Provider Claims and Billing Manual Version Two Publication Date: July 2014

Transcription

Provider Claims and Billing Manual
Version Two
Publication Date: July 2014
Claims and Billing Manual
Table of Contents
Claim Filing..................................................................................................................................... 1
Procedures for Claim Submission ............................................................................................... 1
Claim Submission Instructions .................................................................................................... 2
Claim Filing Deadlines ................................................................................................................ 3
Refunds for Improper Payment or Overpayment of Claims ........................................................ 3
Claim Form Field Requirements ..................................................................................................... 5
Required Fields (CMS-1500 Claim Form) .................................................................................. 5
EDI Mapping for CMS-1500..................................................................................................... 17
Required Fields (UB-04 Claim Forms) ..................................................................................... 23
EDI Mapping Table (UB-04) .................................................................................................... 40
Special Instructions and Examples for CMS-1500, UB-04 and EDI (837) Claims Submissions . 47
I. Supplemental Information ..................................................................................................... 47
A. CMS-1500 Paper Claims – Field 24: ............................................................................... 47
B. EDI – Field 24D (Professional): ...................................................................................... 47
C. EDI – Field 33b (Professional): ....................................................................................... 48
D. EDI – Field 45 and 51(Institutional):............................................................................... 48
E. Reporting NDC on CMS-1500 and UB-04 and EDI: ...................................................... 48
Common Causes of Claim Processing Delays, Rejections or Denials .......................................... 51
Electronic Data Interchange (EDI) for Medical and Hospital Claims ........................................... 54
Electronic Claims Submission (EDI) ............................................................................................ 55
Hardware/Software Requirements............................................................................................. 55
Contracting with Emdeon and Other Electronic Vendors ......................................................... 55
Contacting the EDI Technical Support Group .......................................................................... 55
Specific Data Record Requirements .......................................................................................... 56
Electronic Claim Flow Description ........................................................................................... 56
Invalid Electronic Claim Record Rejections/Denials ................................................................ 57
Plan Specific Electronic Edit Requirements.............................................................................. 57
Exclusions ................................................................................................................................. 57
Resubmitting Professional Corrected Claims ............................................................................ 59
Common Rejections .................................................................................................................. 59
Common Rejections, continued................................................................................................. 60
Supplemental Information ............................................................................................................. 61
Allergy Testing/Immunotherapy ............................................................................................... 61
Ambulatory Surgical Centers .................................................................................................... 61
Anesthesia ................................................................................................................................. 61
Behavioral Health ...................................................................................................................... 61
Chemotherapy ........................................................................................................................... 62
Child HealthCheck (EPSDT) Services ...................................................................................... 62
Dental Claims (DentaQuest)...................................................................................................... 63
Diabetes ..................................................................................................................................... 63
Durable Medical Equipment...................................................................................................... 63
Family Planning ........................................................................................................................ 63
Family Planning (non-obstetric) ................................................................................................ 63
Immunizations ........................................................................................................................... 64
Injectable Drugs ........................................................................................................................ 64
Maternity ................................................................................................................................... 64
Maternity Birthing Center (obstetric) ........................................................................................ 65
Maternity Delivery .................................................................................................................... 65
Maternity Fetal Bio-Physical Profile ......................................................................................... 65
Outpatient Hospital Services ..................................................................................................... 65
Pain Management ...................................................................................................................... 65
Pharmacy Coverage (PerformRx) ............................................................................................. 66
Physical/Occupational and Speech Therapies ........................................................................... 66
Transplants ................................................................................................................................ 66
Vision Care Exams .................................................................................................................... 66
Vision Claims (eyeQuest).......................................................................................................... 67
Weight Assessment and Counseling for Nutritional and Physical Activity (Child/Adolescent)67
Well Child Visits ....................................................................................................................... 67
Women’s Preventive Health Services ....................................................................................... 67
Electronic Billing Inquiries ........................................................................................................... 68
2013 HEDIS Billing Guidelines .................................................................................................... 69
Claim Filing
Important:
Procedures for Claim Submission
AmeriHealth District of Columbia, hereinafter referred to as the
‘Plan’ or ‘AmeriHealth DC’ is required by state and federal
regulations to capture specific data regarding services rendered to
its members. All billing requirements must be adhered to by the
provider in order to ensure timely processing of claims.
When required data elements are missing or are invalid, claims will
be rejected by AmeriHealth DC for correction and re-submission.
Claims for billable services provided to AmeriHealth DC members
must be submitted by the provider or an entity employed by the
provider who performed the services.
Claims filed with AmeriHealth DC are subject to the following
procedures:







Verification that all required fields are completed on the CMS-1500
or UB-04 forms.
Verification that all diagnosis and procedure codes are valid for the
date of service.
Verification for electronic claims against 837 edits at Emdeon
Verification of member eligibility for services under AmeriHealth
DC during the time period in which services were provided.
Verification that the services were provided by a participating
provider or that an out-of-network provider has received
authorization to provide services to the eligible member.
Verification that an authorization or referral has been given for
services that require prior authorization or referral by the Plan.
Verification of whether there is Medicare coverage or any other thirdparty resources and, if so, verification that the Plan is the “payer of
last resort” on all claims submitted to AmeriHealth DC
Rejected Claims are defined as
claims with invalid or missing
required data elements, such as
the provider tax identification
number or member ID number,
that are returned to the provider or
EDI* source without registration in
the claim processing system.
 Rejected claims are not
registered in the claim
processing system and can
therefore be resubmitted as a
new claim within 180 calendar
days from the date of service
or discharge.
Denied Claims are registered in
the claim processing system but do
not meet requirements for payment
under AmeriHealth DC guidelines.
Denied claims must be resubmitted
as corrected claims.

Denied claims must be resubmitted as corrected
claims within 365 days of
the original date of service.
Note: These requirements apply
to claims submitted on paper or
electronically.
* For more information on EDI,
review the section titled Electronic
Data Interchange (EDI) for Medical
and Hospital Claims in this
document.
__________________________________________________________________________________________
* Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the
situation or the service provided. Refer to the NUCC or NUBC Reference Manuals for additional information
www.amerihealthdc.com
1
Provider Services 202-408-2237 or 888-656-2383
Claim Submission Instructions
Important:
Submit claims to AmeriHealth DC via:
Mail:
Please submit paper claims to the appropriate address below:
By Telephone:
Provider Claim Services
202-408-2237 or 888-656-2383
(Select the appropriate prompt.)
AmeriHealth DC/Medicaid
Attn: Claims Processing Department
P.O. Box 7342
London, KY 40742
On Paper:
If you prefer to write, please be
sure to stamp each claim
“corrected” or “resubmission” and
address the letter to the
appropriate claims address, as
listed on the left.
OR
AmeriHealth DC/Alliance
Attn: Claims Processing Department
P.O. Box 7354
London, KY 40742
Electronic:
AmeriHealth DC participates with Emdeon. As long as you have
the capability to send EDI claims to Emdeon, whether through
direct submission or through another clearinghouse/vendor, you
may submit claims electronically. Electronic claim submissions to
AmeriHealth DC should follow the same process as other
electronic commercial submissions.
To initiate electronic claims:
-
Claim Adjustments
Requests for adjustments may be
submitted electronically, on paper,
by telephone.
Contact your practice management software vendor or EDI
software vendor.
Inform your vendor of AmeriHealth DC’s EDI Payer
ID#: 77002.
You may also contact Emdeon at 877-363-3666 or visit to
www.emdeon.com for information on contracting for
direct submission to Emdeon. AmeriHealth DC does not
require Emdeon payer enrollment to submit EDI claims.
Electronically:
Use CLM05-3 to report claim
adjustments electronically.
Claim Disputes
If a claim or a portion of a claim is
denied for any reason or
underpaid, the provider may
dispute the claim within 60 days
from the date of the denial or
payment. Claim disputes must be
submitted in writing, along with
supporting documentation, to:
AmeriHealth DC
Attn: Claim Disputes
P.O. Box 7358
London, KY 40742
Medical Appeals
Any additional questions may be directed to the AmeriHealth DC
EDI Technical Support Hotline by calling 888-656-2383 and
selecting the appropriate prompts or by emailing to
[email protected].
Administrative or medical appeals
must be submitted in writing to:
AmeriHealth DC
Attn: Provider Appeals Department
P.O. Box 7359
London, KY 40742
Note: AmeriHealth DC EDI Payer
ID#: 77002
__________________________________________________________________________________________
2
Claim Filing Deadlines
All original paper and electronic claims must be submitted to AmeriHealth DC within 180 calendar
days from the date services were rendered (or the date of discharge for inpatient admissions).This applies
to capitated and fee-for-service claims. Please allow for normal processing time before re-submitting a
claim either through the EDI or paper process. This will reduce the possibility of your claim being
rejected as a duplicate claim. Claims are not considered as received under timely filing guidelines if
rejected for missing or invalid provider or member data.
Note: Claims must be received by the EDI vendor by 9:00 p.m. in order to be transmitted to the Plan the
next business day.
Rejected claims are defined as claims with missing or invalid data elements, such as the provider tax
identification number or member ID number, that are returned to the provider or EDI source without
registration in the claim processing system. Rejected claims are not registered in the claim processing
system and can be re-submitted as a new claim. Claims originally rejected for missing or invalid data
elements must be re-submitted with all necessary and valid data within 180 calendar days from the date
services were rendered (or the date of discharge for inpatient admissions).
Denied claims are registered in the claim processing system but do not meet requirements for payment
under AmeriHealth DC guidelines. They should be re-submitted as a corrected claim. Claims originally
denied must be re-submitted as a corrected claim within 365 days of the original date of service.
Claims with Explanation of Benefits (EOBs) from primary insurers, including Medicare, must be
submitted within 180 days of the date on the primary insurer’s EOB. Please note, COB claims may be
submitted electronically or on paper.
Refunds for Improper Payment or Overpayment of Claims
If a Plan provider identifies improper payment or overpayment of claims from AmeriHealth DC,
Medicaid or Alliance programs, the improperly paid or overpaid funds must be returned to the Plan.
Providers are required to return the identified funds to AmeriHealth DC by submitting a refund check
directly to the appropriate claims processing department:
AmeriHealth DC/Medicaid
Attn: Provider Refunds
P.O. Box 7342
London, KY 40742
AmeriHealth DC/Alliance
Attn: Provider Refunds
P.O. Box 7354
London, KY 40742
Note: Please include the member’s name and ID, date of service and claim ID.
__________________________________________________________________________________________
3
CMS-1500 Claim Form Field Requirements
__________________________________________________________________________________________
4
Claim Form Field Requirements
The following charts describe the required fields that must be completed for the standard Centers for
Medicare and Medicaid Services (CMS) CMS-1500 or UB-04 claim forms. If the field is required without
exception, an “R” (Required) is noted in the “Required or Conditional” box. If completing the field is
dependent upon certain circumstances, the requirement is listed as “C” (Conditional) and the relevant
conditions are explained in the “Instructions and Comments” box.
The CMS-1500 claim form must be completed for all professional medical services, and the UB-04 claim
form must be completed for all facility claims. All claims must be submitted within the required filing
deadline of 180 calendar days from the date services were rendered (or the date of discharge for inpatient
admissions).
Claims with Explanation of Benefits (EOBs) from primary insurers, including Medicare, must be submitted
within 180 days of the date on the primary insurer’s EOB.
Although the following examples of claim filing requirements refer to paper claim forms, claim data
requirements apply to all claim submissions, regardless of the method of submission (electronic or paper).
Required Fields (CMS-1500 Claim Form)
CMS-1500 Claim Form
Field #
Field Description
Instructions and Comments
Required or
Conditional*
1
Insurance Program Identification
Check only the type of health coverage
applicable to the claim. This field
indicates the payer to whom the claim is
being filed.
R
1a
Insured’s I.D. Number
Enter the Member ID number as it
appears on the AmeriHealth DC
Member ID card. This number begins
with a ‘7’ and is also known as the
Medicaid ID number. For electronic
submissions, this ID must be less than
17 alphanumeric characters.
R
(Enter the Member ID Number)
2
Patient’s Name (Last, First, Middle Enter the patient’s name as it appears on
the member’s AmeriHealth DC Member
Initial)
ID card or enter the newborn’s name
when the patient is a newborn.
3
Patient’s Birth Date/Sex
MMDDYY / M or F
R
R
Enter the patient’s birth date and select
the appropriate gender.
__________________________________________________________________________________________
5
CMS-1500 Claim Form
Field #
Field Description
Required or
Conditional*
4
Insured’s Name (Last, First,
Middle Initial)
Enter the patient’s name as it appears on
the AmeriHealth DC Member ID card,
or enter the newborn’s name when the
patient is a newborn.
R
5
Patient’s Address (Number, Street, Enter the patient’s complete address and
telephone number. (Do not punctuate
City, State, Zip) Telephone (with
the address or telephone number.)
