill it will report claim segments of 50 lines and 5 lines separately. Note, this functionality only applies to Professional billspecs since the header records that are repeated with each service line group do not include information that depends on the individual service lines. If this was an ANSI Institutional/ UB04 bill then the service line dates reflect the from & thru dates, status codes, etc. that need to be reported at the header level, splitting them up would cause many potential problems. Patient Relationship To Insured Field 6 contains 4 boxes that indicate the relationship of the patient to the insured person - box 1 indicates Self, box 2 indicates Spouse, box 3 indicates Child, box 4 indicates Other. This value is determined from the Policy Holder Relationship To Resident settings on the Reimbursement Table Policy screen. The default value is that the resident is the actual policy holder (i.e. Self), if this is not true then a relationship must be entered. Indicate the box number that corresponds to the relationship in the 1500 Box No/Other Code field. Payor Provider # (1500) / Payor Provider # (Skilled) On 08/05 forms, the Legacy provider number that appears on the paper 1500 (boxes 32b & 33b) should be entered in the Payor Provider 1500 Provider # field. Note that Medicare requires that the legacy Provider Identificaton Number (PIN) be preceded by the qualifier 1C with one blank space between the qualifier and the PIN. So for Medicare you should enter the value in the format 1C ProviderNumber. Note also that for ANSI Professional electronic billing the value in the Skilled Provider # is used instead, the electronic billspec internally calculates the correct qualifier segment to be associated with the provider # and so the Medicare number entered in this field Page 4

5 should be in the format ProviderNumber, i.e. no preceding qualifier values. On 02/12 forms these are set to be blank but can be edited, edit the field labeled 1500 Field Locator and select one of the 32B or 33B fields. Place Of Service Code This code indicates how the payor classifies the facility, the value is taken from the Payor Bill Codes screen. Enter the code that is to appear in the place of service column (24B) on the /ANSI Professional Billing for Medicare B Therapy A standard 5010 Medicare B Therapy billspec Medicare B Therapy (02/12)/ANSI 5010X222A1 has been supplied for billing Medicare B Therapies in the ANSI 5010 Professional X222 format. This contains a Medicare B specific paper 1500 billspec and a Medicare B specific ANSI 5010 Professional format billspec that is used for Medicare B Therapy billing. Certifying Physicians Medicare Change Request (CR) 7785, requires the National Provider Identifier (NPI) of the physician certifying the therapy plan of care to be reported on the claim. This CR applies Medicare B therapy claims and may also apply to Commercial B therapy claims. We do not currently have a Physician role for Certifying so for system purposes a Certifying Physician will be identified as any Referring physician ranked in the range 30, 31 and 32. The requirement to report Certifying Physicians will be implemented on a variable timeframe. For the system to start processing physicians this way the check box on the Plan Detail Maintenance Screen, Plan Detail 2 labeled Use Certifying Physician For Therapy? must be checked with an effective Start Date (and End Date if necessary) reflecting the Service Date range of when this feature needs to be enabled. This must be done on each Medicare B or Commercial B plan that needs this feature enabled. Whether a Professional claim comes under the requirements for reporting a Certifying Physician will be determined by the following claim properties: Visit that the claim is for has a Certifying Physician entered Claim is to Medicare B or Commercial B plan Plan has Use Certifying Physician For Therapy? check box enabled as of claim last charge date Claim contains a therapy charge (claim detail line with Revenue Code 042X, 043X, 044X) Note, if it is determined that a claim does not come under the requirements for reporting a Certifying Physician then any Certifying Physicians entered will not appear on the claim in the Referring Physician role. If it is determined that a claim does come under the requirements for reporting a Certifying Physician then only the Certifying Physicians entered will appear on the claim in the Referring Physician role. Payor Provider # (1500) / Payor Provider # (Skilled) The Legacy provider number that appears on the paper 1500 (boxes 32b & 33b) should be entered in the Payor Provider 1500 Provider # field. Note that Medicare requires that the legacy Provider Identificaton Number (PIN) be preceded by the qualifier 1C with one blank space between the qualifier and the PIN. So for Medicare you should enter the value in the format 1C ProviderNumber. Note also that for ANSI 4010 Professional electronic billing the value in the Skilled Provider # is used instead, the electronic billspec internally calculates the correct qualifier segment to be associated with the provider # and so the Medicare number entered in this field should be in the format ProviderNumber, i.e. no preceding qualifier values. 1500/ANSI Professional Billing for Medicare B Professional Services A standard 5010 Medicare B Professional Services billspec Medicare B Prof Services /ANSI 5010X222A1 has been supplied for billing Medicare B Professional Services in the ANSI 5010 Professional X222 format. This Page 5

