Presentation on theme: "Home Health UB-04 Claim form billing instructions for Maricopa Care Advantage and University Physicians Care Advantage."— Presentation transcript:
Home Health UB-04 Claim form billing instructions for Maricopa Care Advantage and University Physicians Care Advantage
Overview This step-by-step presentation is intended to provide information to assist those who bill Maricopa Care Advantage and University Physicians Care Advantage for Medicare covered home health care services. The intent is to help you to complete the UB-04 billing form correctly the first time. This presentation is to be used in conjunction with General Rules, your provider guidelines and supplemental information. Maricopa Care Advantage and University Physicians Care Advantage reimburse for home health service at 100% leaving no cross over for AHCCCS. We hope you find this tutorial helpful
Claims Processing Paper claims submitted by mail go through UPHP’s Document Management Imaging company, Avidity. Avidity processes hardcopy claims using Optical Character Recognition (OCR) scanning. Please make sure your claim form meets OCR specifications. For more information on specifications go to: http://www.webopedia.com/TERM/O/optical_character_recognition. html Use commercially available “red form” versions of the UB-04 CMS- 1450
Not sure if you are using the correct form? The bottom left corner will look like this. Introducing the UB-04
Red = Required Yellow = Optional Top section Top section
Box 1 - Required Box 1 - Required Billing Provider Information Enter the name and address of the Home Health agency requesting to be paid for services rendered. Home Health PO Box ### Anytown, AZ 85###
Box 3a - Required Box 3a - Required Patient Account Number Enter your recipient account number here. This box allows up to twelve characters. UPHP will report this number in Remittance Advices to provide cross reference between UPHP Claim Numbers and the Provider Member Number. X123400
Box 4 - Required Box 4 - Required Type of Bill Enter the three-digit numeric code to identify the type of claim you are billing. Bill Type 322 and 332 are RAP bills Bill Type 329 and 339 are FINAL or LUPA (depending on how many visits occurred during the 60 day episode) Remember: 5 or less visits – last bill is LUPA More than 5 visits – last bill is FINAL 322
120110 120710 Statement Covers Period Enter the beginning and ending dates of services covered by this claim. Please note - this box must list numeric dates of service. Box 6 - Required Box 6 - Required
Recipient Name Enter the recipient’s name exactly as it is printed on the Identification Card. Use the recipient’s last name first. Do not use nicknames. Box 8a-e - Required Box 8a-e - Required Patient, Your
Box 12 - Required 120110 Admission Date Enter the actual admission date, even if the recipient was not eligible on that date.
Box 15 – Admit Source Code - Box 15 – Admit Source Code - Indicates the patient’s point of origin for the admission. The HHA enters any appropriate National Uniform Billing Committee (NUBC) approved code. Box 17- Discharge Status Code Box 17- Discharge Status Code Indicates the patient’s status as of the “through” date of the billing period. Since the “through” date of the RAP will match the “from” date, the patient will never be discharged as of the “through” date. As a result only one patient status is possible on RAPs, code 30 which represents that the beneficiary is still a patient of the HHA. Box 15 and 17 - Required Box 15 and 17 - Required 530
Box 39-41 – Required Value Codes and Amounts Value Code “61” = Location where service is furnished HHAs report the MSA number or Core Based Statistical Area (CBSA) number (or rural state code) of the location where the home health is delivered.
Box 42 - Required Revenue Center Codes Enter the three-digit revenue center code that most accurately describes the service provided. Refer to the following page for a complete list of revenue center codes. 421 424 571 0001
Revenue Center Codes 421 Physical therapy visit charge 424 Physical therapy evaluation/reevaluation 431 Occupational therapy visit 434 Occupational therapy evaluation/reevaluation 441 Speech language pathology visit 444 Speech language pathology evaluation/reevaluation 551 Skilled nursing visit charge 559 Other skilled nursing evaluation 561 Medical Social Services 571 Home health aide visit charge 0001 For total claim Authorization is required for all home health services
Box 44 - Required HPPS Codes Required - On the 0023 revenue code line, the HHA reports the HIPPS code for which payment is being requested. HPPS code is required on both RAP and Final/LUPA. #####
Box 45 - Required Service Date Required - On the 0023 revenue code line, the HHA reports the date of the first billable service provided under the HIPPS code reported on that line. Dates must match as indicated in box 6.