Area Code)
R
6
Patient Relationship To Insured
7
Insured’s Address (Number, Street,
City, State, Zip Code) Telephone
(with Area Code)
8
Reserved for NUCC use
9
Other Insured's Name (Last, First, Refers to someone other than the
patient. Completion of fields 9a
Middle Initial)
through 9d is required if the patient is
covered by another insurance plan.
Enter the complete name of the insured.
C
9a
Other Insured's Policy Or Group # Required if # 9 is completed.
C
9b
To be determined.
Not
Required
9c
To be determined.
Not
Required
9d
Insurance Plan Name Or Program
Name
List AmeriHealth DC as the health plan.
R
10 a,b,c
Is Patient's Condition Related To:
Indicate Yes or No for each category. Is
condition related to:
R
Always indicate self.
R
R
Not used.
Not
Required
a) Employment
b) Auto Accident (Including
Place/State)
c) Other Accident
__________________________________________________________________________________________
6
CMS-1500 Claim Form
Field #
10d
Field Description
Claim Codes
NUCC)
(Designated
Required or
Conditional*
by Enter new Condition Codes as
appropriate. Available 2-digit Condition
Codes include nine codes for abortion
services and four codes for worker’s
compensation. Please refer to NUCC for
the complete list of codes. Examples
include:
AD – Abortion Performed due
to a Life Endangering Physical
Condition Caused by, Arising
from or Exacerbated by the
Pregnancy Itself
 W3 – Level 1 Appeal
Insured's Policy Group Or FECA # Required when other insurance is
available. Complete if more than one
other Medical insurance is available, or
if “yes” to 10 a, b, c. Enter the policy
group or FECA number.
C

11
C
11a
Insured's Birth Date / Sex
Same as # 3. Required if 11 is
completed.
C
11b
Other Claim ID
Enter the following qualifier and
accompanying identifier to report the
claim number assigned by the payer for
worker’s compensation or property and
casualty:
 Y4 – Property Casualty Claim
Number
C
Enter qualifier to the left of the vertical,
dotted line; identifier to the right of the
vertical, dotted line.
11c
Name
Enter name of the other insurance health
plan. Required if 11 is completed.
C
11d
Is There Another Health Benefit
Plan?
Indicate Yes or No by checking the box.
R
If Yes, complete # 9 a-d.
__________________________________________________________________________________________
7
CMS-1500 Claim Form
Field #
Field Description
Required or
Conditional*
12
Patient's Or Authorized Person's
Signature
Not required
13
Insured's Or Authorized Person's
Signature
Not required
14
Date Of Current Illness Injury,
Pregnancy (LMP)
MMDDYY or MMDDYYYY
C
Enter applicable 3-digit qualifier to right
of vertical dotted line. Qualifiers
include:
•
431 – Onset of Current
Symptoms or Illness
•
484 – Last Menstrual Period
(LMP)
Use the LMP for pregnancy.
Example:
__________________________________________________________________________________________
8
CMS-1500 Claim Form
Field #
15
Field Description
Required or
Conditional*
MMDDYY or MMDDYYYY
Other Date
C
Enter applicable 3-digit qualifier
between the left-hand set of vertical
dotted lines. Qualifiers include:
•
•
•
•
•
•
•
•
•
454 – Initial Treatment
304 – Latest Visit or
Consultation
453 – Acute Manifestation
of a Chronic Condition
439 – Accident
455 – Last X-Ray
471 – Prescription
090 – Report Start
(Assumed Care Date)
091 – Report End
(Relinquished Care Date)
444 – First Visit or
Consultation
Example:
16
Dates Patient Unable To Work In
Current Occupation
C
__________________________________________________________________________________________
9
CMS-1500 Claim Form
Field #
17
Field Description
Name Of Referring Physician Or
Other Source
Required or
Conditional*
Required if a provider other than the
member’s primary care physician
rendered invoiced services. Enter
applicable 2-digit qualifier to left of
vertical dotted line. If multiple
providers are involved, enter one
provider using the following priority
order:
1.
Referring Provider
2.
Ordering Provider
3.
Supervising Provider
C
Qualifiers include:
•
DN – Referring Provider
•
DK – Ordering Provider
•
DQ – Supervising Provider
Example:
17a
Other ID Number Of Referring
Physician
(AmeriHealth DC Provider ID#)
17b
National Provider Identifier (NPI)
Enter the AmeriHealth DC Provider ID
Number for the referring physician.
The qualifier indicating what the
number represents is reported in the
qualifier field to the immediate right of
17a. If the Other ID number is the
AmeriHealth DC ID number, enter G2.
If the Other ID number is another
unique identifier, refer to the NUCC
guidelines for the appropriate qualifier.
C
Enter the NPI number of the
referring provider, ordering provider
or other source. Required if #17 is
completed.
R
__________________________________________________________________________________________
10
CMS-1500 Claim Form
Field #
Field Description
Required or
Conditional*
C
18
Hospitalization Dates Related To
Current Services
19
Additional Claim Information
(Designated by NUCC)
Required when place of service is inpatient. MMDDYY (indicate from and
to date).
Enter additional claim information with
identifying qualifiers as appropriate. For
multiple items, enter three blank spaces
before entering the next qualifier and
data combination.
20
Outside Lab
Optional
C
21
Diagnosis Or Nature Of Illness Or
Injury. (Relate To 24E)
Enter the applicable ICD indicator to
identify which version of ICD codes is
being reported:
R
•
•
Not
Required
9 - ICD-9-CM
0 - ICD-10-CM
Enter the indicator between the vertical,
dotted lines in the upper right-hand
portion of the field.
Enter the codes to identify the patient’s
diagnosis and/or condition. List no
more than 12 ICD diagnosis codes.
Relate lines A – L to the lines of service
in 24E by the letter of the line. Use the
highest level of specificity. Do not
provide narrative description in this
field.
Note: Claims with invalid diagnosis
codes will be denied for payment.
__________________________________________________________________________________________
11
CMS-1500 Claim Form
Field #
22
23
24A
Field Description
Required or
Conditional*
Resubmission Code and/or Original For resubmissions or adjustments, enter
the appropriate bill frequency code (7 or
Ref. No.
8 – see below) left justified in the
Submission Code section, and the Claim
ID# of the original claim in the Original
Ref. No. section of this field.
Additionally, stamp “resubmitted” or
“corrected” on the claim
•
7 – Replacement of Prior Claim
•
8 – Void/cancel of Prior Claim
C
Prior Authorization Number
Enter the prior authorization number.
Refer to the Provider Manual to
determine if services rendered require
an authorization.
C
Date(s) Of Service
“From” date: MMDDYY. If the service
was performed on one day there is no
need to complete the “to” date. See
page 43 for additional instructions on
completing the shaded portion of field
24.
R
See page 43 for supplemental
guidance on the shaded portions of
fields 24 A – J.
24B
Place Of Service
Enter the CMS standard place of service
code. “00” for place of service is not
acceptable.
R
24C
EMG
This is an emergency indicator field.
Enter Y for “Yes” or leave blank for
“No” in the bottom (unshaded area of
the field).
C
24D
Procedures, Services Or Supplies
CPT/HCPCS/ Modifier
Enter the CPT or HCPCS code(s) and
modifier (if applicable). Procedure
codes (5 digits) and modifiers (2 digits)
must be valid for date of service.
R
Note: Modifiers affecting
reimbursement must be placed in the
first modifier position.
__________________________________________________________________________________________
12
CMS-1500 Claim Form
Field #
Field Description
Required or
Conditional*
24E
Diagnosis Pointer
Diagnosis Pointer - Indicate the
associated diagnosis by referencing the
pointers listed in field 21 (1, 2, 3, or 4).
Note: AmeriHealth DC can accept up
to eight (8) diagnosis pointers in this
field. Diagnosis codes must be valid
ICD codes for the date of service.
R
24F
Charges
R
24G
Days Or Units
Enter charges. A value must be
entered. Enter zero ($0.00) or actual
charged amount. (This includes
capitated services.)
Enter quantity. Value entered must be
greater than zero. (Field allows up to 3
digits.)
24H
Child HealthCheck (EPSDT)
Services
In Shaded area of field:
C
R
AV - Patient refused referral;
S2 - Patient is currently under treatment
for referred diagnostic or corrective
health problems;
NU - No referral given; or
ST - Referral to another provider for
diagnostic or corrective treatment.
In unshaded area of field:
“Y” for Yes – if service relates to a
pregnancy or family planning
“N” for No – if service does not relate
to pregnancy or family planning
__________________________________________________________________________________________
13
CMS-1500 Claim Form
Field #
24I
Field Description
Required or
Conditional*
If using NPI in field 24J, enter the
qualifier “ZZ”.
ID Qualifier
R
If using a DC Medicaid provider ID for
an atypical provider, enter the qualifier
“1D”.
If the Other ID number is the
AmeriHealth DC ID number, enter G2.
If the Other ID number is another
unique identifier, refer to the NUCC
guidelines for the appropriate qualifier.
24J
Rendering Provider ID NPI in the
bottom (unshaded) portion. Enter
the AmeriHealth DC Provider ID
number in the top (shaded) portion.
The individual rendering the service is
reported in 24J. Enter the AmeriHealth
DC ID number in the shaded area of the
field or, if an atypical provider, enter the
provider’s DC Medicaid ID number.
Enter the NPI number in the
unshaded area of the field.
Physician or Supplier's Federal Tax ID
number.
Recommended
R
25
Federal Tax ID Number SSN/EIN
R
26
Patient's Account No.
Enter the patient’s account number
assigned by the provider
R
27
Accept Assignment
Yes or No must be checked..
R
28
Total Charge
Enter the total of all charges listed on
the claim.
R
29
Amount Paid
Required when another carrier is the
primary payer. Enter the payment
received from the primary payer prior to
invoicing the Plan. Medicaid programs
are always the payers of last resort.
C
30
Reserved for NUCC Use
To be determined.
31
Signature Of Physician Or Supplier Signature on file, signature stamp,
Including Degrees Or Credentials / computer-generated or actual signature
is acceptable.
Date
Not
Required
R
__________________________________________________________________________________________
14
CMS-1500 Claim Form
Field #
Required or
Conditional*
Name And Address Of Facility
Where Services Were Rendered (If
Other Than Home Or Office).
Required. Enter the physical location.
(P.O. Box #’s are not acceptable
here.)
R
32a.
NPI number
Required unless Rendering Provider is
an Atypical Provider and is not required
to have an NPI number.
R
32b.
Other ID#
# (strongly recommended)
R
32
Field Description
(AmeriHealth DC issued Provider
Identification Number)
Enter the G2 qualifier followed by the
DC Medicaid ID #.
Required when the Rendering Provider
is an Atypical Provider and does not
have an NPI number. Enter the twodigit qualifier identifying the non-NPI
number followed by the ID number. Do
not enter a space, hyphen, or other
separator between the qualifier and
number.
33
33a.
Billing Provider Info & Ph #
Required – Identifies the provider that
is requesting to be paid for the services
rendered and should always be
completed. Enter physical location;
P.O. Boxes are not acceptable.
R
NPI number
R
__________________________________________________________________________________________
15
CMS-1500 Claim Form
Field #
33b.
Field Description
Other ID#
# (strongly recommended.)
Required or
Conditional*
R
Required when the Billing Provider is
an Atypical Provider and does not have
an NPI number. For atypical providers
that do not have an NPI, enter the G2
qualifier followed by the DC Medicaid
ID #. Do not enter a space, hyphen, or
other separator between the qualifier
and number.
If using NPI in field 33a, enter the
taxonomy code in 33b and the qualifier
“ZZ” in the box to the left.
Note: *DC Medicaid provider numbers
may only be used for atypical providers.
Atypical providers are providers that do
not meet the definition of healthcare
provider under the Health Insurance
Portability and Accountability Act
(HIPAA); for example waiver
providers, attendant care providers,
chore services providers, respite care
providers.
__________________________________________________________________________________________
16
Professional Claims EDI Mapping
EDI Mapping for CMS-1500
CMS-1500 Claim Form EDI Mapping
Field #
1
Field Description
Insurance Program Identification
Required or
Conditional*
2000B, SBR09 = CI
R
Commercial Insurance
1a
2
3
Insured ID Number
2010BA/NM1
<Plan Name> Member’s
identification number
Use 2330A for COB Data
R
Patient’s Name (Last, First, Middle 2010BA/NM1
New Born (2010CA/NM1)
Initial)
2010CA/NM1
2010CA/NM1
2010BA/DMG
Patient’s Birth Date/Sex
2010CA/DMG - Newborn
R
R
2010BA/NM1
4
Insured’s Name (Last, First,
Middle Initial)
R
5
Patient’s Address (Number, Street, 2010CA/N3/N4
City, State, Zip) Telephone (Include
Area Code)
6
Patient Relationship To Insured
7
Insured’s Address (Number, Street, 2010BA/N3/N4
City, State, Zip Code) Telephone
(Include Area Code)
8
9
Other Insured's Name (Last, First, 2330A/NM1
Middle Initial)
C
9a
Other Insured's Policy Or Group # 2320/SBR
C
9b
Not in IG
NR
9c
Not in IG
NR
9d
Name
2330 NM1
C
R
2000C/PAT01
Blank
R
NR
NR
__________________________________________________________________________________________
17
Field #
10a,b,c
10d
Field Description
Required or
Conditional*
Is Patient's Condition Related To:
2300/CLM11
C
Claim Codes (Designated by
NUCC)
Not in IG
C
2300/PWK
R
11
Insured's Policy Group Or FECA #
11a
Insured's Birth Date / Sex
2010BA/DMG02
2010CA/DMG02
R
11b
Other Claim ID
Not in IG
C
11c
Name
2000B/SBR04
C
11d
Is There Another Health Benefit
Plan?
