1. Online Claims Entry UB-04
Conduent Government Healthcare Solutions

2. Resources When online use: Ask Service Representative
Call Center or
New Mexico Web Portal
Provider Information section
Links and FAQ section
Provider Login section
11/09/2017

3. Purpose of the Workshop
Provide complete explanation of how to fill out the UB-04 paper claim form for:
Claim Form Instructions
Timely Filing
NCCI – National Corrective Coding Initiative
New Hospital Outpatient Payment Method
Add/Manage Templates
Medicaid Primary Claims
Medicaid secondary to a Third Party Liability (TPL)
HMO co-payments
Medicare Replacement Plans
Medicare Primary Claims
11/09/2017

4. Important State Websites
PROGRAM POLICY MANUAL
BILLING INSTRUCTIONS
REGISTERS AND SUPPLEMENTS:
10/9/2017
Family Planning Workshop

5. Important Update
On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets.
The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.
10/9/2017
Family Planning Workshop

6. Claim Form Instructions
Conduent Government Healthcare Solutions

7. Where Do I Get a Copy of Claim Form Instructions?
On the WEB PORTAL: Click Providers then Forms, Publications, and Instructions under Provider Information
Continued on next screen…
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8. Where Do I Get a Copy of Claim Form Instructions?
Scroll down
Open file
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9. Timely Filing
Conduent Government Healthcare Solutions

10. 91604900085000001 What is a Transaction Control Number (TCN)?
The twelfth digit in an adjustment/ void TCN will either be:
1= Debit
2= Credit
The first digit indicates what the claim “media” is:
2 = electronic crossover
3 = other electronic claim
4 = system generated claim or adjustment
8 = paper claim
9 = Web portal claim entry
Batch number
The last two digits of the year the claim was received
Global slide – indicate somehow
The numeric day of the year.
The claim number within the batch.
This is the Julian Date - this represents the date the claim was received by Conduent: this claim was received the 49th day of 2016, or February 18, 2016
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11. Timely Filing Denials Re-filing Claims and Submitting Adjustments
UB-04 Form: Put the TCN in Block 64 on the Paper Form.
0001 1 1
082807
8,100 00
MEDICAID
CONNIE CLIENT
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12. National Corrective Coding Initiative (NCCI)
Conduent Government Healthcare Solutions

13. NCCI
A CMS program that consists of coding policies and edits.  Medicaid NCCI Edits consist of two types: 
NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons
Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas).
11/09/2017

14. NCCI Remittance Advice (RA)/Explanation of Benefits (EOB) Codes:
6501 or Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service.
6503 through Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit.
Please visit the Medicaid.gov webpage for the NCCI in Medicaid:
The National Correct Coding Initiative in Medicaid
11/09/2017

15. New Hospital Outpatient Payment Method
Conduent Government Healthcare Solutions

16. Hospital Outpatient Payment Method for New Mexico Medicaid
All General Acute Hospitals and Rehabilitation Hospitals must include a procedure code on every line item to receive payment.
It is recommended that you bill all outpatient services for the same date of service on the same claim form all inclusive.
11/09/2017

17. New Hospital Outpatient Payment Method for New Mexico Medicaid
The following resources are available on the HSD/MAD website located at:
New Mexico Medicaid Fee Schedules
Hospital Outpatient Payment Method FAQ
Hospital Outpatient Payment Method Revenue Codes
Hospital Outpatient Payment Method Procedure Codes
Notice of Hospital Outpatient Prospective Payment System Rates
Explanation of Simulation Spreadsheet for Outpatient services
11/09/2017

18. Add/Manage Templates
Conduent Government Healthcare Solutions

19. UB-04 Add Claim Template
Please note template are limited to 25 per user.
HINT: think about use procedure code, or dates (billing range dates)
The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice.
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20. UB-04 Add Claim Template
Fill out any information you would like included in your template
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21. UB-04 Add Claim Template
Fill out any information you would like included in your template
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22. UB-04 Add Claim Template
Fill out any information you would like included in your template
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23. UB-04 Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text. View next slide for additional fields.
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24. UB-04 Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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25. UB-04 Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
11/09/2017

26. UB-04 Add Claim Template
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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27. UB-04 Add Claim Template
System will automatically input decimal point.
Fill out any information you would like included in your template.
Sections can be expanded by checking all sections with Red Text.
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28. UB-04 Manage Claim Template
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29. Medicaid Primary Claim Forms
Conduent Government Healthcare Solutions

30. Online Claims Entry
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31. Click on the Red Text for the UB-04 Claim form instructions
Online Claims Entry Primary Claim Continued
Click on the Red Text for the UB-04 Claim form instructions
11/09/2017

32. Sections can be expanded by selecting all sections with Red Text
Additional Information Option
Sections can be expanded by selecting all sections with Red Text
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33. Online Claims Entry Primary Claim Continued
Sections can be expanded by selecting all sections with Red Text
11/09/2017