Service Units Enter the number of days or units for each related revenue center code listed. One visit equals one unit of service. One supply item equals one unit of service. 673673 Box 46 - Required
Total Charges Enter the total usual and customary charge for each related revenue center code listed. Do not list credits. Do not use dashes. 22 30 151 00 5700 Box 47 - Required
Total Enter the total charge amount for all services listed in column 47. Each claim form is a separate document, and is to be totaled as such. Total - Required 230 30
Bottom section Red = Required Yellow = Optional
Payer Name Enter the name and identification number, if available, of each payer who may have full or partial responsibility for the charges incurred by the recipient and from which the provider might expect some reimbursement. If there are no other payers, UPHP should be the only entry. Primary payer Secondary payer Tertiary payer Box 50 - Optional
Prior Payments Enter the total amount paid by other third party resource’s. Do not list write-off’s. Do not include how much MCA or UPCA previously paid. Correspond the placement as outlined in box 50 instructions. Box 54 - Optional
Box 56 - Required National Provider Identifier (NPI) Enter the ten-digit NPI of the Home Health agency billing for services rendered. # # # # # # # # # # #
Provider Number Enter the six digit Medicare Oscar provider number of the Home Health agency billing for services rendered. Do not list other payer provider numbers. Correspond the placement number as outlined in box 50 instructions. Box 57 - Required # # #
Insured’s Unique Identifier http://www.upcareaz.com http://www.mcareaz.com Enter the patient ID# related to the payer(s) in Field 50. AHCCCS ID must be listed last. If you have questions about eligibility or the ID#, contact UPHP Customer Care Department at (800) 582-8686 or visit: http://www.upcareaz.com http://www.mcareaz.com http://www.upcareaz.comhttp://www.mcareaz.com http://www.upcareaz.comhttp://www.mcareaz.com Please note - UPCA and MCA members have a preceding “M” in front of the AHCCCS ID. I.E. MA12345678 X X # # # X # X Box 60 - Required
Treatment Authorization Required - The HHA enters the claim-OASIS matching key output by the Grouper software. This data element links the RAP record to the specific OASIS assessment used to produce the HIPPS code. Box 63 - Required 07JK08AA41GBMDCDLG
Diagnosis Code Enter the recipient’s diagnosis/condition. The diagnosis code must be the reason chiefly responsible for the service being provided as shown in medical records. You may enter up to five codes if necessary by listing them in box 67 - 67D. The diagnosis codes must be carried out to its highest degree of specificity. Do not use the decimal point. Box 66 - Required 7993
Box 76 - Required Attending Provider Name and Identifiers Required - The HHA enters the name and provider identifier of the attending physician that has signed the plan of care. ########## ######
Where to mail your claim Mail your UB-04 claim form to: Maricopa Care Advantage (MCA) PO Box 37169, Phoenix, AZ 85069 University Physician Care Advantage (UPCA) PO Box 35699, Phoenix, AZ 85069
References http://www.cms.gov/manuals/download s/clm104c10.pdf http://www.cms.gov/manuals/download s/clm104c10.pdf http://www.cms.gov/manuals/download s/clm104c10.pdf The Medicare Claims Processing Manual (Chapter 10 – Home Health Agency Billing is available on line at the above web address
Definitions and References Grouper - A software module that “groups” information for payment classification; for HH PPS, data from the OASIS assessment tool is grouped to form HHRGs and output HIPPS codes. Specifications for the HH PPS Grouper are posted on the CMS Web site, and the Grouper module is also built into PPS-compatible versions of HAVEN software, software publicly available automating the OASIS assessment tool. HCPCS Code(s) - Healthcare Common Procedure Coding System. Coding for services or items used in the HCPCS/ Accommodation Rates/HIPPS Rate Codes field on institutional claim formats. A list of HCPCS is accessible on the CMS Web site. HH - Home Health HHA(s) - Home Health Agency(ies) (H)HRG - Home Health Resource Group. One of HH episode payment rates. HIPPS - Health Insurance Prospective Payment System. Procedural coding used in the HCPCS/ Accommodation Rates/HIPPS Rate Codes field on institutional claim formats in association with certain CMS prospective payment systems Admission Date - For HH PPS, date of first