Section 2: Claim Submission and Reimbursement

CLAIMS RESOLUTION UNIT

For help with a claims issue, contact our Claims Resolution Unit at 1-888-566-0008 (select the claims resolution option). Staff in the Claims Resolution Unit answers and/or returns provider calls from 8:30 a.m. to 5:00 p.m., Monday through Friday (except holidays).

Note regarding Behavioral Health Services: The Plan contracts with Beacon Health Strategies to manage the Plan’s behavioral health program. Please direct all questions regarding claims submission for behavioral health services to Beacon Health Strategies at Beaconhealthstrategies.com or call Beacon at 1-866-444-5155. See section 5 of this provider manual for further information.

Contract issues should be directed to your designated provider relations representative.

2.1 Overview

The Plan is committed to reimbursing you quickly for covered services provided to our members. Prompt, successful claims processing and payment depends on both the Plan and you.

Here are some of the ways we work collaboratively with you to prevent reimbursement delays.

BMC HealthNet Plan…	You…
Provides specific claim forms with clear instructions. See section 2.16.	Check member benefits and eligibility with us, MassHealth or Commonwealth Care on each date of service. See section 8.2 for details. All Commercial plans member eligibility must be checked directly with BMC HealthNet Plan.
Coordinates benefits to determine the order of payment from multiple insurers. Plan members may retain alternative coverage such as other health insurance, worker’s compensation insurance, auto insurance, and/or liability insurance.	Follow the coding and billing requirements in the Plan’s reimbursement policies. See the Reimbursement Policies page in the Administrative Resources section at bmchp.org for more information. You do not need a login or password to access this information.

2.2 Covered Benefits

The Plan is responsible for most (but not all) MassHealth benefits available to the Standard, Commonwealth, Basic, Essential and Family Assistance populations. The summary of benefit information on the Plan’s website identifies the MassHealth benefits covered by the Plan and those paid for directly by MassHealth. When billing for services covered directly by MassHealth, you must get any required authorization from MassHealth and bill MassHealth directly.

There are no state-funded or wraparound benefits available for Commonwealth Care or our Commercial plans.

2.3 Provider Reimbursement

Your provider agreement with us explains the terms of provider reimbursement. Please become familiar with these terms if you need to contact us to obtain payment information or when asking questions related to claims payment. We reimburse you for services according to the terms of your provider agreement and Plan policies. All reimbursements are subject to the prior authorization criteria specified in section 3 of this Provider Manual, as well as Plan eligibility and coverage limitations.

To ensure member privacy that meets legal requirements, including HIPAA standards, the Plan assigns a login ID and password to every provider who wishes to access protected health information online. See section 14.3.3.2 for information on how to get a unique provider login ID and password.

2.3.1 Copayments

You collect a copayment from the member for some services.

The only MassHealth service requiring copayment collection is pharmacy. Some Commonwealth Care and Commercial plans services require the collection of copayments; see the summary of benefits at bmchp.org for more information.

Providers may not bill or balance-bill MassHealth members for any covered service. See section 2.3.5 for guidelines on when you may bill a MassHealth member for a non-covered MassHealth service.

2.3.2 Coinsurance and Deductibles

You collect coinsurance or deductibles from the member for some services.

For Commonwealth Care, there is coinsurance for just a few services – but there are no deductibles.

For Commercial plans, there are deductibles and coinsurance for many services. Please see the summary of benefits at bmchp.org for more information about the services that require coinsurance and deductibles.

Members are not required to make payment for any portion of the coinsurance or deductibles at the time services are rendered. However, providers may ask for credit card information or a written guarantee from the member to ensure these charges will be paid.

2.3.3 Contractual Terms

We reimburse you for covered services and supplies furnished to members according to the contractual terms in your provider agreement. This Provider Manual is part of your contract with us.

This Provider Manual consists of all policies in the Manual as well as all other Plan policies (e.g., administrative policies, reimbursement policies, etc.). These other Plan policies are hereby incorporated into this Manual by reference.

See section 8, Provider Responsibilities, for administrative, coverage, and notification requirements for contracted providers and locum tenens physician services.

2.3.4 Prior Authorization Requests and Payment

Submitting cost and pricing information on a prior authorization request does not guarantee payment at the submitted rate. Actual payment is based upon:

Established Plan reimbursement rates based on your participating agreement with the Plan
Compliance with our administrative guidelines including Plan prior authorization and claim submission
Verification of medical necessity
Verification that the service is a covered benefit
Eligibility of the member on the date of service
Adherence to proper CPT/HCPCS and other nationally recognized coding guidelines

See section 3 for Plan prior authorization and notification guidelines for medical/ surgical services and pharmacy prior authorization guidelines.

2.3.5 Member Billing and Reimbursement for Non-Reimbursable Services

2.3.5.1 MassHealth members only

You may not bill MassHealth members for missed appointments.

You may not balance-bill any Plan member the difference between our reimbursement rate and your charges for covered services. You may only charge a MassHealth recipient for copayments related to pharmacy services according to Plan guidelines.

The following table lists some possible scenarios and how the Plan handles them.

Situation	What you do	What we do
A member seeks or requires a non-MCO Covered service (a “wrap around” benefit)	Submit the claim directly to MassHealth.	Continue to coordinate the care with the treating provider.
A member under age 21 seeks or requires a non-covered benefit.	You may request a benefit substitution or approval of the non-covered service through the Plan’s Medical/Surgical Prior Authorization department, Care Management department (if the member’s care is being coordinated by a Plan-affiliated care manager) or Beacon (for behavioral health services).	Reimburse for the service only after our review and approval.

You may bill a MassHealth member for a service that is not medically necessary and not covered by the Plan or MassHealth only if all of the following conditions exist before the specific non-covered service is rendered:

You have informed the member in advance that neither the Plan nor MassHealth covers the service.
The member decides to receive and pay for the non-covered service, and you tell the member that s/he will be responsible for payment of that ser¬vice.
The member acknowledges in writing that s/he is financially responsible for the non-covered service by signing a waiver in advance of the service.
You have the member’s signed financial waiver on file before the service is ren¬dered.

2.3.5.2 Commonwealth Care members only

You may bill Commonwealth Care members for missed appointments.

You may bill Commonwealth Care members only for the following services:

Copayments and coinsurance for services identified in the summary of benefits at bmchp.org
Non-covered services

Balance billing is not allowed for covered services, including emergency services. You may not balance-bill for covered services in the following situations:

You deliver a covered service (not requiring prior authorization) to a member. You may collect any applicable copayment/coinsurance, but may not balance-bill.
You fail to get prior authorization from the Plan before delivering a covered service requiring prior authorization (for example, speech therapy).

You may bill a Commonwealth Care member in the following situation:

You are a network provider who delivers a non-covered service (for example, cosmetic surgery); the claim will be denied and you can bill the member.

2.3.5.3 Commercial Plans members only

Commercial Plan members may be charged for missed appointments.

You may bill Commercial plan members only for the following services:

Copayments, coinsurance and deductibles for services identified in the summary of benefits at bmchp.org
Non-covered services

You may not balance-bill for covered services in the following situations:

You deliver a covered service (not requiring prior authorization) to a member. You may, however, collect any applicable copayment/deductible/ coinsurance.
You fail to get prior authorization from the Plan before delivering a covered service requiring prior authorization (for example, speech therapy).

Providers may bill the member in the following situations:

You are a network provider who delivers a non-covered service (for example, cosmetic surgery); the claim will be denied and you can bill the member.

2.3.6 Member Eligibility

Always check member eligibility—before delivering services - on the date of service, and daily for inpatient admissions. Member eligibility may change from day to day for MassHealth members and on a monthly basis for Commonwealth Care and Commercial plans members. Note: Commercial plans members are generally locked in to their respective plan for a full benefit year. However, a member’s or employer group’s failure to pay premium, or changes in a member’s employment status, may result in termination at the end of any given month.

Terminations that occur retroactively due to failure to pay premiums or for other legitimate bases could result in retroactive claims retractions.

MassHealth members receive two ID cards at enrollment: a MassHealth member ID card and a Plan member ID card. Commonwealth Care and Commercial plans members receive only one BMC HealthNet Plan member ID card. See section 8.2 for guidelines and step-by-step instructions on how to confirm member eligibility in the Plan.

If you have completed our prior authorization process, you can contact us to verify member benefits and eligibility, PCP assignment and provider participation in the Plan. You may also access member benefit information, eligibility and provider participation in the Plan at bmchp.org.

2.3.7 NPI and Tax ID Requirements

Make sure all National Provider Identifier (NPI) and tax ID numbers on electronic 837 formatted claims are valid and correct.

Your NPI number must match (have been registered with) an existing tax identification number (TIN) record on file. Even if the NPI number is valid, we will reject any claim that does not match in this way. This additional data verification check enhances claims accuracy by eliminating claims payment to an incorrect or invalid provider.

The Plan requires written notification of any TIN changes prior to claim submission, and no later than 30 calendar days prior to the effective date of the change. This will enable us to complete any necessary system changes and safeguard against payment disruption.

The NPI requirements described above are federally mandated. Questions regarding NPI or claims payments should be submitted, in writing, to NPI@bmchp.org.