6 contains a Medicare B specific paper 1500 billspec and a Medicare B specific ANSI 5010 Professional format billspec that is used for Medicare B Professional Services billing. Detail Line Diagnoses Any diagnoses that have been associated with an order will be reported at the claim line level. See SR for more information. Rendering Physicians Any Rendering Physicians that have been associated with an order will be reported at the claim line level. See SR for more information. UB & ANSI Type Billspecs Medicaid UB04 Dotmatrix/ANSI 4010X096A1 Medicaid UB04/ANSI 4010X096A1 Medicare A - UB04/ANSI 5010X223A2 Medicare B - UB04/ANSI 5010X223A2 All other custom state and federal UB04/ANSI billspecs These bill specifications are used for UB/ANSI billing. Note, the Medicare A UB04/ANSI billspecs contains a PPS paper format while the Medicare B UB04/ANSI billspecs contain a Non-PPS paper format. For the Laser billspecs, the Custom Printer Settings (Profiles\System\Printers) still needs to be setup for each facility individually. See Custom Printer Settings section at the end for more information. The settings are printer dependent. Note: The standard Medicare ANSI 5010 billspecs are coded as streaming, i.e. no carriage return linefeed characters are used to terminate a segment. If opened in a text editor files will appear as one long line of data. If an intermediary requires a file to be in a Non-Streaning format, i.e. a carriage return linefeed is required to terminate a segment, you must update the Segment Terminator to have CRLF on the end. If opened in a text editor files in this format appear as multiple lines. Billing & Pay-To Addresses For 5010 the full 9-digit zip code is required to process claims, make sure that all Facility addresses have the full zip code entered. The 5010 Implementation Guide mandates that PO Boxes or Lock Box addresses must not be used as the Billing Address (2010AA loop). Under 4010 the address supplied in the 2010AA loop (Billing Address) comes from the Facility Billing Address screen. There is no 2010AB loop (Pay-To Address) created. Under 5010 we have the option create a 2010AA loop (Billing Address) and a 2010AB loop (Pay-To Address) if required. The production of these loops is handled under the Facility Profile using the ANSI Billing Addresses screen. Select the Facility address to use in each instance and determine whether you want to produce a Pay-To loop for all payors or just specific payors. A Billing Address loop is always required. Note, if a Pay-To loop is set to be produced for ANSI, the Pay-To information will also come out on the UB in the FL02 fields. Claim Filing Indicator Code This is an ANSI 837 code that is associated with a payor to identify the type of payor within a segment. The value of this code is taken from the Payor Bill Codes screen. Valid values include 09 Self Pay (ANSI 4010 only), BL Blue Cross/Blue Shield, CH Champus, CI Commercial Insurance Co, MA Medicare Part A, MB - Medicare Part B, MC Medicaid, OF Other Federal Program, VA Veterans Administration Plan, WC Workers Compensation Health Claim. Note: The value for Medicare Part B is officially listed in the specs as MB, but some intermediaries are rejecting claims unless this value is set to MA. Condition Codes Page 6

7 These are set up using the UB Data Entry feature available from Billing Bills. Any code can be entered and it will get shown on a UB. Note that there are some special codes that when entered will cause an automatic check to see if they apply to a bill. Condition codes that you may want to set up depending on how your state/facility bills include: Resident is 100+ years old Code: value "17" (this will be automatically checked) This will produce the condition code 17 when the resident is 100+ years old, if the resident is under 100 then the code will be ignored. Note: Condition Code 21 (Billing For Denial Notice) will be automatically calculated for Medicare A No Pay bills even if a UB Data Entry code has not been entered. Discharge Codes & Resident Status Whether billing uses the Federal discharge codes or the State discharge codes for determining the resident status is controlled by the setting of the Discharge Codes field on the Payor Bill Codes screen. Since the implementation of HIPAA the Federal codes are usually shown for both Medicare and Medicaid, State codes are at this point a Legacy feature. To set the value that will be used for the status still a resident you must enter a value in the Inhouse Code field - usually 30 for UB s. If the resident going on hospital leave does not cause a discharge but does cause a different status to still a resident then you must enter this value in the Hospital Leave Code field, otherwise this field should contain the same value as the Inhouse Code field. Estimated Amount Due Fields If you want to see the Estimated Amount Due fields calculated for payors other than the payor being billed then you must check the Estimated Amount Due Fields field on the Payor UB Controls screen. Note, they will never show for the payor being billed. National Provider ID (NPI) This is the National Provider ID used for billing. If the facility bills all payors using the same NPI then it should be entered into the NPI field on the Facility General Parameters screen. If the facility uses multiple NPI numbers for billing, but only one NPI for each payor then it should be entered into the NPI field on the Payor Provider screen for each payor. If the facility uses multiple NPI numbers per payor then each NPI should be entered into the NPI field on the Plan Maintenance screen for the related plan. Providers must use the NPI number as the main billing Provider Identifier on 1500/UB04/ANSI 837 claims effective 5/23/2007, however some intermediaries are allowing non-compliant transactions as part of their contingency plan. The identifiers used on these claim types are determined on the relevant billspec screen. For paper 1500 & UB04 billing the Show Legacy Fields? check box on the Paper Billspec Maintenance screen will control whether or not Legacy identifiers for the facility & physicians will appear on the claim. For electronic ANSI 837 billing the Provider ID Reporting fields on the Electronic Billspec Maintenance screen will control whether or not Legacy identifiers for the facility & physicians will appear on the claim. Non-Distinct Residents If you want to treat in-house residents in non-distinct beds to as outpatients for UB reporting purposes then you must check the Treat Non-Distincts As OP field on the Payor UB Controls screen. Occurrence Codes These are set up using the UB Data Entry feature available from Billing Bills. Any code can be entered with an associated date and it will get shown on a UB. Note that there are some special codes that when entered will cause an automatic calculation of the relevant dates if they apply to a bill. For these codes you should leave the date blank unless specified or you want to override the autocalculation. Page 7