service of episode or first service in a period of continuous care (multiple episodes) placed in the Admission/Start of Care Date field on the institutional claim. Claim - Second of two transactions at opening and closing of HH PPS episode to receive one of two split percentage payments. CMS - The Center for Medicare & Medicaid Services, the Federal Agency administering the Medicare program and the Federal portions of Medicaid and the Child Health program. DME - Durable Medical Equipment. Billed by revenue codes and/or HCPCS. Paid by CMS according to a CMS DME fee schedule accessible on the CMS Web site. DME- MAC - DME Medicare Administrative Contractor - 4 Medicare contractors nationally processing DME on professional claim formats. Episode - 60-day unit of payment for HH PPS. FI – Fiscal Intermediary (intermediary)
Glossary and Acronym List OASIS - Outcome Assessment Information Set. The HH assessment instrument required by CMS. Outlier - An addition to a full episode payment in cases where costs of services delivered are estimated to exceed a fixed loss threshold. Pricer computes HH PPS outliers as part of Medicare claims payment for all non-LUPA episodes. Patient Status Code – a code in the Patient Discharge Status field on institutional claims which describes patient status at discharge/end of period. PEP - Partial Episode Payment (adjustment). A reduced episode payment that may be made based on the number of service days in an episode (always less than 60 days, employed in cases of transfers or discharges with readmissions). POC - Plan of care. Medicare HH services for homebound beneficiaries must have a physician- established plan. P/O(S) - Prosthetics and orthotics. The (S) is used to also include the supplies and other items associated with the prosthetics and orthotics. PPS - Prospective Payment System. Medicare payment for medical care based on pre-determined payment rates or periods, linked to the anticipated intensity of services delivered and/or beneficiary condition. Inquiry System (HIQH/ELGH) - An online transaction providing information on HH PPS episodes for specific Medicare beneficiaries for HHAs and hospices. Like the HIQA/ELGA eligibility inquiry system, this system is based on batch claim data available in the Common Working File, a component of Medicare claims processing systems, available to providers via their Medicare contractor. Line Item - Service or item-specific detail of claim. Contains repeated entries of revenue code, HCPCS code, service units and charge data. LUPA - Low Utilization Payment Adjustment. An episode of 4 or less visits paid by national standardized per visit rates instead of case-mix groups. MAC – Medicare Administrative Contractor National Standard Per Visit Rates - National rates for each 6 home health disciplines based on historical claims data. Used in payment of LUPAs and calculation of outliers. No-RAP LUPAs - A billing scenario in which only a claim, not a RAP, is submitted for an episode by an HHA because the HHA is aware from the outset that the episode will be four visits or less.
Glossary and Acronym List TOB - Type of Bill (i.e., 32X, 34X). Coding representing the nature of each institutional claim (i.e., type of benefit, such as homebound home health; payment source, such as specific Medicare trust fund; and frequency of bill, such as initial or cancellation) - an “x” in the last digit of numeric three digit TOB means that value can be from 0-9. Pricer - Software modules in Medicare claims processing systems, specific to certain benefits, used in pricing claims, most often under prospective payment systems. RAP - Request for Anticipated Payment. First of two transactions at opening and closing of HH PPS episode to receive one of two split percentage payments. Note although the RAP is submitted on an institutional claim format, it is not a claim according to Medicare statutes. It is not subject to the payment floor, among other differences from claims. Revenue Code - Four position payment codes for services or items placed in the Revenue Codes field on institutional claim formats. Note that a new revenue code 0023 will be used on a distinct line item when billing episode payments. (HIPPS code in HCPCS field, separate line items for visits and supplies follow on claim). An “x” in the last digit of revenue codes means that value can vary from 0-9. RHHI - Regional Home Health Intermediary. Four FIs nationally designated to process Medicare home health and hospice claims.