2.4 Prior Authorization and Retrospective Review Prior to Claim Submission

You must get prior authorization for certain services and products and for inpatient admissions. We understand that certain circumstances may prevent you from getting a prior authorization. In some cases, we handle the request as a retrospective authorization request. See section 3 for details about prior authorization and retrospective authorizations.

2.5 How to Submit a Claim

You can send us claims on paper via mail, or electronically.

Make sure you have obtained any required prior authorization. See section 3.

2.5.1 Submitting a Paper Claim

Send paper claims via US mail to the address below for covered services rendered to Plan members. Sending claims via certified mail does not expedite claim processing and may cause additional delay.

BMC HealthNet Plan
P.O. Box 55282
Boston, MA 02205-5282

Providers must use the CMS-1500 Form to submit paper claims for professional services. The UB-04 Form must be used by providers to submit paper claims for facility services.

A computer-generated claim is defined as a claim form where all required data fields are completed in typed alphanumeric characters. An altered claim is defined as a computer-generated claim with some data fields completed in pen or pencil or crossed out; an altered claim is not considered a clean claim. Claims received with partial handwritten information or crossed-out lines will be denied.

2.5.2 Submitting an Electronic Claim

We receive most of our claims electronically. We accept and process them in the standard HIPAA-compliant claims format using electronic data interchange (EDI). Compared to paper claims, submitting electronic claims provides many important benefits:

Faster claim turnaround
Quicker payments
Fewer keying errors
Reduced administrative costs for mailings
Quicker notification of rejected claims

To expedite your electronic claim, always include your NPI number in the appropriate place on the claim form. Claims submitted without this information will be rejected. Providers must obtain a National Provider Identifier (NPI), described in section 2.3.8.

See the Providers page at bmchp.org for more information on electronic claims submission.

2.5.2.1 When you must file a paper claim

You must file a paper claim, instead of an electronic claim, in the following situations:

Your claim requires an attachment (e.g., transactions such as explanation of benefits (EOB) forms, invoices, or operative reports).
You are filing a clinical and administrative appeal, even if the claim was originally submitted electronically.

2.5.2.2 Ways to Submit Claims Electronically

There are two ways providers can submit claims electronically: directly to the Plan or via a third party. The Plan accepts and processes claims electronically from five major clearinghouse entities:

Capario (formerly known as MedAvant/ProxyMed/MedUnite)
Emdeon (formerly known as WebMD/Envoy)
RelayHealth (McKesson, Per-Se)
The SSI Group
NEHEN (New England Healthcare EDI Network)

If you or your billing agency uses one of these clearinghouses, you can begin sending electronic claims simply by contacting your clearinghouse representative or customer support line. You can also submit claims directly to the Plan using the 837 format. A Plan staff member will work with you to coordinate electronic claims submission and testing before EDI implementation.

If you have any questions about submitting electronic claims, please contact your provider relations representative or call the provider line 1-888-566-0008 and select the provider services option. You can also get more information about electronic claims submission and detailed instructions for electronic data interchange (EDI) in the Plan’s EDI Claims Companion Guide. The EDI Claims Companion Guide and other EDI information are available on the Providers page at bmchp.org.

2.6 Claim Filing Time Limit

For MassHealth and Commonwealth Care Claims:

You must submit initial claims and encounters no later than 150 calendar days from the date of service, unless you are awaiting a payment and remittance (or explanation of payment) from a primary insurer via coordination of benefits. The paper claim receipt date is the date that the claim is received in our Claims department.

For Commercial Plan Claims:

You must submit initial claims and encounters no later than 90 calendar days from the date of service, unless you are awaiting a payment and remittance (or explanation of payment) from a primary insurer via a coordination of benefits. The paper claim receipt date is the date that the claim is received in our Claims department.

If you receive payment or documentation from another insurer more than 150 calendar days after the date of service, you must send your claim/encounter form and the primary insurer’s remittance advice to the Plan within 150 calendar days of receipt of the remittance advice from the other insurer. Include the Explanation of Benefits or remittance with any claims submitted to the Plan.

If you receive payment from both the Plan and another payer, you must contact the Plan’s Coordination of Benefits department regarding any repayment obligations.

Claims submitted for an administrative appeal must be received by the Plan’s Provider Appeals Unit within the timeframe specified in section 10.5.3. A retrospective adjustment beyond this time period is considered at the Plan’s discretion, but the adjustment may not exceed one year from the date of service.

2.7 Other Party Liability Coverage and Credit Balance Adjustments

MassHealth, Commonwealth Care, and their participating managed care organizations (MCOs) are payers of last resort. As a participating MCO, the Plan will not pay for services until all other payment sources have been exhausted. Further, we are required to notify MassHealth and Commonwealth Care when it is determined that a member has other coverage through a payer who may be liable for payment of a healthcare expense.

For Commercial plans members, BMC HealthNet Plan may or may not be the primary payer in Other Party Liability situations.

2.7.1 Provider’s Role

Under MassHealth and Commonwealth Care, providers are required to perform “due diligence” to

Notify the Plan of all instances of other party coverage by calling the Plan’s Coordination of Benefits and Third Party Liability department at 617-748-6188 or by submitting a completed Coordination of Benefits indicator form, located in section 15 of this manual, to the address on the form.
Obtain payment from all other liable parties prior to billing the Plan. This includes billing the primary carrier for previously paid claims when notified of the existence of other coverage by the Plan. NOTE: industry-standard COB procedures dictate that the filing limit for claim submission to the primary insurance is based on the date the provider is notified that other insurance exists, and not the date of service. Therefore, providers should not be penalized if claims are submitted in a timely manner after such notification.
Submit to the Plan for consideration any balance when payment or denial is received from the primary payer. When submitting the claim to the Plan, include the explanation of benefits, remittance advice, or denial letter from the other payer. You have 150 days to bill the Plan after receipt of the primary payer’s determination.

Under Commercial, providers are required to:

Notify the Plan of any other insurance coverage the member has so that we may determine who should pay as primary.
Bill the Plan within 150 days of receipt of the primary payer’s determination.

2.7.2 Role of the Plan’s Other Party Liability Department

The Other Party Liability (OPL) department at the Plan consists of two units: Coordination of Benefits (COB) and Third Party Liability (TPL). The COB and TPL departments can be reached at 617-748-6188.

2.7.2.1 Coordination of Benefits

Coordination of benefits occurs when a member has other insurance.
MassHealth and Commonwealth Care programs are always the payers of last resort; any other insurance will always be primary over these programs. For Commercial members the Plan will coordinate benefits as applicable to determine primary or secondary coverage.

When a provider notifies us, or when we identify through independent sources that COB exists, we will take the following action:

Notify MassHealth that the member has other insurance. MassHealth will verify this information and update the Eligibility System (EVS). EVS may not always reflect COB information immediately and is not a guarantee of payment, especially if the member has another insurance that is primary.
For MassHealth members we will notify you by mail 60 days prior to adjusting any previously paid claims with dates of service during the effective dates of the other insurance.
MassHealth, Commonwealth Care and Commercial members that have other insurance that is primary will have claims adjusted within two years of the date of COB identification.
Deny any claims received subsequent to verification of COB if we are the secondary plan

2.7.2.2 Third Party Liability (TPL)

TPL occurs when members are injured as a result of a liability accident. In these instances another party may be liable for the payment of the member's medical claims. The most common types of TPL cases are motor vehicle accidents, workers' compensation injuries, and slip-and-fall injuries. Because MassHealth and Commonwealth care are payers of last resort, the auto insurance, workers' compensation insurance and general liability insurance are primary payers for these members’ claims related to the accident.

Plan members who are MassHealth recipients are entitled to $8,000 in Personal Injury Protection (PIP) benefits per automobile accident while Commonwealth Care and Commercial recipients are entitled to $2,000.

When a provider notifies us, or when we identify through independent sources that TPL exists, we will take the following action:

Deny any claims related to the incident received subsequent to verification of TPL.
Adjust any previously paid claims related to the incident.

2.7.3 Credit Balance

A credit balance occurs when payment for a claim exceeds the contracted rate for that claim. Common overpayment reasons include payments for services for which another payer is primary, incorrect billing, and claim processing errors such as duplicate payments.

2.7.3.1 Provider’s Role

Providers are required to perform “due diligence” to identify and refund overpayments to the Plan within 60 days of receipt of the overpayment. Credit balances are usually discovered through a review of your credit balance report and Aged Trial Balance (ATB) report. Providers may either:

Self-report credit balances by utilizing the Credit Balance Refund Sheet located in section 15 of this manual. All refund and adjustment requests should be directed to the Credit Balance department at:

BMC HealthNet Plan
Credit Balance Department
Two Copley Place, Suite 600
Boston, MA 02116
FAX 617-897-0811
Or, contact our Credit Balance department at 617-748-6229 to schedule an on-site review of your credit balance reports to identify any overpayments.

2.7.3.2 Role of the Plan’s Credit Balance Department

When you notify us of an overpayment, we will adjust the claim(s) to reflect the correct payment.

When an on-site credit balance review takes place, whether performed by Plan staff or a contractor on behalf of the Plan, we will take the following steps:

Review all findings with your designated representative.
Allow you a 30 day response period.
Retract any overpaid claims after 30 days in the absence of a response.