2000B/SBR05
R
12
Patient's Or Authorized Person's
Signature
2300CLM092320/OI04
C
13
Insured's Or Authorized Person's
Signature
2300CLM08
14
Date Of Current Illness Injury,
Pregnancy (LMP)
2300/DTP03
C
15
Other Date
2300 DTP
C
16
Dates Patient Unable To Work In
Current Occupation
2300/DTP03
NR
17
Name Of Referring Physician Or
Other Source
2310A/NM1
C
17a
Other ID Number Of Referring
Physician (Plan Provider ID#)
2310A/REF02
C
17b
National Provider Identifier (NPI)
2310A/NM109.
C
2000B/SBR
NR
2320/OI04
(Enter the referring provider’s
NPI)
__________________________________________________________________________________________
18
Field #
Field Description
Required or
Conditional*
18
Hospitalization Dates Related To
Current Services
2300/DTP
19
Additional Claim Information
(Designated by NUCC)
2300/NTE01
NR
20
Outside Lab
2400/PS102
NR
21
Diagnosis Or Nature Of Illness Or
Injury. (Relate To 24E)
2300, HIXX
R
22
Resubmission Code and/or Original 2300/REF/Qualifier F8
Ref. NoUsed for Original Claim #
2300/REF/ Qualifier 9F
Required when CLM05-3 (Claim
Frequency Code) indicates this claim
is a replacement or void to a
previously adjudicated claim.
23
Prior Authorization Number
2300/REF/Qualifier G1
Referral Number
2300/REF/ Qualifier 9F
Date(s) Of Service
2400/DTP
R
24A
C
NR
C
See page 41 for supplemental
guidance on the shaded portions of
fields 24 A - J
24B
Place Of Service
2400/SV105
R
24C
EMG
2400/SV109
NR
24D
Procedures, Services Or Supplies
CPT/HCPCS Modifier
2400/SV1
C
24E
Diagnosis Pointer
2400/SV1
R
24F
Charges
2400/SV1
R
24G
Days Or Units
2400/SV1
R
24H
Child HealthCheck Services
2300/CRC03
C
24I
ID Qualifier
2310B/REF01
R
__________________________________________________________________________________________
19
Field #
24J
Field Description
Required or
Conditional*
2310B/NM109
Rendering Provider ID
R
2310B/REF02
25
Federal Tax ID Number SSN/EIN
of Billing Provider
2010AA/REF
R
26
Patient's Account No.
2300/CML01
R
27
Accept Assignment
Not in IG
28
Total Charge
Loop 2300/CLM
R
29
Amount Paid
2320/AMT Qualifier D
C
NR
COB data should be submitted as it
was received from other payer
2320/AMT Qualifier EAF
30
31
Signature Of Physician Or Supplier Loop 2300/CLM06
Including Degrees Or Credentials /
Date
32
Name And Address Of Facility
Where Services Were Rendered (If
Other Than Home Or Office).
NOTE: Ambulance information
should be sent as per 837 IG
NR
NR
2310C
R
2310D/2310E
2300/CRC & CR1
32a.
NPI number of Supervising
Provider name
2310C/NM1
R
32b.
Other ID#
2310C/REF01=G2
R
Strongly recommended
__________________________________________________________________________________________
20
Field #
33
Field Description
Required or
Conditional*
2010AA/NM1
2010AA/N3
2010AA/N4
2010AA/PER
Billing Provider Info & Ph #
R
Submission of Taxonomy is strongly
2000A/PRV
recommended
P.O. Box in the Billing Address will
cause the claim to be rejected at the
clearinghouse. P.O. Box may only
be submitted with the Pay to
Provider
33a.
2010AA
NPI number
R
33b.
Other ID#
AmeriHealth DC issued Provider
Identification #)
If Billing is also the Rendering
Provider:
C
2010BB/REF
Enter the AmeriHealth DC Plan
Provider ID # (strongly encouraged.)
Strongly recommended
Enter the G2 qualifier followed by the
AmeriHealth DC Plan ID #.
2000A/PRV
Required when the Rendering Provider
is an Atypical Provider and does not
have an NPI number.
__________________________________________________________________________________________
21
UB-04 Claim Field Requirements
__________________________________________________________________________________________
22
Required Fields (UB-04 Claim Forms)
UB-04 Claim Form Field Requirements
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
1
Field Description
Unlabeled Field
Billing Provider Name,
Address and Telephone
Number
Service Location, no P.O.
Boxes
Outpatient,
Bill Types
13X, 23X,
33X 83X
Required or Required or
Conditional* Conditional
*
R
R
R
R
Left justified
Line a: Enter the complete
provider name.
Line b: Enter the complete
address.
Line c: City, State, and Zip
Code (Zip Codes should include
Zip + 4 for a total of 9 digits.)
Line d: Enter the area code,
telephone number.
2
Unlabeled Field
Enter Remit Address
Billing Provider’s Designated
Pay-To Name and Address
Billing Provider’s designated
pay-to address. (Zip Codes
should include Zip + 4 for a
total of 9 digits.)
Enter the AmeriHealth DC
Facility Provider ID number.
Left justified
3a
Patient Control No.
Provider's patient
account/control number.
R
R
3b
Medical/Health Record
Number
The number assigned to the
patient’s medical/health record
by the provider.
C
C
__________________________________________________________________________________________
23
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
4
Field Description
Type Of Bill
Enter the appropriate three or
four -digit code.
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
R
R
First position is a leading zero –
Do not include the leading zero
on electronic claims.
Second position indicates type
of facility.
Third position indicates type of
care.
Fourth position indicates billing
sequence.
5
Fed. Tax No.
Enter the number assigned by
the federal government for tax
reporting purposes.
R
R
6
Statement Covers Period
From/Through
Enter dates for the full ranges of
services being invoiced.
MMDDYY
R
R
7
Unlabeled Field
No entry required
8a
Patient Identifier
Patient AmeriHealth DC ID is
conditional if number is
different from field 60.
C
C
__________________________________________________________________________________________
24
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
8b
Field Description
Patient Name
Patient name is required.
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
R
R
R
R
R
R
Last name, first name, and
middle initial. Enter the patient
name as it appears on the
AmeriHealth DC ID card.
Use a comma or space to
separate the last and first names.
Titles (Mr., Mrs., etc.) should
not be reported in this field.
Prefix: No space should be left
after the prefix of a name e.g.,
McKendrick.
Hyphenated names: Both names
should be capitalized and
separated by a hyphen (no
space).
Suffix: A space should separate
a last name and suffix.
9a-e
Patient Address
The mailing address of the
patient
9a. Street Address
9b.City
9c. State
9d. ZIP Code
9e. Country Code (report if
other than U.S.A.)
10
Patient Birth Date
The date of birth of the patient.
Right-justified; MMDDYYYY
__________________________________________________________________________________________
25
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
The sex of the patient recorded
at admission, outpatient service,
or start of care.
R
R
Admission Date
The start date for this episode of
care. For inpatient services, this
is the date of admission. Rightjustified
R
R
13
Admission Hour
The code referring to the hour
during which the patient was
admitted for inpatient or
outpatient care. Left Justified
R
R
14
Admission Type
A code indicating the priority of
this admission/visit.
R
Not
Required
15
Source of Referral for
Admission or Visit
A code indicating the source of
the referral for this admission or
visit.
R
Not
Required
16
Discharge Hour
Code indicating the discharge
hour of the patient from
inpatient care.
R
Not
Required
17
Patient Discharge Status
A code indicating the
disposition or discharge status
of the patient at the end of the
service for the period covered
on this bill, as reported in Field
6.
R
R
11
Patient Sex
12
Admission 12 – 15
12
__________________________________________________________________________________________
26
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
Condition Codes
A code used to identify
conditions or events relating to
the bill that may affect
processing. Please see NUCC
Specifications Manual
Instructions for condition codes
and descriptions to complete
fields 18 – 28.
C
C
29
Accident State
The accident state field contains
the two-digit state abbreviation
where the accident occurred.
Required when applicable.
C
C
30
Unlabeled Field
Leave Blank.
18 - 28
31a,b –
34a,b
Occurrence Codes and Dates Enter the appropriate
occurrence code and date.
Required when applicable.
C
C
35a,b –
36a,b
Occurrence Span Codes And A code and the related dates
that identify an event that
Dates
relates to the payment of the
claim. Required when
applicable.
C
C
Reserved
C
C
C
C
37a,b
38
Leave Blank.
Responsible Party Name and The name and address of the
Address
party responsible for the bill.
__________________________________________________________________________________________
27
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
39a,b,c,d Value Codes and Amounts
–
41a,b,c,d
42
Revenue Code
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
A code structure to relate
amounts or values to identify
data elements necessary to
process this claim as qualified
by the payer organization.
Value Codes and amounts. If
more than one value code
applies, list in alphanumeric
order. Required when
applicable. Note: If value
code is populated then value
amount must also be
populated and vice versa.
Please see NUCC
Specifications Manual
Instructions for value codes and
descriptions to complete fields
39 – 41.
C
C
Codes that identify specific
accommodation, ancillary
service or unique billing
calculations or arrangements.
On the last line, enter 0001 for
the total. Refer to the Uniform
Billing Manual for a list of
revenue codes.
R
R
__________________________________________________________________________________________
28
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
43
Revenue Description
The standard abbreviated
description of the related
revenue code categories
included on this bill. See
NUBC instructions for Field 42
for description of each revenue
code category.
R
R
44
HCPCS/Accommodation
Rates
1. The Healthcare Common
Procedure Coding system
(HCPCS) applicable to
ancillary service and
outpatient bills.
R
R
2. The accommodation rate for
inpatient bills.
45
Serv. Date
Report line item dates of service
for each revenue code or
HCPCS code.
R
R
46
Serv. Units
Report units of service. A
quantitative measure of services
rendered by revenue category or
for the patient to include items
such as number of
accommodation days, miles,
pints of blood, renal dialysis
treatments, observation hours
etc.
R
R
__________________________________________________________________________________________
29
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
47
Total Charges
Total charges for the primary
payer pertaining to the related
revenue code for the current
billing period as entered in the
statement covers period. Total
charges include both covered
and non-covered charges.
Report grand total of submitted
charges at the bottom of this
field to be associated with
revenue code 001. Value
entered must be greater than
zero ($0.00).
R
R
48
Non-Covered Charges
To reflect the non-covered
charges for the destination
payer as it pertains to the related
revenue code. Required when
Medicare is Primary.
C
C
Not
required
Not
required
If there is more than one other
private payer, lump all amounts
together in Field 48 and attach
each company’s EOB or RA.
49
Unlabeled Field
__________________________________________________________________________________________
30
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
50
Payer
Enter the name for each payer
being invoiced. When the
patient has other coverage, list
the payers as indicated below.
Line A refers to the primary
payer; Line B refers to the,
secondary; and Line C refers to
the tertiary.
R
R
51
AmeriHealth DC
Identification Number
The number used by the health
plan to identify itself.
AmeriHealth DC’s Payer ID is
#77002
R
R
52
Rel. Info
Release of Information
Certification Indicator. This
field is required on Paper and
Electronic Invoices.
R
R
payer; Line B refers to the
secondary; and Line C refers to
the tertiary.
It is expected that the provider
have all necessary release
information on file. It is
expected that all released
invoices contain "Y".
53
Asg. Ben.
Assignment of Benefits
Certification Indicator is
required."
R
R
54
Prior Payments
The A, B, C indicators refer to
the information in Field 50.
C
C
__________________________________________________________________________________________
31
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
55
Est. Amount Due
Enter the estimated amount due
(the difference between “Total
Charges” and any deductions
such as other coverage).
C
C
56
National Provider Identifier
– Billing Provider
The unique NPI identification
number assigned to the provider
submitting the bill; NPI is the
national provider identifier.
Required if the health care
provider is a Covered Entity as
defined in HIPAA Regulations.
R
R
A unique identification number
assigned to the provider
submitting the bill to
AmeriHealth DC. Complete if
NPI is not mandated in Field
56. The UB-04 does not use a
qualifier to specify the type of
Other (Billing) Provider
Identifier. Use this field to
report other provider identifiers
as assigned by the health plan
listed in Field 50 A, B and C.