8 Occurrence codes that you may want to set up depending on how your state/facility bills include: Date Active Care Ended Code: value "22" Date: value blank (this will be automatically calculated if left blank) Used on Medicare bills only, this will produce the occurrence code 22 with the date active care ended, i.e. the last day skilled care was received. This will show on the last Medicare Pay bill preceding a drop in level assuming the resident remains in a certified bed. Note: As of RAM 2.5sp04 the 22 code will be automatically calculated for Medicare Pay bills if a UB Data Entry code has not been entered. The above instructions should only become necessary if you wish to override the 22 code with a different date than the calculated date. Date Benefits Exhaust Code: value "23" Amount: value blank (this will be automatically calculated if left blank) Used on Non Medicare bills only, this will produce the occurrence code 23 with the date Medicare benefits exhaust, i.e. the date the residents straight Medicare A plan becomes inactivated. Code: Amount: value "A3", "B3" or "C3" value blank (this will be automatically calculated if left blank) Used on Non Medicare bills only, this will produce the occurrence code A3, B3 or C3 with the date benefits exhaust when the residents plans for payor A, B, or C on the bill become inactivated. Note, if auto calculating this value code then all three codes should be set to auto calculate. Discharge Date Code: value "42" Amount: value blank (this will be automatically calculated if left blank) This will produce the occurrence code 42 with the discharge date if the current bill is a discharge bill. Occurrence Span Codes These are set up using the UB Data Entry feature available from Billing Bills. Any code can be entered with an associated from and thru date and it will get shown on a UB. Note that there are some special codes that when entered will cause an automatic calculation of the relevant dates if they apply to a bill. For these codes you should leave the dates blank unless specified or you want to override the autocalculation. Occurrence Span codes that you may want to set up depending on how your state/facility bills include: Qualifying Hospital Stay Dates Code: value "70" From Date: value blank (this will be automatically calculated if left blank) Thru Date: value blank (this will be automatically calculated if left blank) This will produce the occurrence span code 70 with the from and thru dates of the last qualifying hospital stay for the payor being billed. Medicare <24 Hour Leave Page 8

9 Code: value "74" From Date: value Hospital Leave Start Date (leave #1) Thru Date: value Hospital Leave End Date (leave #1) This will produce the occurrence span code 74 with the from and thru dates of the first hospital stay for the period of the current bill. Since Medicare will only pay for <24hr leaves (regular hospital leaves cause a termination of coverage) this will indicate a <24hr leave. Patient s Relationship To Insured See Policy Holder Relationship To Resident below. Payment Source Code This is a Legacy Flat File UB code that is associated with a payor to identify the type of payor on the Claim 30 (Payor) record. The value of this code is taken from the Payor Bill Codes screen. Valid values are A Self Pay, B Workers Compensation, C Medicare, D Medicaid, E Other Federal Program, F Insurance Company, G Blue Cross, H Champus, I- Other (local coding table applies). This code should be set up for each payor that is going to appear on a UB; this includes all secondary and tertiary payors as well as the primary payor. Payor Contractor# This is a code that identifies a contracted organization, e.g. when participating in the Medicare Choices demonstration. This code is specific only to Legacy Flat File UB Billing and is used in the Claim 31 (Payor) record. The value of this code is taken from the Payor Bill Codes screen. Payor ID This is a code that identifies the payor, the value of this code is taken from the Payor Bill Codes screen. This code is further qualified by the ID Type field on the same screen. It will be reflected in the NM109 (Loop 2010BC) segment of the ANSI file and FL51 (Health Plan ID) of the UB04. In the Legacy Flat File Claim it was in the 30 (Payor) record. See the specific state section for the code to use. Payor ID Type This is a field that qualifies the Payor ID ; it is set from the Payor Bill Codes screen. For example, if the Payor ID field contains a value that reflects Payor ID code for the payor then the ID Type field should be set to Payor ID to indicate this. If it represents the CMS National PlanID, then it should be set to CMS. The value contained in this field is used to determine the Payor Identification Indicator that gets reported in the Legacy Flat File Claim 30 (Payor) record and the Payer Name NM108 (Loop 2010BC) segment for ANSI 837. Note that we have been told that the only current acceptable value is Payor ID. Payor State For Ohio Medicare Legacy Flat File billing the state field on the Payor Payor Address