2.8 Claims Payment

2.8.1 Clean Claims

Our goal is to process clean claims and reimburse you within 30 calendar days of receipt of the claim. We mail the check to the treating provider who submitted the bill, or issue an electronic funds transfer (EFT) if the provider is enrolled in the Plan’s EFT program.

To be considered clean, a claim must have all of the following characteristics:

Contains no defect or impropriety
Includes all required substantiating documentation from contracted or non-contracted providers and suppliers
Does not involve particular circumstances requiring special treatment that prevents timely payment from being made
Includes all documentation substantiating and supporting any special treatment and/or complex procedure(s), including operative reports or use of an assistant surgeon
Follows all prior authorization policies and procedures
Is not under investigation for fraud or abuse
Involves covered benefit(s)
Is properly submitted in the required format with all of the necessary data
Meets the Plan’s adjudication clinical editing guidelines
Is ready for us to process immediately without the need to investigate information related to the claim

2.8.2 Electronic Funds Transfer (EFT)

2.8.2.1 Convenient, Fast Service

EFT is an optional service that permits direct electronic deposit of a Plan claims payment. The program is easy, free and saves you time and money. We automatically issue reimbursement directly into the bank account designated by the contracted provider. EFT methods are faster and more secure for moving funds than paper checks. Since our payments are deposited electronically with EFT, there are no deposit slips for you to prepare.

Advantages of EFT include:

Prompt payment – no waiting for checks to clear
Improved cash flow
No lost checks or postal delays
Savings of administrative and overhead costs
No standing in line at the bank
Simplified record keeping
Reduced paperwork

2.8.2.2 How to Become an EFT Provider

To become an EFT provider, complete an Electronic Funds Transfer Authorization Form (EFT-1). A sample form is available in section 15, or from your Provider Relations representative. Fill out the EFT-1 form and submit it with one of the following forms of documentation from the account in which you wish to receive Plan payments:

Voided check
Letter from your practice's bank confirming the ABA transit number and account number
Letter from you on your practice's letterhead, signed by an authorized signer, explaining the reason why a voided check cannot be supplied, and confirming the ABA transit number and account number to be used for EFT

Please be sure all necessary information is legible, and return the documents to your Provider Relations representative. After the EFT-1 is received, your Provider Relations representative will contact you to verify that the information is complete and correct. You will begin to receive payments via EFT approximately 7 to 10 calendar days after this verification has been completed. If you have not begun receiving your payments within 14 calendar days or two check cycles, whichever is later, contact your Provider Relations representative.

Providers who enroll in the Plan’s EFT program will continue to receive a paper-based remittance advice indicating member names, dates of service, services rendered, and amounts of Plan payments. Your bank statement will continue to reflect deposited amounts and dates of deposit.

2.9 Remittance Advice

A remittance advice summarizes each processed item and lists the subsequent payment amount we reimburse, if any. A remittance advice accompanies all Plan payments. We send one remittance advice that delineates Commonwealth Care, MassHealth and Commercial plans. See section 2.19 for a sample remittance advice.

A list of the explanation codes used on our remittance advice is available in the Administrative Resources section at bmchp.org. You also may view a remittance advice for a specific claim in section 2.19. Each billed item on the remittance advice includes:

Member name
Member ID number
Provider’s patient account number
Billed codes (e.g., CPT-4, revenue code, HCPCS)
Billed amount
Allowed amount (the Plan’s allowed fee)
Adjustment or other insurance amount (amount for which other insurance is primary)
Member cost sharing amount
Amount paid (with the remittance)
Disallow remarks (will provide brief descriptions of disallowable payments and the reasons for the reduction from charges or the line item denial)

2.10 Rejected or Denied Claims

We accept only standard diagnosis and procedure codes in compliance with HIPAA transaction code set standards. Claims containing old codes that have been replaced or deleted will deny and will require resubmission.

You must use current CPT-4, place of service, revenue, bill type, and healthcare common procedure coding system (HCPCS) codes, in combination with current modifiers. We deny any outpatient facility claim submitted with a revenue code if there is no corresponding HCPCS code where required.

The reference number generated during the Plan prior authorization process is not a guarantee of payment. See section 2.13 for claims resubmission guidelines.

2.10.1 Rejected Claims

If a claim is not properly submitted, we cannot process it. The most common reasons we reject claims are:

The NPI is incorrect, is not listed on the claim or does not match the recorded tax identification number registered in our system. Please see section 2.3.7 regarding NPI.
The Plan member ID number is invalid on the claim.
The original claim number is not included on a void, replacement or corrected claim.
EDI void and replacement requests that do not include the required information, such as the original claim number.

See section 2.13.1 for information on submitting a corrected claim.

2.10.2 Denied Claims

After processing properly submitted claims, we deny payment in some cases. Here are the most common reasons we deny processed claims:

Submitted claim is not a clean claim (as defined in section 2.8.1)
Duplicate claim submission
Claim is filed after the claims submission time limits
Member ineligible for Plan benefits at the time of service
Procedure code cannot be billed separately from a primary procedure already paid
Prior authorization was not obtained for all dates of service or service type
Late notification or non-notification of admission
Use of invalid or inappropriate procedure code, diagnosis code, place of service code, or other required clinical information is not provided
Time of admission and/or time of discharge is not provided for inpatient admissions and targeted outpatient services (as specified in section 2.16, block 18 and block 16 of the UB-04 Form)
Procedure or service is not a covered benefit for the member
Invalid procedure and modifier combination used
Billing for newborn is under the incorrect member ID number (see section 2.14.2 for billing guidelines for newborn services)
Claim does not meet clinical editing guidelines (as outlined in section 2.11)

2.10.2.1 Provider Administrative Appeal of a Previously Denied Claim

To appeal a denied claim, you must submit a Provider Administrative Appeal in writing to the Plan Claims Resolution Unit (attention: Provider Appeals department). If you have a question about an Administrative Appeal, call our provider line 1-888-566-0008 and select option 2 to speak with a Claims Resolution representative. Staff is available from 8:oo a.m. to 5:00 p.m., Monday through Friday (except holidays).

See section 10 for information about appeals.

2.11 When and Where to Inquire about a Claim

2.11.1 Provider Services

Our Providers Services staff is ready to help you with payment issues. Provider Services a centralized team of highly trained professionals who work with providers to resolve claims-related questions from your first contact through the adjustment process. If you have a claim-related question or payment issue, call the provider line (using one of the appropriate telephone numbers listed on the bottom of this page) and select the claims status inquiry option.

Provider Staff services provides information by telephone on the status of a claim for a maximum of three claims per request. (See the next section for online claims status inquiry.) Requests for information on more than three claims must be submitted in writing; complete a Claims Resolution Unit Request Form and mail or fax the document to Provider Services. A copy of the form (including the appropriate mailing address and fax number) is available in section 15. All requests must be typed and be limited to claims that have already been processed by the Plan.

See section 10 for additional information on policies related to provider administrative appeals for denied claims. Provider administrative appeals must be sent to the Plan’s Appeals department.

2.11.2 Online Claims Status Inquiry and Remittance Advices

It’s easy and fast to find out the status of a claim on the Administrative Resources page of bmchp.org, which offers the following important information on individual claims:

Claims status inquiry— A printer-friendly version of a claims status inquiry. Once you have entered the claim number and received results on that claim, you can print out a properly formatted document with complete information about the specific claim.
Remittance advices—An image of the remittance advice. The payment reference ID number will be shown as a link that you can click on to view that remittance. Claim payment remittance images are on file for as far back as 365 days. Images of claim remittances that totaled to $0 are on file back to July 2002. The remittance advice images can sometimes be large; however, you can use the FIND function within Acrobat Reader to find a specific claim by its claim number, member ID number, or member name. In order to view the remittance advice image, you must have Adobe Acrobat Reader installed on your computer. If you don’t already have this application, you can get a free copy of it from the Adobe website, adobe.com .

To access this information online, a provider must have a Plan-assigned login ID number and password to ensure that HIPAA privacy standards are maintained for Plan members. See section 14.3.3.2 for information on how a contracted provider may obtain a website login ID number and password. Section 14.3.3.1 includes a list of additional website features available to participating providers.

2.12 Payment Correction, Resubmission, Adjustment and Audit

2.12.1 To Submit a Corrected Claim

A corrected claim is any previously filed paid or denied claim that you resubmit with changed or corrected information. The Plan must receive all corrected claims within 150 calendar days of the original process remit date, not to exceed 300 days from the date of service. Corrected claims are related to one or more of the following:

Incorrect provider name
Incorrect member name or member ID number
Incorrect line item details (e.g., procedures, modifier, units, or charges)
Incorrect place of service

You may not re-submit a claim that was rejected for a missing NPI number as a corrected claim. Re-bill it as a new claim with updated information.

Claims that have been previously denied and are being resubmitted with requested information such as itemizations, invoices or operative notes should not be submitted as corrected claims. These can simply be resubmitted with the additional documentation.

Items submitted for reconsideration of timely filing denials, clinical edit denials, or partial payment denials are considered appeals and must be submitted with appropriate documentation using the administrative appeals process outlined in section 10.5.