34. Sections can be expanded by selecting all sections with Red Text
Online Claims Entry Primary Claim Continued
Sections can be expanded by selecting all sections with Red Text
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35. Online Claims Entry -- Attachments
Click upload
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36. Online Claims Entry Primary Claim Continued
Review the Uploading Attachments Restrictions.
You can attach files up to 10 MB
Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files.
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37. Online Claims Entry Primary Claim Continued
All field with a Red Asterisk (*) are REQUIRED fields
Diagnosis codes do not require a period(.)
Only enter the numeric value
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38. Verify Total charge is correct
Online Claims Entry Primary Claim Continued
Indicate the Total charge x
Verify Total charge is correct
If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits.
11/09/2017

39. Medicaid Third Party Liability (TPL) Claim
Conduent Government Healthcare Solutions

40. Third Party Liability (TPL) Tips
TPL is commercial insurance
TPL must be billed primary to Medicaid
Medicaid does not consider Medicare TPL
What does PEDS stand for?
11/09/2017

41. Third Party Liability (TPL) Tips
Always enter the amount paid in the “Paid Amount” field provided in the “Other Insurance Info” section of claim.
If Medicaid requires a PA for the service, then a PA issued by the Medicaid TPA is always required when TPL is involved, no matter if TPL paid or denied the service.
Attach the TPL EOB showing the payment/denial with the claim.
Always include the explanation page of the EOB along with the page of the EOB that shows payment/denial.
What does PEDS stand for?
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42. Medicaid TPL Claim Example
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43. Medicaid TPL Claim Example
Indicate the Total charge
TPL Payment
Co-pay/Co-insurance/Deductible x
Verify Total charge is correct, If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits.
11/09/2017

44. Medicaid Co-Payment Claim Forms
Conduent Government Healthcare Solutions

45. PPO/HMO Co-Pay Tips
Indicate PPO/HMO under “Other Insurance Info” section of the claim.
Indicate Co-pay amount in the Co-pay field provided in the “Other Insurance Info” section of claim.
Attach the EOB.
In the “Prior Payment Amount” enter the difference between the billed amount and the co-payment\Amount Due.
Enter the co-payment amount in the “Amount Due” field.

46. PPO/HMO Co-pay Claim
11/09/2017

47. Verify Total charge is correct
PPO/HMO Co-pay Claim
Indicate the Total charge
Difference
Co-pay/Co-insurance/
Deductible x
Verify Total charge is correct
If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits.
11/09/2017

48. Medicare Replacement Plan Claim Forms
Conduent Government Healthcare Solutions

49. Medicare Replacement Plan
Indicate “Medicare Advantage” for Medicare Replacement Plan
11/09/2017

50. Medicare Replacement Plan
Attach Copy of EOB
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51. Medicare Replacement Plan
Total Charge
Difference between total charge
and the co-payment amount
Co-Payment Amount X
11/09/2017

52. Medicare Primary Claim Forms
Conduent Government Healthcare Solutions

53. Medicare Primary Claims
Indicate “Medicare” for Medicare Crossover submissions
11/09/2017

54. Medicare Primary Claims
Attach a copy of the EOB
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55. Medicare Primary Claims
Only Indicate Total charge on Medicare Crossovers
Leave the Prior Payment Amount and Amount Due Blank X
11/09/2017

56. Inpatient Claims for Medicare Part B Only Clients
Conduent Government Healthcare Solutions

57. Inpatient Claims for Medicare Part B-Only Clients
Certain Medicaid/Medicare clients only have Medicare Part B coverage.
Medicare may cross over the Part B claim with type of bill 121. This claim does not have an accommodation revenue code on it.
The claim will deny and the provider will need to resubmit and include the following four things on the claim:
What does PEDS stand for?
11/09/2017

58. Inpatient Claims for Medicare Part B-Only Clients
Use type of bill “121”.
Attach a copy of the EOMB indicate Medicare paid amount in previous payment box (form locator 54).
What does PEDS stand for?
11/09/2017

59. Inpatient Claims for Medicare Part B-Only Clients
Indicate “Medicare” for Inpatient Claims for Medicare Part B-Only Recipients
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60. Inpatient Claims for Medicare Part B-Only Clients
Attach a copy of the EOB
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61. Inpatient Claims for Medicare Part B-Only Clients
Total Charge
TPL Payment Amount
Difference between Total Charge and Prior Payment Amount X
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62. UB-04 Tips
Conduent Government Healthcare Solutions

63. Ensure the line item charges are correct and match the total charge.
UB-04 Tips
Ensure the line item charges are correct and match the total charge.
11/09/2017

64. UB-04 Tips Include all appropriate EOB’s for TPL, HMO, etc.
If you are a for profit organization, make sure gross receipts tax is included in the line items, if required.
Rev codes, diagnosis codes, etc., are entered correctly.
11/09/2017

65. Resources When online use: Ask Service Representative
Call Center or
New Mexico Web Portal
Provider Information section
Links and FAQ section
Provider Login section
11/09/2017