screen must be set to OH in order to override the printing of the federal tax id in the Flat File Header 01 (Processor) record and the Flat File Trailer 99 (File Control) record with the skilled provider #. This methodology assumes that no other states have a Medicare address located in Ohio. Payors If you want to see payors that passed charges to the payor being billed on the UB (displayed in the payor section) then the Recognize Payors Passing Charges indicator must be set to yes, select Modify on the Profiles Payors Bill Specifications screen. Note, it is usually the case that this should be set. Policy Holder Relationship To Resident For billing purposes it is usually required that the relationship between the resident and the policy holder be defined, this is done on the Reimbursement Table Policy screen. The default value is that the resident is the actual policy holder, if this is not true then a relationship must be entered. The codes used to identify the relationship vary based on the bill being produced by the payor. For UB/ANSI billing a value must be entered into the ANSI Individual Relationship Code field. This is the ANSI code used to identify the relationship between the resident and the insurance policy holder. Valid 4010 values include: Page 9

10 01 Spouse, 04 Grandparent, 05 Grandchild, 07 Niece/Nephew, 10 Foster Child, 15 Ward Of Court, 17 Stepchild, 18 Self, 19 Child/Insured Financial Responsibility, 20 Employee, 21 Unknown, 22 Handicapped Dependent, 23 Sponsored Dependent, 24 Dependent of a Minor Dependent, 29 Significant Other, 32 Mother, 33 Father, 36 Emancipated Minor, 39 Organ Donor, 40 Cadaver Donor, 41 Injured Plaintiff, 43 - Child/Insured Does Not Have Financial Responsibility, 53 Life Partner, G8 Other Relationship. Note, for ANSI 5010, only the following values are acceptable: 01 Spouse, 18 Self, 19 Child/Insured Financial Responsibility, 20 Employee, 21 Unknown, 39 Organ Donor, 40 Cadaver Donor, 53 Life Partner, G8 Other Relationship. Receiver Identification/Sub-Identification This is a code that identifies the organization designated to receive the claims, the value of this code is taken from the Payor Bill Codes screen. It is used in the Interchange Header record for ANSI 837 and the Header 01 (Processor), Batch Trailer 95 (Batch Control), and Trailer 99 (File Control) records for Legacy UB Flat File billing. Although the specs define this as two fields (Id 5 chars, Sub-Id 4 chars) we collect this as a single (9 char field). See the specific state section for the code to use. Receiver Type Code This is a code that indicates the class of organization designated to receive the claims, it is used in the Legacy Flat File Header 01 (Processor) record. The value of this code is taken from the Payor Bill Codes screen. Valid values are A - Self Pay, B - Workers Compensation, C - Medicare, D - Medicaid, E - Other Federal Program, F - Insurance Company, G - Blue Cross, H - Champus, I- Other (local coding table applies), Z - Multiple principal sources of payment. The following have been established as correct: G C D M When submitting Medicare claims to BlueCross BlueShield of TN. When submitting Medicare claims elsewhere. When submitting Medicaid claims. When submitting Medicaid claims to Unisys for Medicaid of Louisiana. Service Date The printing of the service date (UB detail section) is controlled by the value of the Service Date Printing Method field on the Payor UB Controls screen. Note that if you choose the option to only print the date for certain revenue codes then you must remember to identify these revenue codes on the same screen. Statement Through Date The statement through date is currently set to be the date of the last charge unless the resident has been discharged and the plan is set up not to pay for the day of discharge, in this case the through date is set to be the discharge date. Taxonomy Codes ANSI billing reports a taxonomy code for the facility. This should be set up under the Payor Provider screen in the Provider Taxonomy Code field. The correct taxonomy code for a facility can be found using the master HIPAA Taxonomy Code list available at A Skilled Nursing Facility is listed as having a taxonomy code of X. Termination Of Coverage If the payor that you are setting up to wants to treat terminations in coverage as admits/discharges when reported on the UB then you must set the Treat Termination Of Coverage As An Admission/Discharge field on the Payor UB Controls screen. A termination in coverage is defined as: Hospital Leave Change In Care Level Benefits Exhaust Coverage Ends (plan ended in reimbursement table) Non Certified (resident moves to a non certified bed) Page 10

11 You must also identify the discharge codes to use for each of the above situations when you are treating it as a discharge UB. Entering a discharge code of ## indicates the system should ignore that individual type of termination in coverage. In the case of a termination of coverage due to a hospital leave we will use the leave start time as the discharge time on the discharge bill, and the leave end time (time of return to the facility) as the admit time on the resulting admission bill. Note that there may be an initial setup issue here if we have any residents that should be reporting an adjusted admit date due to a termination of coverage that occurred before our system was installed. For these people make sure that the admit date is set to the date that is to be reported in the UB admission date field; this may not be the actual facility admit date but if we want to show the adjusted date it has to be entered onto our system. Any residents that have a termination of coverage after we start processing data will get adjusted automatically since we will be able to recognize this from our system data, the reason we cannot identify the termination of