If a claim is considered a corrected claim, please indicate this at the top of the claim and include the Plan claim number, which can be found on the remittance advice. Additionally, all corrected claim information should be circled when the claim is resubmitted. Corrected paper claims that are not submitted in this manner may have delays in processing. The claims submission address for corrected paper claims is:

BMC HealthNet Plan
P.O. Box 55282
Boston, MA 02205

2.12.1.1 To Submit Corrected Paper Claims

If you submit corrected claims on paper, the corrected claims will only apply to claims that were previously submitted and paid or denied. They do not apply to original or first-time submissions. The corrected claims must:

Include the original claim number
Include an indication of the item(s) needing correction
Not have handwritten changes
Be submitted within 150 calendar days of the original process remit date (as stated in the claim filing limit guidelines in section 2.6) and must be within 300 days of the date of service
Not include any correction fluid on the paper claim

2.12.1.2 To Submit Corrected Electronic Claims

EDI can process replacement claims, which allow correction of most billing items.

For member and/or provider changes, however (provider name, NPI number, member name, or member ID number), process such a change as a void claim with a new submission.

Replacement and Void Transactions for Electronic Claims
We process electronic claims automatically. This section tells you how our automated system processes void and replacement transactions.

We encourage you to use the “replacement” and “void” options for claims originally submitted to the Plan electronically; this will help you avoid submitting corrected claims on paper.

Void claim— A claim sent incorrectly, or containing incorrect or outdated provider and/or member numbers.

Replacement claim— A resubmission for changing or correcting a previously submitted claim.

Void requests and replacement requests must include the Plan’s original claim number in specified locations; an electronic void or replacement request without this information will be rejected.

We do not accept EDI voids and replacements in the following situations:

The claim is not in a finished status. Finished claims are those printed on a remittance advice with an assigned claim number, or those claims in the claims inquiry section on the Administrative Resources page at bmchp.org, with a status of finished. Claims identified with a status of in process or adjudicated are not considered finished.
The claim is “split” (e.g., a request for a claim that crosses a calendar year span).

You must submit replacement or void requests for unfinished or split claims on paper.

EDI void or replacement transactions do not apply to clinical appeals, administrative appeals, or requests for a claim adjustments (i.e., disputes regarding the original handling of the claim). Appeals and adjustment requests must be submitted on paper. Questions should be directed to your assigned Provider Relations representative or our EDI department.

The original claim number must be in a specific position in the 837: Loop 2300, Segment REF – Original Reference Number (ICN/CDN), with F8 in position 01 (Reference Identification Qualifier) and the original claim number in position 2. Electronic void or replacement requests without this information will be rejected and reported on the initial claims status report (also known as the scrubber report).

2.13 Resubmitting a Claim

A resubmission is any previously filed claim that is resubmitted due to incorrect claims processing by the Plan, or previously denied for additional documentation such as medical records, invoice or itemized bill. Resubmitted claims must be received no later than 300 days from the date of service. Reasons for a resubmission include:

Failure to match authorization
Incorrectly keyed line item details
Incorrectly keyed provider ID number
Incorrectly keyed member ID number
Incorrect eligibility dates
Incorrectly keyed claim coding
Serial denials or rejections
Request for itemized bill
Request for medical records
Request for invoice

If a claim is considered a resubmission, please indicate this at the top of the claim and enclose a copy of the remittance advice with the error highlighted. If you dispute the payment amount of a claim and a discrepancy cannot be identified on the remittance, please contact Provider Services by calling the provider line at 888-566-0008 and selecting the claims option. Contract-related issues should be directed to your designated provider relations representative.

2.13.1 Payment Retraction or Adjustment

Payment retractions or adjustments are necessary when the Plan or the provider makes an error during the processing of a claim for a Plan member. The Plan follows industry-standard protocols related to payment retractions and adjustments. When such errors occur, we request that you process the remittance advice and deposit the associated check as payment for those claims processed correctly on the remittance advice. For incorrectly processed claims, please submit the remittance to the Plan and highlight only those claims that have been processed in error. You should note the incorrect payment on the remittance advice. We will adjust all incorrectly processed claims and retract the overpayments from future remittances. If you issue a refund check or return the check issued by the Plan, it will result in delayed payment for you. If you believe we have underpaid for covered services, you must notify Provider Services or contact your provider relations representative regarding a contract or fee schedule dispute.

2.13.2 Claims Audit

Our Provider Audit department conducts periodic claim audits, which may be conducted on-site at a provider’s location or via desk audit at the Plan. The purpose of our audits is to:

Verify the financial accuracy of claims payment
Evaluate Plan and provider compliance with contract rights and obligations related to claims, including rates of payment
Ensure the appropriateness and accuracy of provider billing practices

In performing these audits, we subscribe to the third-party payer bill audit guidelines in the National Health Care Billing Audit Guidelines developed by the Ameri¬can Health Information Management Association, American Hospital Association, Association of Healthcare Internal Auditors, Blue Cross Blue Shield Association, Healthcare Financial Management Association, and Health Insurance Association of America, unless otherwise specified below or in a specific provider’s contract.

Our policies, including but not limited to medical, authorization, eligibility, claims administra¬tion and reimbursement, apply to all audits. In the event the Plan does not maintain a policy regarding a specific subject, we reserve the right to utilize policies promulgated by MassHealth, Centers for Medicare and Medicaid Services (national or local), American Medical Association, and national health insurance carrier organizations.

2.13.2.1 Your Role

Upon notification by the Plan of its intent to audit, you are required to do all of the following:

Designate someone with relevant knowledge and experience to coordinate audit activities, including someone to attend an exit conference at the conclu¬sion of an on-site audit or to receive audit results (via regular or electronic mail) at the conclusion of a desk audit
Respond to the notification, providing the information and/or documentation requested within the designated time period
Notify us at least 10 working days in advance if an on-site audit must be rescheduled or if you are unable to provide documentation for a desk audit within the designated time period
Provide clinical records and any additional documentation (e.g., signed and dated ancillary department records/logs, signed and dated charge tickets, descriptions and cost of services, supplies, or implants billed as “miscellaneous” items, policies developed, adopted, and periodically reviewed by clinical staff, as evidenced by dates of implementation and review and signatures of policy owner(s), etc) supporting the claims in question, and charge description masters spanning the service dates of the claims in question, at a mutually agreed upon time and location for on-site audits or in the documentation packet for desk audits
Identify and present, at the beginning of an on-site audit or in the documentation packet of a desk audit, any charges omitted from the final bill or billed in insufficient quantity on the final bill that you would like considered for payment
Provide a suitable work area for on-site audits during the course of the audit
Provide such additional information and/or documentation as is necessary to allow our auditors to understand the exact nature of specific charges
Provide copies of medical records, if requested
Respond to audit findings within 30 days of the Audit Summary Report date, unless otherwise agreed upon
Submit late charge type claims for any agreed upon previously unbilled or under-billed charges to the Plan auditor within 30 days of the Audit Summary Report date.

2.13.2.2 Role of Our Audit Department

We use a variety of criteria to identify claims for review. We may cat¬egorize audits as generic (generally consisting of a variety of claim types) or focused (generally consisting of claims related to a specific service). If we identify additional areas of concern during the course of an audit, we may expand the scope of the audit. We reserve the right to extrapolate findings of an audit sample to a designated universe of claims. In no circumstance does the Plan pay a fee to conduct an audit.

In the performance of these audits, we will:

Identify claims using internal criteria consistent with recognized statistical sam¬pling and probability methodology.
Select claims for audit with a final bill-paid date that is not more than two years prior to the proposed audit date (unless otherwise agreed to in your contract), except in the case of suspected fraud or abuse, in which case there is no restriction on the look-back period.
Notify you in writing of our intent to audit not less than 30 days prior to the pro-posed audit date, providing sufficient information regarding the nature of the audit and the specific claims to be audited as is required to allow you to com¬ply with your responsibilities as described above.
Employ auditors with reasonable expertise, integrity and professionalism
Verify service descriptions and prices against the appropriate charge description master
Accept all documentation containing sufficient information to identify the indi-vidual completing the documentation and his or her credentials as evidence that specific services were provided.
Give you written results – at the conclusion of the audit – for each claim reviewed, either one Audit Summary Report for each claim reviewed on-site or a single Audit Summary Report detailing the findings for each claim reviewed by desk audit.
Allow you a response period of 30 days for all claims with audit discrepancies, unless oth¬erwise agreed upon.
Accept late charge bills submitted within 30 days of the Audit Summary Report for any agreed upon previously unbilled or under-billed services/items you identified at the beginning of an on-site audit or submitted with the documentation packet for a desk audit.
Provide a Final Audit Summary Report, one for each claim for which an Audit Summary Report was presented at the conclusion of an on-site audit or a Final Audit Summary Report for all claims for which a single Audit Summary Report was presented at the conclusion of a desk audit.
Adjust or retract claim payments as indicated by the Final Audit Summary Report, at the conclusion of the 30 day response period.
Identify audit-related retractions and/or claim adjustments on our Remittance Advice.