C
C
57 A,B,C Other (Billing) Provider
Identifier
AmeriHealth DC issued
Provider Identification
Number (strongly
recommended)
__________________________________________________________________________________________
32
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
58
Insured's Name
Information refers to the payers
listed in field 50. In most cases
this will be the patient name.
When other coverage is
available, the insured is
indicated here.
R
R
59
Patient Rel
Enter the patient’s relationship
to insured. For Medicaid
programs the patient is the
insured.
R
R
Enter the patient's Member ID
exactly as it appears on the
AmeriHealth DC Member ID
patient's AmeriHealth DC ID
Number
card on line B or C. When
other insurance is present, enter
the AmeriHealth DC Member
ID on line A.
R
R
Use this field only when a
patient has other insurance and
group coverage applies. Do not
use this field for individual
coverage.
C
C
Code 18: Self
60
Insured’s Unique Identifier
61
Group Name
payer; B, secondary; and C,
tertiary.
__________________________________________________________________________________________
33
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
Use this field only when a
patient has other insurance and
group coverage applies. Do not
use this field for individual
coverage. Line A refers to the
primary payer; B, secondary;
and C, tertiary.
Enter the AmeriHealth DC prior
authorization number. Line A
refers to the primary payer; B,
secondary; and C, tertiary. Field
63A is required.
C
C
R
R
DCN
Document Control Number.
New field. The control number
assigned to the original bill by
the health plan or the health
plan’s fiscal agent as part of
their internal control. Note:
Resubmitted claims must
contain the original claim ID.
C
C
65
Employer Name
The name of the employer that
provides health care coverage
for the insured individual
identified in field 58. Required
when the employer of the
insured is known to potentially
be involved in paying this
claim.
C
C
66
The qualifier that denotes the
Diagnosis and Procedure
Code Qualifier (ICD Version version of International
Classification of Diseases (ICD)
Indicator)
reported. A value of 9 indicates
ICD-9, a value of 0 indicates
ICD-10.
R
R
62
Insurance Group No.
63
Treatment Authorization
Codes
64
__________________________________________________________________________________________
34
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
67
Field Description
Prin. Diag. Cd. and Present
on Admission (POA)
Indicator
67 A - Q Other Diagnosis Codes
68
Unlabeled Field
69
Admitting Diagnosis Code
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
The ICD codes describing the
principal diagnosis (i.e., the
condition established after study
to be chiefly responsible for
causing the use of hospital
services that exists at the time
of services or develops
subsequently to the service that
has an effect on the length of
stay.
R
R
The ICD diagnoses codes
corresponding to all conditions
that coexist at the time of
service, that develop
subsequently, or that affect the
treatment received and/or the
length of stay. Exclude
diagnoses that relate to an
earlier episode which have no
bearing on the current hospital
service.
C
C
The ICD diagnosis code
describing the patient’s
diagnosis at the time of
admission as stated by the
physician. Required for
inpatient and outpatient
admissions.
R
R
__________________________________________________________________________________________
35
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
The ICD diagnosis codes
describing the patient’s reason
for visit at the time of outpatient
registration. Required for all
outpatient visits. Up to three
ICD codes may be entered in
fields A, B and C.
70
Patient’s Reason for Visit
71
Prospective Payment System No entry required
(PPS) Code
72a-c
73
External Cause of Injury
(ECI) Code
The ICD diagnosis codes
pertaining to external cause of
injuries, poisoning, or adverse
effect. External Cause of Injury
“E” diagnosis codes should not
be billed as primary and/or
admitting diagnosis. Required
if applicable.
Unlabeled Field
No entry required
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
C
R
C
C
C
C
__________________________________________________________________________________________
36
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
74
Field Description
Principal Procedure Code
and Date
The ICD code that identifies the
principal procedure performed
at the claim level during the
period covered by this bill and
the corresponding date.
Inpatient facility – Surgical
procedure code is required if the
operating room was used.
Other Procedure Codes and
Dates
C
75
Unlabeled Field
C
R
R
The ICD codes identifying all
significant procedures other
than the principal procedure and
the dates (identified by code) on
which the procedures were
performed.
C
Inpatient facility – Surgical
procedure code is required if the
operating room was used.
R
Outpatient facility or
Ambulatory Surgical Center –
CPT, HCPCS or ICD code is
required when a surgical
procedure is performed.
33X 83X
*
Outpatient Facility or
Ambulatory Surgical Center –
CPT, HCPCS or ICD code is
required when a surgical
procedure is performed.
74a-e
Outpatient,
Bill Types
13X, 23X,
C
R
No entry required
__________________________________________________________________________________________
37
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
Field Description
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
76
Attending Provider Name
and Identifiers
NPI#/Qualifier/Other ID#
Enter the NPI of the physician
who has primary responsibility
for the patient’s medical care or
treatment in the upper line, and
their name in the lower line, last
attending physician
name first. If the Attending
Physician has another unique
ID#, enter the appropriate
descriptive two-digit qualifier
issued Provider ID number
followed by the other ID#.
Enter the last name and first
Enter the two digit qualifier name of the Attending
that identifies the Other ID Physician.
number as the AmeriHealth
DC issued Provider ID
number
R
R
77
Operating Physician Name
and Identifiers –
Enter the NPI of the physician
who performed surgery on the
patient in the upper line, and
their name in the lower line, last
name first. If the operating
physician who performed
physician has another unique
surgery
ID#, enter the appropriate
descriptive two-digit qualifier
followed by the other ID#.
Enter the last name and first
issued Provider ID number
name of the Attending
Physician.
C
C
R
R
Enter the two digit qualifier
that identifies the Other ID
number
Required when a surgical
procedure code is listed.
__________________________________________________________________________________________
38
Inpatient,
Bill Types
11X, 12X,
18X, 21X,
22X, 32X
Field #
78 – 79
80
Field Description
Enter the NPI# of any
physician, other than the
attending physician, who has
responsibility for the patient’s
Enter the NPI number of
medical care or treatment in the
another attending physician
upper line, and their name in the
lower line, last name first. If
issued Provider ID number the other physician has another
unique ID#, enter the
Enter the two digit qualifier
that identifies the Other ID appropriate descriptive twodigit qualifier followed by the
other ID#.
number
Other Provider (Individual)
Names and Identifiers –
Remarks Field
81CC,a-d Code-Code Field
Outpatient,
Bill Types
13X, 23X,
33X 83X
*
C
C
Leave Blank
C
C
To report additional codes
related to Form Locator
(overflow) or to report
externally maintained codes
approved by the NUBC for
inclusion in the institutional
data set.
C
C
__________________________________________________________________________________________
39
Institutional Claims EDI Mapping
EDI Mapping Table (UB-04)
UB-04 Claim Form EDI Mapping
Inpatient, Bill Outpatient,
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
1
2
Field Description
Unlabeled Field
Billing Provider Name,
Address and Telephone
Number
2010AA/NM1
Submission of Taxonomy is
strongly recommended
2000A
Unlabeled Field
Billing Provider’s Designated
Pay-to Name and Address
Conditional* Conditional*
R
R
R
R
201AA/N3 & N4
2010AB/N3 & N4
3a
Patient Control No.
2300 CLM01
R
R
3b
Medical/Health Record
Number
2300/REF
C
C
R
R
Qualifier EA
4
Type Of Bill
5
Fed. Tax No.
2010AA
R
R
6
Statement Covers Period
From/Through
2300/DTP
R
R
CLM05
__________________________________________________________________________________________
40
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
Field Description
7
Unlabeled
Not in IG
NR
NR
8a
Patient Identifier
2010BA
C
C
8b
Patient Name
2010BA/NM1
2010CA/NM1 - Newborn
R
R
Patient Address
2010BA
R
R
10
Patient Birth Date
2010BA/DMG
R
R
11
Patient Sex
2010BA/DMG
R
R
12
Admission 12 – 15
12
Admission Date
2300/DTP
C
C
13
Admission Hour
2300/DTP
C
C
14
Admission Type
2300/CL1
R
Not
Required
15
Source of Referral for
Admission or Visit
2300/CL1
R
Not
Required
16
Discharge Hour (Date)
2300/DTP
R
C
17
Patient Discharge Status
2300/DTP
R
C
9a-e
__________________________________________________________________________________________
41
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
Field Description
18 - 28
Condition Codes
HIXX where HI01= BG
C
C
29
Accident State
2300/REF
C
C
30
Unlabeled Field
Not in IG
NR
NR
31a,b –
34a,b
Occurrence Codes and Dates HIXX where H101 = BH
C
C
35a,b –
36a,b
Occurrence Span Codes And HIXX where H101 = BI
Dates
C
C
Not in IG
NR
NR
Responsible Party Name and Not in IG
Address
NR
NR
HIXX where H101 = BE
C
C
37a,b
38
Reserved
39a,b,c,d Value Codes and Amounts
–
41a,b,c,d
42
Rev. Cd.
2400/SV2
R
R
43
Revenue Description
Not in IG
NR
NR
44
HCPCS/Accommodation
Rates/HIPPS Rate Codes
2400/SV2
R
R
45
Serv. Date
2400/DTP
R
R
46
Serv. Units
2400/SV2
R
R
47
Total Charges
2300/CLM0
R
R
48
Non-Covered Charges
2300/AMT01
C
C
NR
NR
COB data should be
submitted as received by
other payer
49
Unlabeled Field
Not in IG
__________________________________________________________________________________________
42
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
50
Field Description
Payer
2010BB/ref
R
R
Plan Payer ID
51
Health Plan Identification
Number
2010BB
R
R
52
Rel. Info
Not in IG
NR
NR
53
Asg. Ben.
Not in IG
NR
NR
54
Prior Payments
Not in IG
NR
NR
55
Est. Amount Due
Not in IG
NR
NR
56
National Provider Identifier
– Billing Provider
2010AA/NM1
R
R
2010BB/REF
C
C
R
R
57 A,B,C Other (Billing) Provider
Identifier
2310A/REF
QUALIFIER G2
58
Insured's Name
2010BA/NM1
2010CA/NM1 - Newborn
59
P. Rel
If 2000C/PAT01
R
R
60
Insured’s Unique Identifier
2010BA/NM1
R
R
__________________________________________________________________________________________
43
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
Field Description
61
Group Name
2000B/SBR
62
Insurance Group No.
63
64
C
C
Not in IG
NR
NR
Treatment Authorization
Codes
Not in IG
NR
NR
DCN
2300/REF02 where REF01=
F8 (Original Reference
number)
C
C
NR
NR
Not
Not
Required
Use for submission of
original claim number for
adjusted or voided claims
Not in IG
65
Employer Name
66
Use ICD code qualifiers per
Diagnosis and Procedure
Code Qualifier (ICD Version IG
Indicator)
67
Prin. Diag. Cd. and Present
on Admission (POA)
Indicator
67 A - Q Other Diagnosis Codes
2300/HIXX
Required
R
R
C
C
NR
NR
Qualifier BK
2300/HIXX
Qualifier BF
68
Unlabeled Field
Not in IG
__________________________________________________________________________________________
44
Field #
69
Field Description
Admitting Diagnosis Code
2300/HIXX
Types 11X,
Bill Types
12X, 18X,
13X, 23X,
21X, 22X,
33X 83X
32X
C
C
C
C
R
R
C
C
NR
NR
C
C
C
C
NR
NR
R
R
Qualifier BJ
70
Patient’s Reason for Visit
2300/HIXX
Qualifier PR
71
Prospective Payment System 2300/HIXX
(PPS) Code
Qualifier DR
External Cause of Injury
(ECI) Code
2300HIXX
73
Unlabeled Field
Not in IG
74
Principal Procedure code
and Date
2300/HIXX
72a-c
74a-e
Qualifier BN
Qualifier BR
Other Procedure Codes and 2300/HIXX
Dates
Qualifier BQ
75
Unlabeled Field
Not in IG
76
Attending Provider Name
and Identifiers
2310A/NM1
2310/REF
Qualifier G2
attending physician
Attending Provider is
required
__________________________________________________________________________________________
45
Types 11X,
Bill Types
12X, 18X
13X, 23X,
21X, 22X,
33X 83X
32X
Field #
77
Field Description
Operating Physician Name
and Identifiers –
2310B/NM1
C
C
2310C/NM1
C
C
2300/NTE. Can leave blank
C
C
NR
NR
physician who performed
surgery
78 – 79
Other Provider (Individual)
Names and Identifiers –
Enter the NPI number of
another attending physician
80
Remarks Field
81CC,a-d Code-Code Field
Not in IG
__________________________________________________________________________________________
46
Common Causes of Claim Processing
Delays, Rejections or Denials
Special Instructions and Examples for CMS-1500, UB-04 and
EDI (837) Claims Submissions
I. Supplemental Information
A. CMS-1500 Paper Claims – Field 24:
Important Note: All unspecified Procedure or HCPCS codes require a narrative description be reported in
the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry of 61 characters
from the beginning of 24A to the end of 24G.
The following are types of supplemental information that can be entered in the shaded lines of Item Number
24:
 Narrative description of unspecified codes
 National Drug Codes (NDC) for drugs (Only enter one NDC per EDI claim line.)