coverage for the initial residents is that we do not have any system data relating to the time prior to the install of our system. Testing Procedures A billspec can have two modes of operation - production mode and test mode (production is the default mode). The current mode is indicated by the Claims Processing Mode field on the Electronic Bill Specification maintenance screen. When you are submitting an electronic test, you should have the value set to Test Mode, under normal operation you should have the value set to Production Mode. Therapy Units The units to be used for reporting therapies in the UB detail area and in value codes 50, 51, & 52 are controlled by the value of the Therapy Unit Printing Methods fields on the Payor UB Controls screen. Type Of Bill This is a three digit field used on uniform bills to identify the type of bill. The first digit indicates the type of facility, we take this code from the corresponding values entered into the Type Of Facility fields on the Payor UB Controls screen. The second digit indicates the bill classification, we take this code from the corresponding values entered into the Classifications fields on the Payor UB Controls screen. The third digit indicates the frequency of the bill (first claim, continuing claim, etc.), the code associated with each possibility is taken from the corresponding values entered into the Frequencies fields on the Payor UB Controls screen. Value Codes These are set up using the UB Data Entry feature available from Billing Bills. Any code can be entered with an associated amount and it will get shown on a UB. Note that there are some special codes that when entered will cause an automatic calculation of the relevant amounts if they apply to a bill. For these codes you should leave the amount blank unless specified or you want to override the autocalculation. Note that for UB04 billing the value codes "80" (Covered Days), "81" (Non-Covered Days), "82" (Coinsurance Days), and "83" (Lifetime Reserve Days) will be autocalculated by the billing program when applicable without any codes entered under UB Data Entry. See futher note below about suppression if a facility requires these not to show on the bill. Value codes that you may want to set up depending on how your state/facility bills include: Average Daily Semi-Private Room Rate Code: value "01" Amount: value blank (this will be automatically calculated if left blank) This will produce the value code 01 with an amount equal to the amount of the average daily semi-private room rate. Page 11

12 Medicare Coinsurance Amount Code: value "09" Amount: field MCRA - Coinsurance Charges This will produce the value code 09 with an amount equal to the Medicare Coinsurance being billed. On pay bills that contain no coinsurance charges (i.e. Full Benefits Exhaust bills) the value will be calculated to $1.00. CMS has indicated that the FISS will assign the correct coinsurance amount based off the CWF response in this case. Physical Therapy Visits Code: value "50" Amount: value blank or number of treatments occurring prior to install If there are any physical therapy charges associated with a bill this will produce the value code 50 with an amount equal to the number of physical therapy visits from onset through this bill. The onset date is taken to be the date entered in occurrence code 35. The amount field is used to record the number of treatments for the current course of therapy that occurred prior to the installation of the system. Once a client is using the system we can track any therapies that occur, so for a course of therapy that starts once our system is installed this value will be blank or zero. Occupational Therapy Visits Code: value "51" Amount: value blank or number of treatments occurring prior to install If there are any occupational therapy charges associated with a bill this will produce the value code 51 with an amount equal to the number of occupational therapy visits from onset through this bill. The onset date is taken to be the date entered in occurrence code 44. The amount field is used to record the number of treatments for the current course of therapy that occurred prior to the installation of the system. Once a client is using the system we can track any therapies that occur, so for a course of therapy that starts once our system is installed this value will be blank or zero. Speech Therapy Visits Code: value "52" Amount: value blank or number of treatments occurring prior to install If there are any speech therapy charges associated with a bill this will produce the value code 52 with an amount equal to the number of speech therapy visits from onset through this bill. The onset date is taken to be the date entered in occurrence code 45. The amount field is used to record the number of treatments for the current course of therapy that occurred prior to the installation of the system. Once a client is using the system we can track any therapies that occur, so for a course of therapy that starts once our system is installed this value will be blank or zero. Private Portion Amount Used. Code: value 80 Amount: field Private Portion Amount Charged This Bill If there are any private portion charges associated with a bill this will produce the value code 80 with an amount equal to the amount of the private portion. Code: Amount: field (A/B/C)1 When MCRB Deductible Charges field MCRB - Deductible Charges Page 12