If you dispute the audit findings on a Final Audit Summary Report, you may submit a letter of appeal to the Provider Audit Department within 30 days of the date of the Final Audit Summary Report. The letter must be accompanied by all clinical documentation related to the charge in question, any relevant policies as previously described, and any other supporting information. The Provider Audit Director will review your appeal, research the issue(s), and consult Plan clinicians and other subject matter experts as necessary. The Plan will make best efforts to review the appeal and notify you in writ¬ing of the final determination within 30 days of receipt of the appeal; provided, however that the Plan reserves the right to extend the review period if necessary to complete a full and final review. If the review period is extended beyond 60 days, the Plan will notify you in writing of the extension. The Plan’s appeal determinations are final. Any claim adjustments resulting from the final determination of an appeal will be processed by the Plan within 30 days of the final appeal determination.

2.14 Plan-Specific Billing Guidelines by Service

Please refer to our reimbursement policies for detailed information on coding and billing requirements. See the Administrative Resources page at bmchp.org to view policies. We will deny your claim if you fail to bill according to these payment terms.

A description of our billing guidelines for you to use when billing for services delivered to Plan members is also available on our website without a website login ID number and password.

You must submit claims in compliance with HIPAA standards to ensure accurate claims payment and encounter reporting.

In addition, our website Providers page contains lists of codes for some services as a guide for you. The use of any code identified in Plan documents is not a guarantee of payment. Payment will be made based on the member’s eligibility, authorization status, Plan benefits and other clinical criteria that may apply to a specific code or code set. We will update the code listings as soon as possible and provide relevant information to assist you with the use of codes that are being replaced. However, we cannot accept terminated codes regardless of their presence on a Plan code list. We use effective and termination dates for CPT/HCPCS codes as published by the AMA or CMS as the dates for claim processing.

2.14.1 Billing Behavioral Health Services

BMC HealthNet Plan contracts with Beacon Health Strategies to manage the Plan’s behavioral health program. Please direct all questions regarding claims submission for behavioral health services to Beacon Health Strategies at Beaconhealthstrategies.com or call Beacon at 1-866-444-5155.

2.14.2 Billing Newborn Care

You must bill separately for the mother's and newborn's care, using a unique member ID number for each Plan member. We create a temporary ID number for the newborn so you do not need to delay your billing processes. Treating providers (including hospitals and pediatric practices) must bill medical care for newborns under the child’s unique ID number.

Please see section 3.7.1 for Plan authorization requirements notification for maternity admissions. We will give the child’s temporary (for MassHealth and Commonwealth Care) or permanent (for Commercial plans) member ID number via fax to the provider who gave the birth notification. The treating provider can bill the Plan for the inpatient stay and all services for a newborn child in one of two ways:

Bill with the Plan-assigned temporary (for MassHealth and Commonwealth Care) or permanent (for commercial) member ID number for the newborn; or
Wait for the MassHealth-assigned member ID number and use that number for billing (for MassHealth and Commonwealth Care).

See section 8.2.6.2 for a description of how to check member eligibility for newborns.

2.14.3 Billing Primary Care Services

We will pay for primary care services delivered to a member if the member is assigned to the treating PCP’s panel or assigned to a PCP in the covering group. Physicians who provide specialty care services and also carry a primary care panel will need to use the appropriate modifier to identify specialty care services when billing us. We must approve and credential physicians with dual specialties in both specialties. In addition, you must use a modifier when billing for primary care services delivered after hours. If you do not use the appropriate modifier, we will deny claims submitted for care rendered to members who are not part of the PCP’s panel of the PCP’s covering group.

2.14.3.1 Reimbursement for services provided by mid-level clinicians

Mid-level clinicians include, but are not limited to nurse practitioners, nurse midwives and physician assistants.

We reimburse mid-level clinicians according to the practice or group’s participating provider agreement when:

the clinician practices under the direct supervision of a physician or under guidelines developed in conjunction with a physician, and
the applicable participating provider agreement does not include capitation for primary care or other services.

We don't reimburse mid-level providers on a fee-for-service basis when:

the applicable participating provider agreement includes capitation for primary care or other services, or
the service would ordinarily be capitated for primary care or other services.
the clinician is a physician assistant and the services rendered are for the purpose of assisting a surgeon during surgical procedures.

We do not make distinctions in capitation based on provider licensure level; the only distinctions used in differentiating capitation and fee-for-service are code itself and the terms of the participating provider agreement.

We allow a member to change his/her PCP assignment at the time of care. See section 12.7 for guidelines on a PCP transfer and the effective date of the new PCP assignment.

2.14.4 Billing Requirements for EPSDT Visits and Behavioral Health EPSDT Screenings

Provider Responsibilities:

This section explains the billing requirements and reimbursement information for EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) and Behavioral Health EPSDT screenings, which are a mandatory part of every well child visit for MassHealth members. See the EPSDT Periodicity Schedule in section 8.9 for more information.

When billing for an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service, you must bill using the EPSDT add-on procedure code S0302 in order to receive an enhanced reimbursement from the Plan. Bill with the appropriate office visit code for the EPSDT service and procedure code S0302 for the additional reimbursement. The HCPCS procedure code S0302 is not a modifier; billing this code as a modifier will result in a denied claim. Using the S0302 code will ensure that you receive the enhanced payment for performing EPSDT services.

Use the distinct modifiers indicated in the table below when billing the CPT code 96110 for the Behavioral Health screening tools. Failure to include the appropriate modifier will result in denial of the claim.

Reimbursement Terms - Non-Capitated Providers:

We reimburse for administering one standardized BH screening tool per MassHealth member, per day, regardless of the number of BH screening tools administered on the same day for a given member. Our reimbursement for these services complies with the terms established within your existing participating provider agreement.

Submit any claims for the BH screening tool using the following Current Procedural Terminology (CPT) service code:

96110 Developmental testing, limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report

Reimbursement Terms -Capitated Providers:

This screening is considered a component of your primary care capitation, and as such, no separate payment will be made.

Modifiers for Use with CPT Code 96110
Servicing provider	CPT/HCPCS modifier for use when no behavioral health need identified *	CPT/HCPCS modifier for use when behavioral health need identified *
Physician, independent nurse midwife, independent nurse practitioner, community health center (CHC), Outpatient Hospital department (OPD)	U1	U2
Nurse midwife employed by physician or CHC	U3	U4
Nurse practitioner employed by physician or CHC	U5	U6
Physician assistant employed by physician or CHC	U7	U8

Note: failure to submit a modifier for the screening will result in service denial.

2.14.5 Billing School-Based Health Center Services

For our MassHealth members, a contracted PCP may continue to bill for services provided to students within the school-based health center that a PCP staffs, even if those students are not on the PCP’s primary care panel. To ensure accurate payment for school-based services, use the 03 place of service indicator when billing us. You must notify us in advance when you want to provide school-based care or you will not be reimbursed for the service.

2.14.6 Inpatient Facility Billing

Inpatient admission requires prior authorization. Reimbursement for the entire inpatient admission is calculated based on the contract/reimbursement rate in effect on the date and time of admission.

We allow interim billing only for acute inpatient care, rehabilitation facility, skilled nursing facility, hospice, and/or home care services provided to Plan members. You must use the appropriate frequency code in block 4 on the UB-04 Form. Interim billing is not allowed if the facility is paid based on DRG payment terms.

2.14.7 Modifiers

We comply with HIPAA billing guidelines, and, therefore, mandate the use of HIPAA-standardized modifiers. Modifiers are used to better define the service rendered to Plan members. When billing with the CMS-1500 Form, put the appropriate modifier in block 24D. When billing with the UB-04 Form, put the necessary modifier in block 44. A narrative may not be used in place of the modifier. Invalid modifiers will be denied. Below is a description of modifiers by service type to clarify Plan guidelines in selected areas. This is a sample of the modifiers recognized by the Plan and not a comprehensive list of modifiers established by HIPAA and accepted by the Plan.

2.14.7.1 Ambulance Modifiers

When billing for ambulance services, please include the appropriate modifier.

2.14.7.2 Laboratory and Radiology Modifiers

Providers delivering both the technical and professional components of laboratory or radiology services may bill with a global code. Bill the global code only if you are responsible for both the facility and professional overhead costs. You must use the appropriate modifier, TC or 26, when billing for only one component of the service. CMS guidelines are used to determine whether technical and professional components are applicable.

Modifier TC denotes the technical component (i.e., staff and equipment costs) of a laboratory or radiology procedure. You may use a TC modifier only if financially responsible for administrative overhead, staffing, equipment, or facility costs.

Modifier 26 denotes the professional component (i.e., the physician’s service) of a laboratory or radiological procedure. A physician may bill with this modifier if the professional service rendered is not going to be billed by any other entity (i.e., the facility where the service was rendered). If physicians are not paid directly by a facility for their professional services, they may bill the professional component.

Modifiers TC and 26 are only applicable for certain codes, as dictated by CMS. Make sure you bill the TC and 26 modifiers with appropriate CPT codes, or the claim could deny as an invalid procedure/modifier code combination.

2.14.7.3 Operative Note Required with Modifier

If you use modifiers 22 or 59 when billing for services, you must submit the operative/medical notes with the claim. We will conduct a clinical review to appropriately pay your claim with these modifiers.