 Vendor Product Number – Health Industry Business Communications Council (HIBCC)
 Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN) formerly
Universal Product Code (UPC) for products
 Contract rate
The following qualifiers are to be used when reporting these services.
N4
Narrative description of unspecified code (all miscellaneous fields require this section be
reported)
National Drug Codes
VP
Vendor Product Number Health Industry Business Communications Council (HIBCC)
OZ
Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN)
CTR
Contract rate
ZZ
To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not
enter a space between the qualifier and the number/code/information. Do not enter hyphens or spaces
within the number/code.
More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the first
qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the
next qualifier and number/code/information.
B. EDI – Field 24D (Professional):
Details pertaining to Anesthesia Minutes, and corrected claims may be sent in Notes (NTE). Details sent in
claim level NTE that will be included in claim processing (837):
 Please include L1, L2, etc. to show line numbers related to the details. Please include these letters AFTER
those specified below:
o Anesthesia Minutes need to begin with the letters ANES followed by the specific times
o
Corrected claims need to begin with the letters RPC followed by the details of the original claim (as
per contract instructions)
o
DME Claims requiring specific instructions should begin with DME followed by specific details
__________________________________________________________________________________________
47
C. EDI – Field 33b (Professional):
Field 33b – Other ID# - Professional: 2310B loop, REF01=G2, REF02+ Plan’s Provider Network
Number. Less than 17 Digits Alphanumeric. Field is strongly suggested. Note: do not send the provider
on the 2400 loop. This loop is not used in determining the provider ID on the claim.
D. EDI – Field 45 and 51(Institutional):
Field 45 – Service Date must not be earlier than the claim statement date.
Service Line Loop 2400, DTP*472
Claim statement date Loop 2300, DTP*434
Field 51 – Health Plan ID – the number used by the health plan to identify itself. AmeriHealth DC’s
Health Plan EDI Payer ID# is 77002.
EDI – Reporting DME
DME Claims requiring specific instructions should begin with DME followed by specific details.
Example: NTE* DME AEROSOL MASK, USED W/DME NEBULIZER
Example: NTE*ADD* NO LIABILITY, PATIENT FELL AT HOME~
E. Reporting NDC on CMS-1500 and UB-04 and EDI:
1. NDC on CMS-1500
 NDC should be entered in the shaded sections of item 24A through 24G
 To enter NDC information, begin at 24A by entering the qualifier N4 and then the 11 digit NDC information
o
Do not enter a space between the qualifier and the 11 digit NDC number
o
Enter the 11 digit NDC number in the 5-4-2 format (no hyphens)
o
Do not use 99999999999 for a compound medication, bill each drug as a separate line item
with its appropriate NDC
 Enter the drug name and strength
 Enter the NDC quantity unit qualifier
o
F2 – International Unit
o
GR – Gram
o
ML – Milliliter
o
UN – Unit
 Enter the NDC quantity
o
Note: The NDC quantity is frequently different than the HCPC code quantity
__________________________________________________________________________________________
48
Example of entering the identifier N4 and the NDC number on the CMS-1500 claim form:
N4 qualifier
NDC Unit Qualifier
11 digit NDC
NDC Quantity
2. NDC on UB-04
 NDC should be entered in Form Locator 43 in the Revenue Description Field
 Report the N4 qualifier in the first two (2) positions, left-justified
o
Do not enter spaces
o
Enter the 11 character NDC number in the 5-4-2 digit format (no hyphens)
o
Do not use 99999999999 for a compound medication, bill each drug as a separate line item
with its appropriate NDC
 Immediately following the last digit of the NDC (no delimiter), enter the Unit of Measurement Qualifier
o
F2 – International Unit
o
GR – Gram
o
ML – Milliliter
o
UN – Unit
 Immediately following the Unit of Measure Qualifier, enter the unit quantity with a floating decimal for
fractional units limited to 3 digits (to the right of the decimal)
o
Any unused spaces for the quantity are left blank
Note that the decision to make all data elements left-justified was made to accommodate the largest quantity
possible. The description field on the UB-04 is 24 characters in length. An example of the methodology is
illustrated below.
N 4
1
2
3
4
5
6
7
8
9
0
1
U N 1
2
4
5
.
5
6
7
3. NDC via EDI
The NDC is used to report prescribed drugs and biologics when required by government regulation, or as
deemed by the provider to enhance claim reporting/adjudication processes.
EDI claims with NDC info should be reported in the LIN segment of Loop ID-2410. This segment is used
to specify billing/reporting for drugs provided that may be part of the service(s) described in SV2. Please
consult your EDI vendor if not submitting in X12 format for details on where to submit the NDC number to
meet this specification.
__________________________________________________________________________________________
49
When LIN02 equals N4, LIN03 contains the NDC number. This number should be 11 digits sent in the 54-2 format with no hyphens. Submit one occurrence of the LIN segment per claim line. Claims requiring
multiple NDC’s sent at claim line level should be submitted using CMS-1500 or UB-04 paper claim.
When submitting NDC in the LIN segment, the CTP segment is required with 5010 HIPAA. This segment
is to be submitted with the Unit of Measure and the Quantity.

Federal Tax ID on UB-04:
Federal Tax ID on UB-04 (Box# 5) will come from Loop 2010AA, REF02.

Condition codes
Condition codes (Box number 18 thru 29) will come from 2300 CRC01 – CRC07

Patient reason DX
Patient reason DX (Box 70) qualifier will be PR qualifier from 2300, HI01.
__________________________________________________________________________________________
50
Common Causes of Claim Processing Delays, Rejections or
Denials
Authorization Number Invalid or Missing A valid authorization
number must be included on the claim form for all services requiring
prior authorization from AmeriHealth DC.
Attending Physician ID Missing or Invalid – Inpatient claims must
include the name of the physician who has primary responsibility for
the patient's medical care or treatment, and the medical license number
on the appropriate lines in field number 76 (Attending Physician ID) of
the UB-04 claim form. A valid medical license number is formatted as
two alpha, six numeric, and one alpha character (AANNNNNNA) OR
two alpha and six numeric characters (AANNNNNN). An attending
physician is required.
Billed Charges Missing or Incomplete – A billed charge amount
must be included for each service/procedure/supply on the claim form.
Diagnosis Code Missing 4th or 5th Digit – Precise coding sequences
must be used in order to accurately complete processing. Review the
ICD-9-CM or ICD-10-CM manual for the 4th and 5th digit extensions.
Look for the th or th symbols in the coding manual to determine
when additional digits are required.
Diagnosis, Procedure or Modifier Codes Invalid or Missing Coding
from the most current coding manuals (ICD-9-CM, or ICD-10-C, CPT
or HCPCS) is required in order to accurately complete processing. All
applicable diagnosis, procedure and modifier fields must be completed.
EOBs (Explanation of Benefits) from Primary Insurers Missing or
Incomplete – A copy of the EOB from all third party insurers must be
submitted with the original claim form for paper claims. Include pages
with run dates, coding explanations and messages. AmeriHealth DC
accepts EOBs via paper or electronic format (EDI).
External Cause of Injury Codes – External Cause of Injury “E”
diagnosis codes should not be billed as primary and/or admitting
diagnosis.
Future Claim Dates – Claims submitted for Medical Supplies or
Services with future claim dates will be denied, for example, a claim
submitted on October 1 for bandages that are delivered for October 1
through October 31 will deny for all days except October 1.
Important: Include all primary and
secondary diagnosis codes on the claim.
Important: Missing or invalid data
elements or incomplete claim forms will
cause claim processing delays,
inaccurate payments, rejections or
denials.
Important: Regardless of whether
reimbursement is expected, the billed
amount of the service must be
documented on the claim. Missing
charges will result in rejections or denials.
Important: All billed codes must be
complete and valid for the time period in
which the service is rendered.
Incomplete, discontinued, or invalid
codes will result in claim rejections or
denials.
Important: State level HCPCS coding
takes precedence over national level
codes unless otherwise specified in
individual provider contracts.
Important: The services billed on the
claim form should exactly match the
services and charges detailed on the
accompanying EOB. If the EOB charges
appear different due to global coding
requirements of the primary insurer,
submit claim with the appropriate coding
which matches the total charges on the
EOB.
Important: Child HealthCheck services
may be submitted electronically or on
paper.
__________________________________________________________________________________________
51
Handwritten Claims – Completely handwritten claims will be
rejected. Legible handwritten claims are acceptable on resubmitted
claims. (See Illegible Claim Information)
Important: For claims with COB, the
adjudication date of the other payer is
required for EDI and paper claims
Highlighted Claim Fields – (See Illegible Claim Information)
Important: Submitting the original copy
of the claim form will assist in assuring
claim information is legible.
Illegible Claim Information – Information on the claim form must be
legible in order to avoid delays or inaccuracies in processing. Review
billing processes to ensure that forms are typed or printed in black ink,
that no fields are highlighted (this causes information to darken when
scanned or filmed), and that spacing and alignment are appropriate.
Handwritten information often causes delays or inaccuracies due to
reduced clarity.
Incomplete Forms – All required information must be included on the
claim forms in order to ensure prompt and accurate processing.
Member Name Missing – The name of the member must be present
on the claim form and must match the information on file with the
Plan.
Member Plan Identification Number Missing or Invalid – Enter the
patient’s Member ID exactly as it appears on the patient’s AmeriHealth
DC Member ID card. The member’s AmeriHealth DC ID must be
included on the claim form or electronic claim submitted for payment.
Newborn Claim Information Missing or Invalid – Always include
the first and last name of the mother and baby on the claim form. If the
baby has not been named, insert “Baby Girl” or “Baby Boy” in front of
the mother’s last name as the baby’s first name. Verify that the
appropriate last name is recorded for the mother and baby.
Payer or Other Insurer Information Missing or Incomplete –
Include the name, address and policy number for all insurers covering
the Plan member.
Place of Service Code Missing or Invalid – A valid and appropriate
two digit numeric code must be included on the claim form. Refer to
CMS-1500 coding manuals for a complete list of place of service
codes.
Provider Name Missing – The name of the provider of service must
be present on the claim form and must match the service provider name
and TIN on file with the Plan.
Important: The individual provider name
and NPI number as opposed to the group
NPI number must be indicated on the
claim form.
Important: Do not highlight any
information on the claim form or
accompanying documentation.
Highlighted information will become
illegible when scanned or filmed.
Important: Do not attach notes to the
face of the claim. This will obscure
information on the claim form or may
become separated from the claim prior to
scanning.
Important: Submit newborn’s facility bill
for child at the time of delivery using the
baby’s Medicaid ID. The newborn’s
Medicaid ID is to be used on well babies,
babies with extended stays (sick babies)
past the mother’s stay and on all
aftercare and professional bills. The
facility or provider should obtain the
newborn’s Medicaid ID via the eligibility
verification system operated by DHCF
before submitting the claim to
AmeriHealth DC.
Important: The claim for baby must
include the baby’s date of birth as
opposed to the mother’s date of birth.
Important: On claims for twins or other
multiple births, indicate the birth order in
the patient name field e.g. Baby Girl
Smith A, Baby Girl Smith B, etc.
Important: Date of service and billed
charges should exactly match the
services and charges detailed on the
accompanying EOB. If the EOB charges
appear different due to global coding
requirements of the primary insurer,
submit claim with the appropriate coding
which matches the total charges on the
EOB.
__________________________________________________________________________________________
52
Provider NPI Number Missing or Invalid – The individual
NPI and group NPI numbers for the service provider must be
included on the claim form.
Revenue Codes Missing or Invalid – Facility claims must
include a valid four-digit numeric revenue code. Refer to UB-04
coding manuals for a complete list of revenue codes.
Spanning Dates of Service Do Not Match the Listed
Days/Units – Span-dating is only allowed for identical services
provided on consecutive dates of service. Always enter the
corresponding number of consecutive days in the days/unit field.
Tax Identification Number (TIN) Missing or Invalid - The
Tax ID number must be present and must match the service
provider name and payment entity (vendor) on file with the Plan.
Third Party Liability (TPL) Information Missing or
Incomplete – Any information indicating a work related
illness/injury, no fault, or other liability condition must be
included on the claim form. Additionally, a copy of the primary
insurer’s explanation of benefits (EOB) or applicable
documentation must be forwarded along with the claim form.
Type of Bill – A code indicating the specific type of bill (e.g.,
hospital inpatient, outpatient, adjustments, voids, etc). The first
digit is a leading zero. Do not include the leading zero on
electronic claims.
Taxonomy –The provider’s taxonomy number is required if
needed by the plan to determine the provider’s plan ID when
using NPI only is not effective.
Important: The individual service
provider name and NPI number must be
indicated on all claims, including claims
from outpatient clinics. Using only the
group NPI or billing entity name and
number will result in rejections, denials,
or inaccurate payments.
Important: When the provider or facility
has more than one NPI number, use the
NPI number that matches the services
submitted on the claim form. Imprecise
use of NPI numbers results in inaccurate
payments or denials.