13 If there are any Medicare B deductible charges associated with a bill this will produce the value code A1, B1, or C1 depending on whether Medicare B is payor A, B, or C and a value code amount equal to the amount of the charges. Code: Amount: field (A/B/C)2 When MCRA Coinsurance Charges field MCRA - Coinsurance Charges If there are any Medicare A coinsurance charges associated with a bill this will produce the value code A2, B2, or C2 depending on whether Medicare A is payor A, B, or C and a value code amount equal to the amount of the charges. Code: Amount: field (A/B/C)2 When MCRB Coinsurance Charges field MCRB - Coinsurance Charges If there are any Medicare B coinsurance charges associated with a bill this will produce the value code A2, B2, or C2 depending on whether Medicare B is payor A, B, or C and a value code amount equal to the amount of the charges. Note that the therapy services that are included in the calculation of value codes 50, 51, & 52 are the services with revenue codes that have been linked with these value codes via the revenue code profile menu. Integer Value Codes There are some payors that require certain value codes to be reported as integers, i.e. with spaces in the cents portion of the amount field. For example they may want value code 80 reported as $$ rather than $$.cc, e.g. 30 vs To make this happen the value code should entered into the Integer Value Codes field on the Paper Billspec Maintenance screen. Multiple codes can be identied using a comma delimited list e.g. 80,81,82. Value Code Suppression Sometimes there are cases when a facility does not want a value code to appear on the bill, either they are paper only, electronic only, or should just not show at all. In this case when we have a value code that needs to be suppressed we can identify the code in the Integer Value Codes field on the Paper Billspec Maintenance screen with a minus sign appended. So a value 80- indicates value code 80 should not appear on any claims. Multiple entries are allowed as a comma delimited list, eg. 80-,81-,82-. If a value code should appear on paper only then a P can be appended to make this happen, e.g. 80P indicates value code 80 should only appear on the paper bill. If a value code should appear in the electronic file only then an E can be appended to make this happen, e.g. 80E indicates value code 80 should only appear in the electronic claim. Value Code Amount Custom Formatting There are some payors that require certain value codes to be reported with the amount displayed in a different format from the standard 9.99 format. To make this happen the value code should entered into the Integer Value Codes field on the Paper Billspec Maintenance screen and a special format character appended. Multiple codes can be identied using a comma delimited list e.g. 36>,37^,38!,39%. Note that the default format is to report the amount with a minimum of one leading digit, e.g..25 reports as 0.25 The list of special format characters and their meaning is as follows: > (greater than) Report the amount with no minimum leading digits, e.g. the amount.25 reports as.25 ^ (caret) Report the amount with a minimum of two leading digits, e.g. the amount.25 reports as 00.25! (exclamation point) If the amount is zero then report the amount as blank % (percent) Report the amount as a percentage, i.e. divide it by 100, e.g. the amount 47 reports as.47 UB/ANSI Billing for Commercial Page 13

14 The standard billspecs Medicare A - UB04/ANSI 5010X223A2 and Medicare B - UB04/ANSI 5010X223A2 can be copied and adjusted for Commercial billing purposes. Note that Commercial billspecs are not considered regulatory, if development needs to troubleshoot a client custom Commercial billspec it will usually be as part of a Custom (billable) project. Value Codes These are set up using the UB Data Entry feature available from Billing Bills. Any code can be entered with an associated amount and it will get shown on a UB. Note that there are some special codes that when entered will cause an automatic calculation of the relevant amounts if they apply to a bill. For these codes you should leave the amount blank unless specified or you want to override the autocalculation. It was noted above (under Medicare Billing) that for ANSI/UB bill processing value code "82" (Coinsurance Days) would be autocalculated by the billing program when applicable without any codes entered under UB Data Entry. The NUBC definition of value code 82 indicates that it only applies to Medicare Coinsurance days. In line with this definition any value code 82 autocalculations will only ocurr if the day is a Medicare Coinsurance day. Some Commercial payors want to report any coinsurance day with Value Code 82 regardless of whether or not it is Medicare Coinsurance. To make this happen it needs to be set up using UB Data Entry as detailed below: Coinsurance Days Code: value 82 Amount: field Coinsurance Days This will produce value code 82 with the sum of the inhouse days coming from coinsurance p charges being passed on by the payor being billed, i.e. coinsurance charges passed by the current payor, not coinsurance being billed to the current payor. Note, if a matching dollar amount needs to be reported on the bill it can be shown using the field Coinsurance Charges. UB/ANSI Billing for Medicare Secondary The standard billspecs Medicare A - UB04/ANSI 5010X223A2 and Medicare B - UB04/ANSI 5010X223A2 (or any intermediary specific billspecs, e.g. Medicare A Noridian - UB04/ANSI 5010X223A2 ) can be used for MSP billing. For Medicare Secondary billing to work correctly the following need to be set up: Claim Adjustment Segments CAS segments need to be created to indicate what charges the Primary Payor did not pay fully and the reason why. These are normally returned electronically via an 835 file. If an 835 file is not returned they can be entered manually on the Account/Receipts/COB Information screen from the paper Remittance Advice. Condition Codes The appropriate condition codes may be required. Use code 77 when the facility accepts or is required to accept the primary plan's payment as payment in full. These must be set up at the visit/billspec level using the UB Data Entry feature. Note, on an MSP bill if Condition Code 77 is present the Standard Type Of Bill codes will be reported (211, 212, 213, 214) instead of it being considered a no pay (210) Type Of Bill. Occurrence Codes An appropriate occurrence code and date may be required depending on the primary payor. These must be set up at the visit/billspec level using the UB Data Entry feature. Remarks Page 14