2.14.7.4 Primary Care Modifiers

We believe that the relationship between you and your patient is vitally important to maintain a member’s good health. Therefore, the Plan will pay for primary care services provided only to a member who is on a PCP’s panel or on the panel of a physician in the PCP’s covering group. You must accurately communicate your covering arrangements with the Plan.

Do not bill for primary care services delivered to members who are not already part of your panel prior to 5 p.m., Monday through Friday. A PCP who delivers after-hours care to members who are not assigned to the PCP’s covering group may bill using the TU modifier (for care rendered after 5 p.m.) and/or the TV modifier (for care rendered weekends and holidays), as appropriate.

Exception: You may continue to bill for services delivered to students within the school-based health center(s) that you staff, even if those students are not on your primary care panel. We recognize that these services are important extensions of the primary care relationship.

If you have a dual specialty approved and recognized by the Plan and provide both specialty care services and have an assigned primary care panel, you will need to use the TS modifier to identify specialty care services when billing us. If you do not use this modifier, we will deny claims submitted for care rendered to members who are not part of your primary care panel.

Only participating physicians will be paid for primary care services rendered to Plan members unless prior authorization is obtained prior to care being provided.

2.14.7.5 Wound Care Modifiers

Use modifiers A1-A9 to indicate the number of wounds on which a specific dressing is being used to treat. For example, if a member has four wounds but a dressing is being used on only two, the HCPCS for the specific dressing used should be billed with the A2 modifier, not A4.

2.14.8 Billing Enterals

Oral and powdered enterals are administered by Northwood, Inc.

2.15 Compliance with the Deficit Reduction Act and HIPAA Requirements

We comply with the requirements of the Deficit Reduction Act of 2005 (DRA) and our obligations related to fraud and abuse under our MassHealth and Commonwealth Care programs. Under the DRA, any entity that receives more than $5 million per year in Medicaid payments is required to provide information to its employees and contractors about the Federal False Claims Act, any applicable state False Claims Act, their rights be protected as whistleblowers, and the Plan’s policies and procedures for detecting and preventing fraud, waste and abuse.

To ensure compliance with the DRA, the Plan provides all its employees, provider network, contractors and agents with information about the False Claims Acts and published the Plan Fraud and Abuse Policy internally as well as on the Providers page at bmchp.org.

Plan employees, contractors and providers are expected to immediately report any potential false, inaccurate or questionable claims or any other type of suspected fraud and/or abuse to the Plan’s Fraud and Abuse Coordinator, or the Chief Compliance Officer or the Compliance hotline 1-888-411-4959 in accordance with the Plan’s Fraud and Abuse policy.

We are prohibited by law from retaliating in any way against anyone who reports, in good faith, a perceived problem, concern, fraud or abuse issue. Please review and adhere to the complete Plan Fraud and Abuse policy. To read the policy in its entirety, go to bmchp.org and click on the Fraud and Abuse Policy link at the bottom of the home page.

The Plan has adopted the standards set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for service and business transactions, including billing codes, modifiers, units of service, and claims submission guidelines. See our website at www.bmchp.org for the most up-to-date reimbursement policies and guidelines.

2.16 CMS-1500 Claim Forms

Summary of Billing Requirements for Medical/Surgical Services (Page 1 of 5)

TYPE OF SERVICE	REQUIRED FORM	SPECIFIC REQUIREMENTS
Ambulatory Surgery Center – Freestanding	UB-04 Form	Freestanding ambulatory surgery centers must bill with the outpatient bill type and must bill only those procedures identified in their contractual fee schedule.
Administratively Necessary Days (AND)	UB-04 Form	AND is a covered benefit for members (except for MassHealth Essential)in an acute care hospital only for medical/surgical care or for members in a DMH licensed hospital bed for behavioral health services (behavioral health AND are to be billed to Beacon).
Ambulance Transportation	CMS-1500 Form	The Plan is responsible for payment of emergency transportation. The non-emergent transportation benefit is administered by MassHealth unless the destination is 50 miles or more outside of the state of Massachusetts.
Anesthesia Services	CMS-1500 Form	Anesthesiologists must bill using the appropriate anesthesia CPT-4 or HCPCS codes and an anesthesia modifier. For anesthesia services, providers should bill using the total number of minutes for the service(s) performed; the minutes should be indicated in the units field of the CMS-1500 Form. Surgeons performing anesthesiology services should bill using CPT-4 codes for anesthesia services.
Chiropractic Services	CMS-1500 Form	See clinical policy # 3.59 at bmchp.org in the Administrative Resources section for coverage guidelines and the complete list of chiropractic covered codes we recognize.
Durable Medical Equipment (DME) and Medical Supplies	CMS-1500 Form	The Plan has partnered with Northwood, Inc. to manage durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provided by the following provider types for all Plan members: Durable medical equipment providers Emergency response system providers Wig providers Breast prosthesis providers Medical supply providers Pharmacy providers (who distribute/dispense DMEPOS) Orthotics/prosthetics providers Oxygen/respiratory equipment providers Speech generating device providers Ocular prosthetic providers Mobility providers Home infusion providers* Home care providers* Specialty pharmacy providers* Sleep study providers** * Exception: When these provider types bill for medical supplies and equipment related to infusion/parenteral/tube fed nutrition, BMC HealthNet Plan is responsible to manage/pay for those supplies/equipment/claims. All such claims should be submitted directly to the Plan and must follow the Plan’s billing requirements for these services/products. ** Exception: When this provider type bills for professional studies supporting sleep services, BMC HealthNet Plan is responsible to manage/pay those services/claims. Northwood is responsible for the following services related to DMEPOS when DMEPOS are provided by any of the above provider types: Prior authorization of DMEPOS Claims processing and adjudication Member and provider services related to DMEPOS requests Data reporting Provider contracting, credentialing and management Provider inquiries, grievances and appeals
Early Intervention Services	CMS-1500 Form	A modifier is required when billing for all early intervention services. See section 2.14.4 for billing guidelines for early intervention modifiers.
EPSDT	CMS-1500 Form	You must use the add-on procedure code S0302 to identify EPSDT services. See section 2.14.4 for additional information. For Behavioral Health screenings, use code 96110 with the modifiers identified in section 2.14.4.
Emergency Services	CMS-1500 Form or UB-04 Form
Family Planning Services	CMS-1500 Form
Home Health and Home Infusion Services	CMS-1500 Form	Home Health Care on a UB-04 Form: If home health services are billed on a UB-04 Form, the provider must include the appropriate outpatient bill type. Postpartum Home Visit: Postpartum home visit billing must include the appropriate diagnosis code (V240 to V242), and the service must be billed under the mother’s member ID number.
Inpatient Facility Services	UB-04 Form	Appropriate ICD-9 and current bill type codes are required for proper processing for all inpatient billing.
Laboratory Services (Free-Standing)	CMS-1500 Form	Modifiers are required when billing for the technical or professional component of laboratory services;
Medications	See our Medication Reimbursement Policy # PP 4.10 at bmchp.org in the Administrative Resources section for coverage and billing guidelines for medications.
Newborn Billing	UB-04 Form/ CMS-1500 Form	All newborn statistical information should be faxed to our Enrollment department within 24 hours of delivery. We will only accept notification by fax, and the notification must be directed to our Enrollment department (rather than the Prior Authorization department). The Enrollment department’s fax number is 617-748-6074. This should include the following information: Newborn mother’s first and last name Newborn mother’s member ID number Newborn mother’s address and phone number Newborn’s first and last name Birth weight (grams) Gender Gestational age Date of delivery The Enrollment department will create a temporary, Plan-specific member ID number (T-number) for the newborn and will fax this information back to the hospital for billing purposes within two business days. The T-number will be the only number required for billing purposes. This change will expedite the payment of newborn claims if all required information is received by the Plan. This does not replace existing Notification of Birth (NOB) form that must be submitted to MassHealth within 30 days of the child’s date of birth. Failure to submit the NOB form to MassHealth may result in claim retractions for any payments made for the child’s admission if no MassHealth ID number is issued. Please refer to section 3 for authorization guidelines.
Observation Days	UB-04 Form	See clinical policy # 3.190, ‘Observation Stay’ at bmchp.org at Provider e-services/Clinical Coverage Policies.
Occupational Therapy	CMS-1500 Form	See reimbursement policy # RP 4.609 at bmchp.org in the Administrative Resources section for billing procedures for physical therapy.
Optometry Services	CMS-1500 Form	We do not manage the benefit for eyeglasses, frames, or lenses; claims for these items must be submitted directly to MassHealth for reimbursement. For Commonwealth Care members we do not manage the benefit for eyeglasses, contact lenses and routine eye-exams; claims for these services must be submitted directly to VSP for reimbursement. Please see policy ‘Optometry Code Set’ at bmchp.org at Provider e-services/Code Information/Specific Service Coding.
Outpatient Professional Charges	CMS-1500 Form	You must submit claims in compliance with HIPAA standards to ensure accurate claims payment.
Pharmacy		For outpatient drug therapy, copayments for prescription and over-the-counter medications are required for some members. A pharmacy may not refuse service to a member who cannot pay the copayment. However, the pharmacist may bill the member later for the copayment.
Physical Therapy	CMS-1500 Form	See reimbursement policy # RP 4.609 at bmchp.org in the Administrative Resources section for billing procedures for physical therapy.
Podiatry Services (including Orthotics and Prosthetics)	CMS-1500 Form	Please see policy ‘Podiatry Code Set’ at bmchp.org at Provider e-services/Code Information/Specific Service Coding.
Primary Care Services	CMS-1500 Form	Modifiers are required for after-hours primary care services to members. Also, contracted PCPs with a dual specialty must use a modifier when billing for specialty services. See sections 2.14.3 – 2.14.7 for billing guidelines for primary care services.
Radiology Services (Free-Standing)	CMS-1500 Form	A modifier is required when billing for the technical or professional component of radiology services. See section 2.14.7.2 for billing guidelines.
School-Based Health Center Services	CMS-1500 Form	A contracted PCP may continue to bill for services provided to students within the school-based health center that a PCP staffs, even if those students are not on the PCP’s primary care panel. To ensure accurate payment for school-based services, use the 03 place of service indicator when billing the Plan. The Plan must be notified in advance that the practitioner provides school-based care or the provider will not be reimbursed for the service.
Speech, Language and Hearing Services	CMS-1500 Form
Unlisted Codes	UB-04 Form/ CMS-1500 Form	You must submit the operative note for Plan review when billing for a procedure with an unlisted code. Unlisted/Unclassified codes require operative notes in order for us to pay the claim.
Vaccine and Immunization Administration	CMS-1500 Form	All claims submitted for the reimbursement of an immunization administration must include the specific antigen code; payment will not be made without this information. If the antigen is state supplied, use the SL modifier. If the vaccine is not state supplied, follow the guidelines in our Immunization Reimbursement Policy. When billing for multiple vaccine administrations, a provider must use the appropriate administration codes and number of units. We will not pay more for vaccine administration than is permitted under federal regulations. See the Immunization Reimbursement policy for billing and reimbursement guidelines for immunizations and vaccines.