Important: When submitting
electronically, the provider NPI number
must be entered at the claim level as
opposed to the claim line level. Failure to
enter the provider NPI number at the
claim level will result in rejection. Please
review the rejection report from the EDI
software vendor each day.
Important: Claims without the provider
signature will be rejected. The provider is
responsible for re-submitting these claims
within 180 calendar days from the date of
service. See timely filing guidelines on
page 3.
Important: Claims without a tax
identification number (TIN) will be
rejected. The provider is responsible for
re-submitting these claims within 180
calendar days from the date of service.
See timely filing guidelines on page 3.
Important: Any changes in a
participating provider’s name, address,
NPI number, or tax identification
number(s) must be reported to
AmeriHealth DC immediately. Contact
Provider Services at 202-408-2237 or
888-656-2383 to assist in updating the
AmeriHealth DC record.
__________________________________________________________________________________________
53
Electronic Data Interchange (EDI) Quick Tips
Electronic Data Interchange (EDI) for Medical and Hospital
Claims
Electronic Data Interchange (EDI) allows faster, more efficient and
cost-effective claim submission for providers. EDI, performed in
accordance with nationally recognized standards, supports the health
care industry’s efforts to reduce administrative costs.
The benefits of billing electronically include:
 Reduction of overhead and administrative costs. EDI eliminates
the need for paper claim submission. It has also been proven to
reduce claim re-work (adjustments).
 Receipt of clearinghouse reports makes it easier to track the status
of claims.
 Faster transaction time for claims submitted electronically. An
EDI claim averages about 24 to 48 hours from the time it is sent
to the time it is received. This enables providers to easily track
their claims.
Important: Please allow for normal
processing time before resubmitting
the claim either through EDI or paper
claim. This will reduce the possibility
of your claim being rejected as a
duplicate claim.
Important: In order to verify satisfactory
receipt and acceptance of submitted
records, please review both the Emdeon
Acceptance report, and the R059 Plan
Claim Status Report.
Refer to the Claim Filing section for
general claim submission guidelines.
 Validation of data elements on the claim form. By the time a
claim is successfully received electronically, information needed
for processing is present. This reduces the chance of data entry
errors that occur when completing paper claim forms.
 Quicker claim completion. Claims that do not need additional
investigation are generally processed quicker. Reports have
shown that a large percentage of EDI claims are processed within
10 to 15 days of their receipt.
All the same requirements for paper claim filing apply to
electronic claim filing.
__________________________________________________________________________________________
54
Electronic Claims Submission (EDI)
The following sections describe the procedures for electronic
submission for hospital and medical claims. Included are a high
level description of claims and report process flows, information on
unique electronic billing requirements, and various electronic
submission exclusions.
Hardware/Software Requirements
There are many different products that can be used to bill
electronically. As long as you have the capability to send EDI
claims to Emdeon, whether through direct submission or through
another clearinghouse/vendor, you can submit claims electronically.
Contracting with Emdeon and Other Electronic
Vendors
If you are a provider interested in submitting claims electronically
to the Plan but do not currently have Emdeon EDI capabilities, you
can contact the Emdeon Provider Support Line at 877-363-3666.
You may also choose to contract with another EDI clearinghouse or
vendor who already has Emdeon capabilities.
Contacting the EDI Technical Support Group
Providers interested in sending claims electronically may contact
the EDI Technical Support Group for information and assistance in
beginning electronic submissions.
Important: Emdeon is the largest
clearinghouse for EDI Healthcare
transactions in the world. It has the
capability to accept electronic data
from numerous providers in several
standardized EDI formats and then
forwards accepted information to
carriers in an agreed upon format.
Important: Contact AmeriHealth DC’s
EDI Technical Support by calling 202408-2237 or 888-656-2383 and
choosing the appropriate prompts.
Or by e-mail at
[email protected]
Important: Providers using Emdeon
or other clearinghouses and vendors
are responsible for arranging to have
rejection reports forwarded to the
appropriate billing or open receivable
departments.
Important: The Payer ID for
AmeriHealth DC is 77002
NOTE: Plan payer specific edits are
described in Exhibit 99 at Emdeon.
When ready to proceed:
 Read over the instructions within this booklet carefully, paying
special attention to the information on exclusions, limitations, and
especially, the rejection notification reports.
 Contact your EDI software vendor and/or Emdeon to inform them
you wish to initiate electronic submissions to the Plan.
 Be prepared to inform the vendor of the Plan’s electronic payer
identification number.
__________________________________________________________________________________________
55
Specific Data Record Requirements
Claims transmitted electronically must contain all the same data
elements identified within the EDI Claim Filing sections of this
booklet. EDI guidance for Professional Medical Services claims
can be found beginning on page 13. EDI guidance for Facility
Claims can be found beginning on page 36. Emdeon or any other
EDI clearing-house or vendor may require additional data record
requirements.
Electronic Claim Flow Description
In order to send claims electronically to the Plan, all EDI claims
must first be forwarded to Emdeon. This can be completed via a
direct submission or through another EDI clearinghouse or vendor.
Once Emdeon receives the transmitted claims, the claim is validated
for HIPAA compliance and the Plan’s Payer Edits as described in
Exhibit 99 at Emdeon. Claims not meeting the requirements are
immediately rejected and sent back to the sender via an Emdeon
error report. The name of this report can vary based upon the
provider’s contract with their intermediate EDI vendor or Emdeon.
Accepted claims are passed to the Plan, and Emdeon returns an
acceptance report to the sender immediately.
Claims forwarded to the Plan by Emdeon are immediately validated
against provider and member eligibility records. Claims that do not
meet this requirement are rejected and sent back to Emdeon, which
also forwards this rejection to its trading partner – the intermediate
EDI vendor or provider. Claims passing eligibility requirements are
accepted for claims processing. Claims are not considered as
received under timely filing guidelines if rejected for missing or
invalid provider or member data.
Important: Rejected electronic claims
may be resubmitted electronically
once the error has been corrected.
Important: Emdeon will produce an
Acceptance report * and a R059 Plan
Claim Status Report** for its trading
partner whether that is the EDI vendor
or provider. Providers using Emdeon
or other clearinghouses and vendors
are responsible for arranging to have
these reports forwarded to the
appropriate billing or open receivable
departments.
* An Acceptance report verifies
acceptance of each claim at Emdeon.
** A R059 Plan Claim Status Report is
a list of claims that passed Emdeon’s
validation edits. However, when the
claims were submitted to the Plan,
they encountered provider or member
eligibility edits.
Important: Claims are not
considered as received under timely
filing guidelines if rejected for missing
or invalid provider or member data.
Timely filing Note: Your claims must
be received by the EDI vendor by 9:00
p.m. in order to be transmitted to the
Plan the next business day.
Providers are responsible for verification of EDI claims receipts.
Acknowledgements for accepted or rejected claims received from
Emdeon or other contracted EDI software vendors, must be
reviewed and validated against transmittal records daily.
Because Emdeon returns acceptance reports directly to the sender,
submitted claims not accepted by Emdeon are not transmitted to the
Plan.
 If you would like assistance in resolving submission issues
reflected on either the Acceptance or R059 Plan Claim Status
reports, contact the Emdeon Provider Support Line at 1-800-8456592.
 If you need assistance in resolving submission issues identified on
the R059 Plan Claim Status report, contact the AmeriHealth DC
EDI Technical Support Hotline by calling 202-408-2237 or 888656-2383 and selecting the appropriate prompts or by e-mail at
[email protected]
__________________________________________________________________________________________
56
Invalid Electronic Claim Record Rejections/Denials
All claim records sent to the Plan must first pass Emdeon HIPAA
edits and Plan specific edits prior to acceptance. Claim records that
do not pass these edits are invalid and will be rejected without being
recognized as received at the Plan. In these cases, the claim must be
corrected and re-submitted within the required filing deadline of 180
calendar days from the date of service. It is important that you
review the Acceptance or R059 Plan Claim Status reports received
from Emdeon or your EDI software vendor in order to identify and
re-submit these claims accurately.
Plan Specific Electronic Edit Requirements
The Plan currently has specific edits and guidelines for professional
and institutional claims sent electronically:
 Member Number must be less than 17 AN
 Statement date must be not be earlier than the date of
service
 Plan Provider ID is strongly encouraged
 Taxonomy ID is strongly encouraged
 Claim line may be zero for encounters
 Release of Information permits a Y or I
 Only one NDC number is permitted per claim line
 Claims for dates of service prior to May 1, 2013 will be
rejected for incorrect payer ID.
Exclusions
Certain claims are excluded from electronic billing. These
exclusions fall into two groups:
These exclusions apply to inpatient and outpatient claim types.
Important: Requests for adjustments
may be submitted electronically, on
paper or by telephone.
By Telephone:
Provider Claim Services
202-408-2237 or 888-656-2383
(Select the appropriate prompts.)
On Paper:
If you prefer to write, please be sure
to stamp each claim submitted
“corrected” or “resubmission” and
address the letter to the appropriate
claims address as listed on page 2.
Important: Contact Emdeon Provider
Support Line at 1-800-845-6592
Important: Claims submitted can only
be verified using the Accept and/or
Reject Reports. Contact your EDI
software vendor or Emdeon to verify
you receive the reports necessary to
obtain this information.
Important: When you receive the
Rejection report from Emdeon or your
EDI vendor, the plan does not receive
a record of the rejected claim.
Important: Plan expects claims to
be submitted for the subscriber,
including newborns. The use of the
2010CA loop should be limited.
Excluded Claim Categories At this time, these claim records
must be submitted on paper.
Claim records requiring supportive documentation.
Claim records for medical, administrative or claim appeals.
Excluded Provider Categories Claims issued on behalf of
the following providers must be submitted on paper.
Providers not transmitting through Emdeon or providers
sending to Vendors that are not transmitting (through
Emdeon) NCPDP Claims
__________________________________________________________________________________________
57
Electronic Submission of Coordination of Benefits
(COB) Claims
COB data may be submitted via the 837 claim transactions. The
claim must be adjudicated prior to submission to the plan(s), and the
claim must contain payment details from the other carrier(s).
COB information should be submitted to AmeriHealth DC as it was
received from the other payer. If received at the line level, please
submit the claim’s COB information at line level. If received at
claim level, please submit the claim’s COB information at claim
level. As an example, 837P COB claims are typically at the line
level and 837I COB claims are typically at claim level.
COB data must include the adjudication data from the other payer.
AmeriHealth DC should not to be included as another payer for
COB data.
__________________________________________________________________________________________
58
Common Rejections
Resubmitting Professional Corrected Claims
Providers using electronic data interchange (EDI) can submit
“professional” corrected claims electronically rather than via paper
to AmeriHealth DC. Please send the correct identifier on the CLM
segment (CLM05-3 of 6, 7, or 8) and include the previous claim
number in the 2300 loop, REF segment, using the F8 qualifier. You
may also send the claim number in the claim level notes segment
(2300n loop, NTE segment, ADD qualifier. RPC must be the first 3
characters of the NTE02 element).
Remember to:
 Use frequency code “6” for replacement of a prior claim or
frequency code “7” for adjustment of prior claims utilizing bill
type in loop 2300, CLM05-03 (837P)
 Include the original claim number in Loop 2300, segment
REF01=F8 and REF02=the original claim number; no dashes
or spaces
 Do include the Plan’s claim number in order to submit your
claim with the 6 or 7
 Do use this indicator for claims that were previously processed
(approved or denied)
 Do not use this indicator for claims that contained errors and
were not processed (rejected upfront)
 Do not submit corrected claims electronically and via paper at
the same time
For more information, please contact the AmeriHealth DC EDI
Hotline by calling 202-408-2237 or 888-656-2383 and selecting the
appropriate prompts or by emailing to:
[email protected].
Common Rejections
Invalid Electronic Claim Records – Common Rejections
from Emdeon
Claims with missing or invalid batch level records
Claim records with missing or invalid required fields
Claim records with invalid (unlisted, discontinued, etc.) codes
(CPT-4, HCPCS, ICD-9 or ICD-10, etc.)
Claims without member numbers
Important: Claims originally
rejected for missing or invalid data
elements must be corrected and
re-submitted within 180 calendar
days from the date of service.
Rejected claims are not registered
as received in the claim processing
system. (Refer to the definitions of
rejected and denied claims on
page 1 and to the timely filing
guidelines on page 3.)
Important: Before resubmitting
claims, check the status of your
submitted claims by calling
Provider Services or inquiring
online at www.amerihealthdc.com.
Important: Corrected Professional
Claims may be sent in on paper via
the CMS-1500 form or via EDI
submission.
If sending paper, please stamp
each claim submitted “corrected” or
“resubmission” and send all
corrected or resubmitted claims to
the appropriate mailing address as
listed on page 2.
Important: Corrected Institutional
and Professional claims may be
resubmitted electronically using the
appropriate bill type to indicate that
it is a corrected claim. Adjusted
claims must be identified in the bill
type.