15 The address of the primary payor may also need to appear in FL38 or the Remarks (FL80) section on the UB04. This can be accomplished by editing the bill after the bill-data has been created. Type of Bill If the primary insurer payment covers the full amount that Medicare would have paid, then there are no Medicare charges. In this case, Medicare still wants to receive a non-payment bill showing the covered charges and covered days as the amount Medicare would have covered if it had been primary. This UB04 bill s type-of-bill will have a zero as the third digit frequency code, except when Condition Code 77 is present (see above). Sometimes Medicare may pay at least part of the unpaid portion of services covered by the primary insurer. This happens if the payment due from the primary plan includes Medicare covered services but is less than the Medicare reimbursement amount and the facility is not required to accept the primary insurer s payment as payment in full. In this case, Medicare wants the bill to show the total charges and the covered days to be the amount Medicare would have covered had it been the primary payer. This UB04 bill s type-of-bill will NOT be a zero for the third digit frequency code; it will be a 1, 2, 3, or 4 as normally would be set if Medicare were primary. Value Codes A value code with the amount paid by the primary payor for Medicare covered services must show on the bill. The value code must be set up at the visit/billspec level using the UB Data Entry feature. Code: value depends on primary payor (12-16, 41-43, and 47) Amount: field Est. Amt Due From Payor for Covered ; Payor# 1 Note: If the Primary Plan is correctly set up to cover what will actually be paid by the insurance company then the above Est. Amt Due From Payor for Covered ; Payor# 1 field can be used successfully. However, if the Primary Plan setup expects something to be reimbursed and the insurance company does not reimburse it then this field will not work, you will have to manually enter the actual dollar amount in the value code each time you produce a bill for the resident, or use the Edit Bill Data function to edit the value codes on the bill. The Obligated to accept as payment in full amount (OTAF) should be identified using value code 44. This can either be set up using UB Data Entry, or edited directly onto the bill using Edit Bill Data. If an amount is not specified then the OTAF will be determined from the CO (Contractual Obligation) CAS segments supplied in the ANSI 837 file. Note that if value code 44 is entered and it does not match the amounts reported in the CO CAS segments then Medicare will return the claim to the provider. The UB04 Billing Manual indicates that value codes 12-16, 41-43, and 47, will report the actual amounts paid. Value code 44 should always be equal to, or greater than the amounts indicated in these value codes. If Value code 14 (Auto) is on the bill then the ANSI file will automatically report AM as the Claim Filing Indicator code for the primary payor. If Value code 15 (Worker s Comp) is on the bill then the ANSI file will automatically report WC as the Claim Filing Indicator code for the primary payor. If Value code 41 (Veteran Administration) is on the bill then the ANSI file will automatically report VA as the Claim Filing Indicator code for the primary payor. If Value code 47 (Liability) is on the bill then the ANSI file will automatically report LI (for ANSI 4010) or LM (for ANSI 5010) as the Claim Filing Indicator code for the primary payor. Troubleshooting Tips Problem: Receiving a MSP Claim Level Balancing error message when creating a MSP ANSI file indicating that the T3 Amount Not Equal To C4 plus CAS Adjustments. Solution: This warning indicates that the total amount billed to Medicare (reported in the AMT*T3, and CLM02 segments) does not equal the Primary Payor Paid Amount (AMT*C4 segment as determined from the relevant Value codes 12-16, 41-43, and 47) plus the CAS adjustments. Page 15

16 The amounts from the file will be listed and you should investigate further, Medicare will reject the claim if these values do not balance. Check that all value codes and CAS adjustment (COB records) have been entered correctly. UB/ANSI Billing for Medicare A No Pay SNF s are required to produce No Payment Bills even though no benefits may be payable. CMS maintains a record of all inpatient services for each beneficiary, whether the service is covered or not. This information is used for national healthcare planning and also enables CMS to keep track of the beneficiary s benefit period. For No Pay billing to work correctly the Medicare PPS payor should be setup with a standard Medicare plan and a Medicare No Pay plan. See the Medicare A Benefits Exhaust-No Pay Setup doc for further details. The are two categories of bill for No Pay billing, Benefits Exhaust bills and No Pay bills. The category a bill falls in is determined by the No Pay Status field, see below. Benefits Exhaust Bills A Benefits Exhaust bill will look basically like a standard Pay bill, dollars will be in the covered column, days show as covered, standard Type Of Bill 213 (etc). Like Pay bills they must be produced on a monthly basis. Medicare will accept this bill and make the determination as to what is covered and when benefits actually exhausted. Benefits Exhaust bills should continue to be produced while the resident remains at a skilled level of care. No Pay Bills A No Pay bill differs in that the dollars will show in both the covered and the non covered