2.16.1 Claim Form Requirements for the CMS-1500 Form

You must bill professional charges, including charges for DME or supplies, on a CMS-1500 Form. You must submit claim/encounter forms for all services rendered. You can bill multiple dates of service and/or procedures on a single CMS-1500 Form. The following information is required for every CMS-1500 Form submitted to us for payment:

Member’s name, address, and Plan member ID number. The member ID number is on the member’s ID card. The member ID number is a nine-character number beginning with the letter “B.”
Individual servicing provider’s name, address, phone, tax ID number, and NPI number. Claims submitted without a valid NPI will be returned unprocessed. The provider/facility/supplier NPI number must be placed in block 33 of the CMS-1500 Form.
Current ICD-9 diagnosis coding, CPT-4 and/or HCPCS codes, place-of-service codes, and units.
If billing the Plan as a secondary payer, include a copy of the primary carrier’s Explanation of Benefits, remittance advice, or letter of denial of service.

For more detailed information on what is necessary for proper claim submission, please see the step-by-step instructions for the CMS-1500 form listed in section 2.16.3 below.

2.16.2 Step-by-Step Block Instructions for the CMS-1500 Form

We designed the following information to help you complete a paper CMS-1500 Form. We have provided instructions for the critical fields; however, you need to complete all applicable fields on the claim form. This chart indicates if a particular data element is mandatory, optional or not applicable. We have adopted HIPAA standards for claim submissions.

Step-by-Step Block Instructions for the CMS-1500 Form

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 1a Mandatory	Insured's ID number	Enter the member's current ID number as it appears on his/her Plan ID card and/or it can be obtained from MassHealth EVS. Transposed or incomplete ID numbers will cause a delay in processing or result in denial of the claim. The member ID number is nine characters beginning with the letter “B.” In EVS, a 10-digit number will be displayed. Use only the first nine digits for billing purposes; ignore the tenth digit.
Block 2 Mandatory	Patient’s name	Enter the member’s name in the following manner; Mary O’Hara as OHARA, MARY Do not include any titles (such as Mr. or Mrs.), suffixes (ex. Jr. or Sr.), apostrophes, hyphens, or any other marks of punctuation besides the comma. See the above example.
Block 3 Mandatory	Patient’s birth date and sex	Enter the member’s date of birth using an eight-digit format. For example, enter July 1, 2000 as 07012000. Enter the member’s gender in full.
Block 4 Mandatory	Insured’s name	Enter the member’s name in the following manner; Mary O’Hara as OHARA, MARY. Do not include any titles (such as Mr. or Mrs.), suffixes (ex. Jr. or sr.), apostrophes, hyphens, or any other marks of punctuation besides the comma. See the above example.
Block 5 Mandatory	Patient’s address	Enter the member’s current address. It is very important to verify the member’s address and eligibility on a regular basis.
Block 6 Mandatory	Patient relationship to insured	Always enter an “X” in the “Self” box of the claim- the patient is always the member for the plan.
Block 7 Mandatory	Insured’s address	It is very important to complete this block by entering the member’s complete address, including the zip code. Do not use “same” or enter any extraneous information in this block.

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 9 (a-d) Mandatory	Other insured’s name and other information	Complete this field only when the member is covered under another health benefit plan that is primary, and the Plan is the secondary payer. If the Plan is the secondary payer and you bill the Plan as primary, your claim will reject. Enter the full name of the policyholder and include the following information in blocks 9 (a) – (d): (a) Other insured’s policy or group number (b) Other insured’s date of birth and sex (c) Other insured’s insurance plan or program name Note: When using this field you must also complete block 11D and block 29.
Block 10 (a-c) Mandatory	Is patient’s condition related to....	For each category (Employment, Auto Accident, Other*), insert an “X” in the YES or NO box. When applicable, attach an EOB or letter from the auto carrier indicating that PIP benefits have been exhausted. Use if the diagnosis code is between 800.00 and 999.9 or an E-code.
Block 11d Mandatory	Is there another health plan?	Enter an “X” in the appropriate box. If yes, complete blocks 11a-c. Please make sure that you bill the primary carrier before billing the Plan. Once the primary carrier pays the claim, attach an EOB to the completed CMS-1500 Form and submit to the Plan for claim consideration.

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 14 Mandatory	Date of current (illness, injury or pregnancy)	Injury- Enter date the accident occurred. Illness- Enter for an acute medical emergency only and include onset date of condition. Pregnancy- Enter the anticipated date of birth. Surgery- For post-operative visits, please enter the date of surgery. Date of injury or onset date of condition must be reported if the diagnosis is between 800.00 and 999.9 or an E-code.
Block 17 Mandatory	Name of referring physician or other source	Complete this block when: Consultations are performed. A laboratory is rendering services at the physician’s request. The member is referred to a non-participating provider.
Block 18 Mandatory	Hospitalization dates related to current services	The admission and discharge dates must be entered for services related to inpatient hospitalizations.
Block 19 Not Applicable	Reserved for local use
Block 20 Not Applicable	Outside lab

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 21 (1-4) Mandatory	Diagnosis or nature of illness or injury	Enter the appropriate three, four, or five digit ICD-9_CM diagnosis code(s) for which services have been performed. List the primary diagnosis in line one with additional diagnoses listed, as necessary, on lines two through four. Adding extraneous zeros to three and four digit codes may make them invalid and result in claim denial. To ensure accurate claims processing and to avoid claim denials, the diagnoses reported in block 21 and procedure codes reported in block 24 must be compatible. Submit either: Illness diagnosis with an illness procedure code; or Routine diagnosis with a preventive procedure code.
Block 23 Optional	Prior authorization number	Fill out this block for services requiring referrals or prior authorizations.
Block 24A Mandatory	Date(s) of service	It is very important that you fill out this block correctly. Do not use a “date range.” For DME billing, the same “from” and “to” date must be used.
Block 24B Mandatory	Place of service	Use HIPAA-compliant place of service codes. See section 2.16.3.
Block 24C Optional	EMG (Emergency)	If the procedure line is deemed to be an emergency, enter Y for “Yes.” Otherwise, enter N for “No” next to that particular procedure.

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 24D Mandatory	Procedure services or supplies	Complete this field with the valid CPT/HCPCS procedure codes and any applicable modifiers. See section 2.14.7 for instructions on the use of modifiers when billing for healthcare services provided to Plan members.
Block 24E Mandatory	Diagnosis code	Enter the line-item diagnosis code as it related to the services reported in block 24D.
Block 24F Mandatory	Line item charges	Enter the charges for each line with a blank space separating the dollars and cents (ex., Enter $60.00 as 60 00).
Block 24G Mandatory	Days or units	Enter the units of service rendered for the procedure. Anesthesia billers: Record the time in minutes. DME: DME rentals must be billed using 1 unit/month of rental
Block 24J	Rendering provider NPI ID Number	Enter the NPI number for the rendering provider of that particular procedure code.
Block 25 Mandatory	Federal tax ID number	Enter the federal tax ID number for the rendering provider.
Block 26 Mandatory	Patient’s account number	Enter member’s account number.
Block 27 Not applicable	Assignment
Block 28 Mandatory	Total charge	Enter the sum of all line charges. Do not enter “Continued” in this block.