Invalid Electronic Claim Records – Common Rejections
from the Plan (EDI Edits within the Claim System)
Claims received with invalid provider numbers
Claims received with invalid member numbers
Claims received with invalid member date of birth
o
__________________________________________________________________________________________
59
Common Rejections
Common Rejections, continued
NPI Processing – The Plan’s Provider Number is determined from
the NPI number using the following criteria:
1. Plan ID, Tax ID and NPI number
2. If no single match is found, the Service Location’s ZIP code
is used
3. If no service location is include, the billing address ZIP
code will be used
4. If no single match is found, the Taxonomy is used
5. If no single match is found, the claim is researched to
determine the appropriate Plan Provider Number to use for
claims processing.
6. If a Plan Provider ID is sent using the G2 qualifier, it is
used as the provider on the claim. The legacy Plan ID is
used as the primary ID on the claim
7. If you have submitted a claim, and you have not received a
rejection report, but are unable to locate your claim via
online inquiry, it is possible that your claim is in review by
AmeriHealth DC. Please check with provider services and
update you NPI data as needed. It is essential that the
service location of the claim match the NPI information sent
on the claim in order to have your claim processed
effectively.
Important: If you have not
received a rejection for a claim,
and the claim is not available via
claim status inquiry, please
contact Provider Services
(Claims Unit). Resolution of the
NPI data may be needed in order
to avoid claim denials for invalid
provider.
Contact the Emdeon Provider
Support Line at: 1-800-845-6592
Contact AmeriHealth DC EDI
Technical Support by calling:
202-408-2237 or 888-656-2383
(and selecting the appropriate
prompts)
Important: Provider NPI number
validation is not performed at
Emdeon. Emdeon will reject claims
for provider NPI only if the provider
number fields are empty.
Important: The Plan’s Provider ID
is recommended as follows:
837P – Loop 2310B, REF*G2[PIN]
837I – Loop 2310A, REF*G2[PIN]
__________________________________________________________________________________________
60
Appendix
Supplemental Information
Allergy Testing/Immunotherapy
AmeriHealth DC reimburses complete service codes that allow for combined billing of preparation and
injection. Provision of allergen preparation and injection services may be reimbursed together.
Evaluation and management visit codes may be reimbursed in addition to allergen immunotherapy only if
other identifiable services are provided and documented during the same visit.
Preparation of single dose vials, procedure code 95144, may be reimbursed only when an allergist is preparing
extract to be injected by another physician. Preparation of a multiple dose vial may be reimbursed only once
per treatment cycle using procedure codes 95145-95170.
Ambulatory Surgical Centers
Ambulatory Surgical Centers (ASC) are required to bill on CMS-1500 or 837 Format.
Multiple surgery deduction is paid at 100% of payment group rate for the primary procedure on line one,
50% of the payment group for the secondary procedure on line 2, 25% of the tertiary procedure on line 3,
25% for all subsequent procedures.
Medicaid payment for a single bilateral procedure in one day is 150 percent of the payment group rate. It is
billed on line 1 of the claim using modifier 50.
Anesthesia
Anesthesia claims must be submitted via the CMS-1500 or electronic equivalent with the following
information in each line or loop:
 Item 24D/Loop 2400 – report the appropriate ASA procedure code and modifier (if applicable).
 Item 24F/Loop 2300 – report the actual charged amount.
 Item 24G/Loop 2400 – report the actual total anesthesia time in minutes.
 Fifteen (15) minute time increments will be used by the claims payment system to determine the
payment from the actual total anesthesia time in minutes, as reported in 24G/Loop 2400.
Behavioral Health
Behavioral health providers will follow the same claim submission procedures as medical health care
providers.
__________________________________________________________________________________________
61
Appendix
Chemotherapy
Effective July 1, 2013, AmeriHealth DC will require oncology providers to obtain prior authorization for
chemo and/or any other specialty drugs, including injectables, from PerformRx via the process described
below.
1. Select the appropriate prior authorization form, available online at www.amerihealthdc.com. [Hint:
Click Providers at the top of the page and then click Forms on the left. Look for the specialty prior
authorization forms under the heading “Pharmacy Authorization Forms.”]
2. Complete the appropriate form and fax to PerformRx at 855-811-9332.
3. Upon approval by PerformRx, the requested drug will be shipped to your practice within 48 hours.
Please indicate the appropriate mailing address on the prior authorization form at the time of your
request.
4. You may choose to either:
o Use your private stock and replace it with the shipment from PerformRx; OR,
o Schedule services around the delivery of the shipment from PerformRx.
Child HealthCheck (EPSDT) Services
All AmeriHealth District of Columbia PCPs are responsible to provide HealthCheck services to members
from birth to age 21, according to the DC Medicaid HealthCheck Periodicity Schedule and the DC
Medicaid Dental Periodicity Schedule. View the most recent Periodicity Schedules at
www.dchealthcheck.net.
Specific billing guidance for screenings is provided below. For additional information, please see
“Immunizations,” “Well Child Visits” and “Weight Assessment and Counseling for Nutritional and
Physical Activity.”
Procedure Code(s)
Service
99381
Initial Med Screen < age 1
99382
Initial Med Screen age 1 to 5
99383
99384
99385
99391
Periodic Med Screen < age 1
99392
Periodic Med Screen age 1 to 5
99393
99394
__________________________________________________________________________________________
62
Appendix
99395
83655
Lead Screening in Children
Dental Claims (DentaQuest)
DentaQuest is the delegated manager of dental services covered by AmeriHealth DC. Please visit
www.dentaquest.com for more information about how to bill for these services or contact their Provider
Services department at 800-341-8478.
Diabetes
Please refer to the 2013 HEDIS guidelines provided at the back of this document.
Durable Medical Equipment
Claims for durable medical equipment will be submitted via the same claim submission procedures as other
medical services.
Family Planning
Submit claims via CMS-1500, UB-04 or via 837 electronic format.
AmeriHealth DC members may access family planning services through any family planning clinic or
provider without a referral. Some services may require prior authorization. Certain services such as
sterilizations and hysterectomy require the submission of a consent form with the claim.
Family Planning (non-obstetric)






Only one initial family planning visit per recipient per birth center can be reimbursed.
Training on use of natural family planning methods is not reimbursable.
Insertion or removal of Norplant is reimbursable in addition to a family planning initial or annual visit
or an evaluation and management visit if all components of an evaluation and management visit are met
and documented in addition to the Norplant services.
Insertion of an IUD is reimbursable in addition to a family planning initial or annual visit or an
evaluation and management visit if all components of an evaluation and management visit are met and
documented in addition to the IUD service.
Reimbursement for the IUD device is covered using the appropriate J-code or HCPCS procedure code,
including J7300, J7302, J7306, and J7307. Procedure code 99070 is not an appropriate code and cannot
be reimbursed for an IUD.
Removal of an IUD is reimbursable when performed as a separate procedure. No visits can be
reimbursed on the same day to the same provider.
__________________________________________________________________________________________
63
Appendix

Family planning procedure codes are not reimbursable on the same date of service to the same recipient
with any evaluation and management procedure codes.
Immunizations
Injectable Drugs
All specialty drugs and injectables currently require prior authorization from PerformRx via the process
described below:
1. Select the appropriate prior authorization form, available online at www.amerihealthdc.com. [Hint:
Click Providers at the top of the page and then click Forms on the left. Look for the specialty prior
authorization forms under the heading “Pharmacy Authorization Forms.”]
2. Complete the appropriate form and fax to PerformRx at 855-811-9332.
3. Upon approval by PerformRx, the requested drug will be shipped to your practice within 48 hours.
Please indicate the appropriate mailing address on the prior authorization form at the time of your
request.
4. You may choose to either:
o Use your private stock and replace it with the shipment from PerformRx; OR,
o Schedule services around the delivery of the shipment from PerformRx.
Injectable medications are reimbursed by billing the appropriate A, J, Q, S or HCPCS procedure code when
a provider purchases and administers the medication in the office. Providers must enter the National Drug
Code (NDC) on the claim when billing for any injectable medication.
All drugs billed are required to be submitted with NDC information and may be submitted via CMS-1500
or 837 electronic format. Refer to NDC instructions in Supplemental Information section on page 47.
The NDC number and the HCPCS code for drug products are required on both the 837 format and the
CMS-1500 for reimbursable medications. Claims submitted without NDC information and a valid HCPCS
code will be denied.
Maternity
Conditions related to the prenatal period must be billed as prenatal visits. Services provided during the
pregnancy that are not related to the pregnancy diagnosis code may be billed as evaluation and management
visits with the appropriate non-pregnancy diagnosis code. Prenatal hospital visits in the obstetrical unit for a
length of stay less than 24 hours are billed with the appropriate evaluation and management observation
codes. The Prenatal Risk Screening should be offered at the first prenatal visit. The prenatal visit that
includes completion of the Prenatal Risk Screening is reimbursed once per pregnancy by billing procedure
code H1001, add modifier TG if the screening is completed during the first trimester.
__________________________________________________________________________________________
64
Appendix
Prenatal visits must be billed using H1001 or other acceptable codes. Venipuncture, specimen handling and
transportation, urinalysis and H&H are included in the prenatal visit reimbursement To prevent
inappropriate claim denials, providers are advised to bill prenatal visits as they occur.
Maternity Birthing Center (obstetric)
The procedure code is H1000. Manual or automated urine, hemoglobin and hematocrit tests performed as
part of an evaluation and management visit are not reimbursed in addition to the evaluation and
management visit. The provider may not bill for them as separate procedures. Conditions related to the
prenatal period must be billed as prenatal visits. Services provided during the pregnancy that are not related
to the pregnancy diagnosis code may be billed as evaluation and management visits with the appropriate
non-pregnancy diagnosis code. To prevent inappropriate claim denials, providers are advised to bill prenatal
visits as they occur. The Prenatal Risk Screening should be offered at the first prenatal visit. The prenatal
visit that includes completion of the Prenatal Risk Screening is reimbursed once per pregnancy by billing
procedure code H1001, add modifier TG if the screening is completed during the first trimester. H1001 is
included in the total number of prenatal visits. Do not bill H1001 with a modifier 22. This is not a valid
modifier for this code.
Maternity Delivery
Delivery procedure codes 59410, 59515, 59614, and 59622 include immediate postpartum services within
the delivery hospitalization. Deliveries of less than 20 full weeks gestation are billed using procedure codes
59820 or 59821, not a delivery procedure code. When there is a vaginal delivery followed by a cesarean
section, the provider must bill both the procedure code for the vaginal delivery and the procedure code for
the cesarean section with a modifier 22 on the same claim form.
Maternity Fetal Bio-Physical Profile
If more than two biophysical profiles are required, the additional biophysical profiles must be billed with a
modifier 22. A report must be submitted with the claim that documents the medical necessity for the
biophysical profile and the result of each component. Without all of these components and proper
documentation, the claim will be denied.
Outpatient Hospital Services
For each outpatient hospital services, AmeriHealth DC will reimburse according to the individual provider
contract rates. As a reminder, members should be referred to LabCorp for outpatient lab services. For more
information on LabCorp, please visit www.labcorp.com or call 888-LABCORP.
Pain Management
Please note, anesthesiologists must also be credentialed to provide pain management services to members of
AmeriHealth DC.
__________________________________________________________________________________________
65
Appendix
Routine postoperative pain management, except for continuous epidural, is not reimbursable to the
anesthesiologist. Pain management by epidural catheter on the days after the catheter insertion for
obstetrical anesthesia may be reimbursed using procedure code 01996 with no time increments.
Pharmacy Coverage (PerformRx)
PerformRx is the delegated manager of pharmacy services covered by AmeriHealth DC for Medicaid
members. For more information on the provision of pharmacy services, including our formulary, specialty
and oral prior authorization forms, and pharmacy directory, please visit the provider area of our website at
www.amerihealthdc.com. With the exception of oncology, specialty items are drop shipped via our
specialty pharmacy program. For questions regarding pharmacy services or to submit a prior authorization
request, contact PerformRx at:


Provider Services (Medicaid): 888-602-3741
Prior Authorization Fax: 855-811-9332
Pharmacy services for AmeriHealth DC Alliance members are covered directly by the Department of
Health Care Finance (DHCF) and fulfilled by its designated pharmacy network. The Alliance formulary and
list of participating pharmacies may also be found on the provider area of our website at
www.amerihealthdc.com. AmeriHealth DC will cover an emergency supply for Alliance members only
when the pharmacies in their designated network are closed or the member is out of the network area. For
questions regarding pharmacy services for Alliance members, contact PerformRx at:

Provider Services (Alliance): 888-987-5821
Physical/Occupational and Speech Therapies
Therapy services may be billed on a UB-04 or CMS-1500 claim form or via 837 electronic format.
Transplants
AmeriHealth DC covers pre-transplant work-ups, including evaluations, and post-transplant services after
discharge from the transplant-related admission. The transplant and related inpatient services are covered by
the District’s fee-for-service Medicaid program and must be billed to DC Medicaid.
Vision Care Exams
Medicaid does not reimburse both an evaluation and management visit and a general ophthalmological visit
on the same day for the same member without a referral for the general ophthalmological visit. As a
reminder, vision care is not a covered benefit for Alliance members.