columns, days will show as non covered, and the Type Of Bill will be 210. No Pay bills can be produced on a monthly basis or they can be summarized one bill spans multiple months. No Pay bills should continue to be produced while the resident remains in a certified bed. No Pay Bill Method Whether a No Pay bill is produced on a monthly or on a summarized basis is determined by the No Pay Bill Method field. This is set to a default value on the Plan Maintenance screen for the Medicare A No Pay Plan and can be overridden on an individual resident basis on the Reimbursement Table Detail screen for the Medicare No Pay Plan. Note, Benefits Exhaust bills should be produced monthly. No Pay Status On the resident Reimbursement Table Detail screen for the Medicare A No Pay plan a value should be entered for the date range that a resident goes No Pay for Medicare. The No Pay Status identifies whether this date range is considered Benefits Exhaust or No Pay and will directly control the type of bills that come out. If a value is not identified then neither type of No Pay bill will be produced and warnings will appear when generating charges. If there is an instance where a No Pay bill is demanded to be produced even though the resident is no longer in a certified bed then setting the value to Non Certified No Pay will result in a No Pay bill being produced. If there is an instance where no bill is required then setting the value to No Bill will accomplish this. Note that changing the status to No Bill will cause a billing discharge. Termination Of Coverage Note that changes will need to be made to the Termination Of Coverage settings for the Medicare A Payor when No Pay bills are required. A No Pay setup would require no Termination (discharge bill) for Benefits Exhaust, Level Of Care, and Coverage Ends, this can be done by entering ## in the BE, LC, and CE fields. This indicates that the system should ignore these conditions while still considering the other Terminations as requiring a discharge bill. Also, code 04 should be entered in the Non Certifed NC field. This will indicate that a change to a non certified bed will be considered a discharge with patient status code 04. UB Codes Page 16

17 Certain UB Codes are required for No Pay billing, the following are a quick summary. Refer to the detailed sections above for more specific instructions as to how to set up each type of UB code using the UB Data Entry function. Condition codes - Condition Code 21 (Billing For Denial Notice) will be automatically calculated for Medicare A No Pay bills even if a UB Data Entry code has not been entered. Occurrence codes - Occurrence Code 22 (Date Active Care Ended) will be automatically calculated for Medicare Pay bills even if a UB Data Entry code has not been entered. Value codes - Value Code 09 (Medicare Coinsurance Amount) will be automatically adjusted to a value of $1.00 for Medicare Pay bills that contain no coinsurance charges (i.e. Full Benefits Exhaust bills). CMS has indicated that the FISS will assign the correct coinsurance amount based off the CWF response in this case. Note that a UB Data Entry code must have been entered for this to work. UB/ANSI Billing for Medicare B A standard Medicare B billspec Medicare B - UB04/ANSI 5010X223A2 has been supplied for billing Medicare B claims. This billspec contains minor MCRB specific differences from the MCRA billspec, e.g. it is not a PPS bill type, it has a different ancillary sort, it does not show non-covered charges. For facilities that submit Medicare B claims to an intermediary that does not use the standard Medicare A billspec (i.e. there is an intermediary specific Medicare A billspec for them) we will also supply an intermediary specific Medicare B billspec for install, e.g. Medicare B Noridian - UB04/ANSI 5010X223A2. Certifying Physicians Medicare Change Request (CR) 7785, requires the National Provider Identifier (NPI) of the physician certifying the therapy plan of care to be reported on the claim. This CR applies Medicare B therapy claims and may also apply to Commercial B therapy claims. We do not currently have a Physician role for Certifying so for system purposes a Certifying Physician will be identified as any Referring physician ranked in the range 30, 31 and 32. The requirement to report Certifying Physicians will be implemented on a variable timeframe. For the system to start processing physicians this way the check box on the Plan Detail Maintenance Screen, Plan Detail 2 labeled Use Certifying Physician For Therapy? must be checked with an effective Start Date (and End Date if necessary) reflecting the Service Date range of when this feature needs to be enabled. This must be done on each Medicare B or Commercial B plan that needs this feature enabled. As of RAM26sp10 the Medicare B - UB04/ANSI 5010X223A2 billspec and the associated intermediary specific billspecs have been updated to report a Referring Physician to meet the requirements of CR CR 7785 requires that for Institutional claims the first Certifying Physician be reported as the Attending Physician, if a second Certifying Physician is needed then it needs to be reported as the Referring Physician. This will be handled by the system internally. For setup purposes, if the current Attending Physician is also the Certifying Physician then no additional Certifying Physician entry is necessary for claims to come out correctly since the first Certifying is reported in the Attending Physician role. If it is determined that a Certifying Physican needs to be linked to the visit (possibly due to the need for a second Certifying to be reported or for a Professional claim) then any Attending Physician that is also Certifying must also be added as a Certifying (Referring 30,31,32) for them to continue to be reported as Certifying in the Attending Physician role. Page 17