__________________________________________________________________________________________
66
Appendix
Vision Claims (eyeQuest)
EyeQuest is the delegated manager of vision services covered by AmeriHealth DC. Please visit www.eyequest.com for more information about how to bill for these services. Or contact their Provider Services
department at 800-341-8478.
Weight Assessment and Counseling for Nutritional and Physical Activity
(Child/Adolescent)
Well Child Visits
Women’s Preventive Health Services
__________________________________________________________________________________________
67
Appendix
Electronic Billing Inquiries
Please direct inquiries as follows:
Action
Contact
If you would like to transmit claims
electronically…
Contact Emdeon at:
877-363-3666
If you have general EDI questions …
Contact AmeriHealth DC EDI Technical Support
by calling:
202-408-2237 or 888-656-2383 and selecting the
appropriate prompts
or by emailing:
[email protected]
If you have questions about specific
claims transmissions or acceptance and
R059 - Claim Status reports…
Contact your EDI Software Vendor or call the
Emdeon Provider Support Line at 866-496-2722
If you have questions about your R059 –
Plan Claim Status (receipt or completion
dates)…
Contact Provider Claim Services by calling 202408-2237 or 888-656-2383 and selecting the
appropriate prompts
If you have questions about claims that are
reported on the Remittance Advice….
Contact Provider Claim Services 202-408-2237 or
888-656-2383 and selecting the appropriate
prompts
If you need to know your provider NPI
number…
Contact Provider Services at: 202-408-2237 or
888-656-2383
If you would like to update provider,
payee, NPI, UPIN, tax ID number or
payment address information…
For questions about changing or verifying
provider information…
Please Contact Provider Services:
By Fax: 202-408-1277
By Telephone: 202-408-2237
or toll-free at 888-656-2383
If you would like information on the 835
Remittance Advice…
Contact your EDI Vendor or call Emdeon at 877363-3666
Check the status of your claim…
Review the status of your submitted claims by
calling Provider Services or online at
Sign up for Electronic Funds Transfer
Contact Emdeon at 866-506-2830, Option 1
__________________________________________________________________________________________
68
Appendix
2013 HEDIS Billing Guidelines
Please note, the following information is reprinted with permission from the HEDIS 2013, Volume 2: Technical
Specifications for Health Plans by the National Committee for Quality Assurance (NCQA). HEDIS® is a registered
trademark of the National Committee for Quality Assurance (NCQA). To purchase copies of this publication, contact
NCQA Customer Support at 888-275-7585 or www.ncqa.org/publications.
EFFECTIVENESS OF CARE AND PREVENTION
Measure/Coding Directions
Adult BMI Assessment (ABA)
(Code the visit+ BMI code)
Requirement
CPT
Outpatient Visits
99201-99205, 99211-99215, 99217-99220, 9924199245 99341-99345, 99347-99350, 99385-99387,
99395-99397, 99401
BMI
UB Revenue
051x, 0520-0523, 0526-0529,
0982, 0983
V85.0-V85.5
Requirement
Weight Assessment and Counseling
for Nutrition and Physical Activity for
Children/Adolescents
(Code the visit+each appropriate
component)
Outpatient Visits-(Must be
with a PMP or OBGYN)
CPT
BMI percentile
Counseling for Nutrition
ICD-9-CM Diag/Proc
99201-99205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 99381-99387,
99391-99397, 99401
V85.5x (use as
secondary or greater
diagnosis code)
V65.3 (use as
97802-97804
diagnosis code)
V65.41 (use as
diagnosis code)
Counseling for physical
activity
Childhood Immunization Status
(CIS)
When coding E&M and vaccine
administration services on the same
date you must append modifier 25
to E&M code effective 01/01/2013
ICD-9-CM Diag/Proc
Requirement
CPT
ICD-9-CM Diag/Proc
Dtap
90698, 90700, 90721,
90723
99.39
IPV
90698, 90713, 90723
99.41
MMR
90707, 90710
99.48
Measles and Rubella
90708
Measles
90705
Mumps
90704
Rubella
90706
HiB
90645-90648, 90698,
90721, 90748
Hepatitis B
90723, 90740, 90744,
90747, 90748
070.2, 070.3, V02.61
VZV
90710, 90716
052, 053
Pneumococcal conjugate
90669
HCPCS
UB
Revenue
051x,
0520-0523,
0526-0529,
0982, 0983
S9470, S9452,
S9449
S9451
__________________________________________________________________________________________
* Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the
service provided. Refer to the NUCC or NUBC Reference Manuals for additional information
69
Appendix
Immunizations for Adolescents
(IMA)
When coding E&M and vaccine
administration services on the same
date you must append modifier 25
to E&M code effective 01/01/2013.
Hepatitis A
90633
070.0, 070.1
Rotavirus (2 doses)
90681
Rotavirus (3 doses)
90680
Influenza
90655, 90657, 90661,
90662
Meningococcal
90733, 90734
Tdap
90715
Td
90714, 90718
Tetanus
90703
99.38
Diphtheria
90719
99.36
99.52
99.39
Human Papillomavirus Vaccine for
Female Adolescents
HPV
09649, 09650
When coding E&M and vaccine administration services
on the same date you must append modifier 25 to E&M
code effective 01/01/2013.
Requirement
CPT
HCPCS
UB Revenue
Breast Cancer Screening (BCS)
Mammography
77055-77057
G0202, G0204, G0206
0401, 0403
Cervical Cancer Screening
88141-88143, 88147,
88148, 88150, 8815288155, 88164-88167,
88174, 88175
G0123, G0124,
G0141, G0143,
G0147, G0148, Q0091
923
Chlamydia testing
87110, 87270, 87320,
87490-87492, 87810
Requirement
CPT
LOINC
Lead Tests
83655
5671-3, 5674-7, 10368-9, 10912-4, 14807-2, 17052-2,
25459-9, 27129-6, 32325-3
Requirement
CPT
ICD-9-CM Diag
UB Revenue
Outpatient
99201-99205, 9921199215, 99217-99220,
99241-99245, 9938299385, 99392-99395,
99401-99404, 99411,
99412, 99420, 99429
462, 463, 034.0
051x, 0520-0523, 0526-0529,
0982, 0983
ICD-9-CM Diag/Proc
UB Revenue
460, 465
051x, 0520-0523, 0526-0529,
0982, 0983
466
051x, 0520-0523, 0526-0529,
0982, 0983
Cervical Cancer Screening
Chlamydia Screening in Women
(CHL)
Lead Screening for Children (LSC)
Appropriate Testing for Children
with Pharyngitis
Appropriate Treatment for Children
with Upper Respiratory Infection
(URI)
(Code the visit+URI associated
diagnosis)
Requirement
Outpatient Visits
CPT
99201-99205, 9921199215, 99217-99220,
99241-99245, 9938199385, 99391-99395,
99401-99404, 99411,
99412, 99420, 99429
Outpatient Visits
99201-99205, 9921199215, 99217-99220,
99241-99245, 99385,
99386, 99395, 99396,
99401-99404, 99411,
99412, 99420, 99429
Avoidance of Antibiotic Treatment in
Adults with Acute Bronchitis (AAB)(Code the visit + bronchitis
associated diagnosis)
__________________________________________________________________________________________
70
Appendix
Use of Spirometry Testing in the
Assessment and Diagnosis of COPD
(SPR)
(Code the visit + COPD associated
diagnosis)
Spirometry Testing
94010, 94014-94016,
94060, 94070, 94375,
94620
491, 492, 493.2, 496
051x, 0520-0523, 0526-0529,
0982, 0983
Outpatient Visits
99201-99205, 9921199215, 99217-99220,
99241-99245, 9934199345, 99347-99350,
99382-99386, 9939299396, 99401-99404,
99411, 99412, 99420,
99429
493.0, 493.1, 493.8,
493.9
051x, 0520-0523, 0526-0529,
0982, 0983
Use of Appropriate Medication for
People with Asthma(ASM)
(Code the visit + asthma associated
diagnosis)
Controlling High Blood Pressure
(CBP)
(Code the visit + hypertension
associated diagnosis)
Cholesterol Management for
Patients with Cardiovascular
Conditions (CMC)
(Code the visit + each appropriate
component)
Requirement
ICD-9-CM Diag/Proc
Hypertension
401
Requirement
CPT
Outpatient Visits
99201-99205, 99211-99215, 99241-99245, 99384-99387, 99394-99397
Requirement
CPT
PCI
ICD-9-CM Diag/Proc
00.66, 36.06, 36.07
92980, 92982, 92995
411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434,
440.1, 440.2, 440.4, 444, 445
IVD
Requirement
CPT/CPT Category II
LOINC
LDL Screening
80061, 83700, 83701,
83704, 83721, 3048F,
3049F, 3050F
2089-1, 12773-8, 1357-7, 18261-8, 18262-6, 22748-8,
55440-2, 39469-2, 49132-4, 69419-0
Requirement
CPT
UB Revenue
Outpatient
99201-99205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 99384-99387,
99394-99397, 99401-99404, 99411, 99412, 99420,
99429, 99455, 99456
051x, 0520-0523, 0526-0529,
0982, 0983
EFFECTIVENESS OF CARE-DIABETES
Comprehensive Diabetes Care (CDC)
(Code the visit + diabetes
diagnosis+appropriate component)
Requirement
ICD-9-CM Diag/Proc
Diabetes
250, 357.2, 362.0, 366.41, 648.0
Requirement
CPT
UB Revenue
Outpatient Visits
99201-99205, 99211-99215, 99217-99220, 9924199245, 99341-99345, 99347-99350, 99384-99387,
99394-99397, 99401-99404, 99411, 99412, 99420,
99429, 99455, 99456
051x, 0520-0523, 0526-0529,
0982, 0983
__________________________________________________________________________________________
71
Appendix
Requirement
CPT/CPT Category II
LOINC
A1C test
83036, 83037, 3044F, 3045F, 3046F
LDL-C screening
80061, 83700, 83701, 83704, 83721, 3048F, 3049F,
3050F
4548-4, 4549-2, 17856-6,
59261-8, 62388-4, 71875-9
2089-1, 12773-8, 13457-7,
18261-818262-6, 22748-8,
39469-2, 49132-4, 55440-2,
69419-0
Nephrophathy screening
test
82042, 82043, 82044, 84156, 3060F, 3061F
USE OF SERVICES-When coding E&M and vaccine administration services on the same date you must append modifier 25 to E&M code effective 01/01/2013.
Requirement
CPT
ICD-9-CM Diag/Proc
Well-Child Visits in the First 15
Months of Life (W15)
Well-Child Visit
99381, 99382, 99391,
99392, 99461
V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Well-Child Visits in the Third, Fourth,
Fifth, and Sixth Years of Life (W34)
Well-Child Visit
99382, 99383, 99392,
99393
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Adolescent Well-Care Visits (AWC)
Well-Child Visit
99383-99385, 9939399395
V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
ACCESS-AVAILABILITY OF CARE
Prenatal and Postpartum Care
(PPC)
(One of these four options has to
occur)
Frequency of Prenatal Care (FPC)
(One of these four options has to
occur)
Option 1: Any prenatal care visit to an OB practitioner, a midwife or family practitioner or other PMP with
documentation of when prenatal care was initiated.
Option 2: Any visit to an OB practitioner or midwife with one of the following:
•Obstetric panel •Rubella antibody/titer with Rh incompatibility (ABO/Rh blood typing) •TORCH antibody panel
•Ultrasound (echocardiography) of pregnant uterus •Pregnancy-related diagnosis code
Option 3: Any visit to a family practitioner or other PMP with a pregnancy-related ICD-9 CM diagnosis code AND one of
the following:
•Obstetric panel •Rubella antibody/titer with Rh incompatibility (ABO/Rh blood typing) •TORCH antibody panel
•Ultrasound (echocardiography) of pregnant uterus
When using a visit to a family practitioner or other PMP, it is necessary to determine that prenatal care was rendered
and the member was not merely diagnosed as pregnant and referred to another practitioner for prenatal care.
Option 4: Any visit to a family practitioner or other PMP with diagnosis-based evidence of prenatal care in the form of
a documented LMP or EDD with a completed obstetric history or risk assessment and counseling/education
Postpartum Care (PPC)
Postpartum visit to an OB/GYN practitioner or midwife, family practitioner, or other PMP on or between 21 and 56
days after delivery. Documentation in the medical record must include a note indicating the date when a postpartum
visit occurred and one of the following.
• Pelvic exam, or
• Evaluation of weight, BP, breasts and abdomen, or
– Notation of “breastfeeding” is acceptable for the “evaluation of breasts” component.
• Notation of postpartum care, including, but not limited to:
– Notation of “postpartum care,” “PP care,” “PP check,” “6-week check.”
– A preprinted “Postpartum Care” form in which information was documented during the visit.
__________________________________________________________________________________________
72

Provider Claims and Billing Manual Version Two Publication Date: July 2014

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