Block # and Requirement	Information	Instructions for CMS-1500 Form
Block 29 Mandatory	Amount paid by primary insurer (this field should be completed in conjunction with blocks 9a-9d)	Report payments you have already received from another insurer in this block. Attach a copy of the other insurer’s EOB and complete blocks 9a-9d. Please note: If the Plan is the secondary carrier, do not submit a claim until you’ve received the primary carrier’s payment and EOB.
Block 30 Mandatory	Balance due	Once you have received payment from another insurer, enter the balance due from the Plan.
Block 31 Mandatory	Signature of physician or supplier	Have the physician or supplier sign here.
Block 32 Mandatory	Name and address of facility where services were rendered	Enter the facility’s name and address.
Block 33, 33A, & 33B Mandatory	Physician/facility/supplier’s billing name, address, NPI and phone number	33. Enter the name and address of the provider/facility/supplier who should receive payment for the services identified on the claim. A. Enter the NPI ID number for the receiving provider/facility/supplier. (The NPI ID number must be listed in this block or the claim will not be processed.) B. Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Always make sure that the tax ID number in block 25 is the appropriate number for the designated payee.

2.16.3 Place of Service Codes (Block 24B of the CMS-1500 Form)

This section includes the place of service codes and descriptions. These codes should be used on professional claims to specify where a service was rendered; place of service codes must be submitted correctly for provider claims to be properly processed. The Plan recognizes the service codes mandated by HIPAA.

Place of Service Codes for CMS-1500 Form

Place of Service Code(s)	Place of Service Name	Place of Service Description for the CMS-1500 Form
01	Pharmacy	A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients
02	Unassigned	Not applicable
03	School	A facility whose primary purpose is education.
04	Homeless Shelter	A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g. emergency shelters, individual or family shelters).
05	Indian Health Service Free-Standing Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives who do not require hospitalization.
06	Indian Health service Provider-Based Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.
07	Tribal 638 Free-Standing Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization.
08	Tribal 638 Provider-Based Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients and outpatients.
09	Prison-correctional Facility	A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either federal, state, or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.
10	Unassigned	Not applicable
11	Office	Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
12	Home	Location, other than a hospital or other facility, where the patient receives care in a private residence.
13	Assisted Living Facility	Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services.

Place of Service Code(s)	Place of Service Name	Place of Service Description for the CMS-1500 Form
15	Mobile Unit	A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
16-19	Unassigned	Not applicable.
20	Urgent Care facility	Location, distinct from a hospital emergency room, and office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
21	Inpatient Hospital	A facility, other than psychiatric, which primarily provides diagnosis, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22	Outpatient Hospital	A portion of a hospital, which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23	Emergency Room Hospital	A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24	Ambulatory surgical Center	A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
25	Birthing Center	A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, or immediate postpartum care, as well as immediate care of newborn infants.
26	Military Treatment Facility	A medical facility operated by one or more or the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health service (USPHS) facilities now designated as Uniform Service Treatment Facilities (USTF).
27-30	Unassigned	Not applicable.
31	Skilled Nursing Facility	A facility which primarily provides to residents skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32	Nursing Facility	A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

Place of Service Code(s)	Place of Service Name	Place of Service Description for the CMS-1500 Form
33	Custodial Care Facility	A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34	Hospice	A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
35-40	Unassigned	Not applicable.
41	Ambulance – Land	A land vehicle specifically designed, equipped, and staffed for lifesaving and transporting the sick or injured.
42	Ambulance – Air or Water	An air or water vehicle specifically designed, equipped, and staffed for lifesaving and transporting the sick or injured.
43-48	Unassigned	Not applicable.
49	Independent Clinic	A location, not part of a hospital and not described by any other place of service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
50	Federally Qualified Health Center	A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51	Inpatient Psychiatric Facility	A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility – Partial Hospitalization	A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53	Community Mental Health Center (CMHC)	A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services, day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54	Intermediate Care Facility/ Mentally Retarded	A facility which primarily provides health related care and services above the level 9 of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

Place of Service Code(s)	Place of Service Name	Place of Service Description for the CMS-1500 Form
55	Residential Substance Abuse Treatment facility	A facility, which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56	Psychiatric Residential treatment Center	A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically, planned and professionally staffed group living and learning environment.
57	Non-residential Substance Abuse	A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
58-59	Unassigned	Not applicable.
60	Mass Immunization Center	A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall, but may include a physician office setting.
61	Comprehensive Inpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
63-64	Unassigned	Not applicable.
65	End-Stage Renal disease treatment Facility	A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
66-70	Unassigned	Not applicable.
71	Public Health clinic (formerly State or Local Public Health Center)	A facility maintained by either state or local health departments that provide ambulatory primary medical care under the general direction of a physician.
72	Rural Health Clinic	A certified facility, which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
73-80	Unassigned	Not applicable.
81	Independent Laboratory	A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.
82-98	Unassigned	Not applicable.
99	Other Place of Service	Other place of service not identified above.

2.16.4 Sample CMS-1500 Form

Sample CMS-1500 Form

2.17 UB-04 Claim Forms

2.17.1 Claim Form Requirements for the UB-04 Form

Bill for facility charges on the UB-04 Form based on the guidelines listed above. Submit claim/encounter forms for all services rendered. You can use a single UB-04 form for multiple dates of service and/or procedures.

The following information is required for all facility charges billed on a UB-04 Form:

Member’s name, address, and Plan member ID number. The member ID number is nine characters beginning with “B.” This number is on the member’s ID card.
Individual servicing provider’s name, attending physician’s name, address, phone, tax ID number, as well as the servicing provider’s NPI number. Claims submitted without an NPI number will be returned unprocessed. The NPI number must be placed in block 56 of the UB-04 Form.
Current ICD-9 diagnosis codes, bill types, CPT-4 and/or HCPCS codes (when applicable), and revenue codes and units.
When including ancillary or pharmacy charges, appropriate revenue code(s), CPT-4 and/or HCPCS codes are also required.
If billing the Plan as a secondary payer, include a copy of the primary carrier’s EOB, remittance advice, or letter of denial of service.
It is important to complete block 74 (code and date).

2.17.2 Step-by-Step Block Instructions for the UB-04 Form

This section describes how to complete a paper UB-04 form. The following chart indicates if a particular data element is mandatory, optional or not applicable. We have adopted HIPAA standards for claim submission.

Step-by-Step Block Instructions for the UB-04 Form

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 1 Mandatory	Provider Name and Address	Enter provider name and billing address- P.O. Box may be used for addresses. Phone and fax numbers are helpful if complications arise with the claim.
Block 2 Not Applicable	Pay to Name and Address	Do not enter any data in this block.
Block 3 Mandatory	Patient Control No.	A. Enter member account number. B. Enter the member medical record number.
Block 4 Mandatory	Type of Bill	4 positions is now required (submit leading 0) See section 2.18, Bill Type Codes.
Block 5 Mandatory	Federal Tax ID Number	Enter hospital/provider federal tax ID number. Federal tax ID numbers must be entered on all claims.
Block 6 Mandatory	Statement Covers Period	Enter beginning (from) and ending (through) dates for period covered by this bill (MMDDCCYY).

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 8a 8b Mandatory	Patient ID Patient Name	A. Enter the patient ID number B. Enter member’s last name, first name, and middle initial, if any (ex. MARTIN, JOHN F).
Block 9 Mandatory	Patient Address	Enter member’s full mailing address, including: A. Street number and name, P.O. box B. City C. State D. Zip code E. Country code
Block 10 Mandatory	Birth Date	Enter member’s date of birth as MMDDCCYY (ex. September 9, 1994 = 09091994).
Block 11 Mandatory	Sex	Enter M (male) or F (female)
Block 12 Mandatory	Admission Date	Enter month, day, and year of admission (MMDDCCYY).
Block 13 Mandatory	Admission HR (Hour)	Enter the two-digit code indicating time of admission. This information is required for outpatient claims with revenue codes in the 450-459 range.
Block 14 Mandatory	Admission Type	Enter the appropriate admission code. Required for inpatient services only.
Block 15 Mandatory	Admission SRC (Source)	Enter the appropriate source of admission code. Required for inpatient services only.
Block 16 Mandatory	D HR (Discharge Hour)	Enter the time the member was discharged. Required for inpatient and may be used for emergency room claims.
Block 17 Mandatory	STAT (Patient Status)	Enter the member status as of the through date of the billing period.

Block # and Requirement	Information	Instructions for the UB-04 Form
Blocks 18-28	Condition Codes	Enter the appropriate two-digit code(s); it must be a valid code per National Uniform Billing Committee (NUBC) guidelines.
Block 29	Accident State
Block 31-34	Occurrence Codes and Dates	The Plan requires all accident-related occurrence codes to be reported, especially when related to motor vehicle accidents. If code entered, it must be valid per NUBC guidelines.
Blocks 35-36	Occurrence Span	Enter code(s) and associated beginning (from) and ending (through) dated defining a specific event related to the billing period. If a code is entered, it must be valid per NUBC guidelines.
Block 38 Mandatory	Member name and address	Enter the full name and address of the member. First name, middle initial and last name order is accepted here only (ex. JOHN F. MARTIN)
Block 39-41 Not Applicable	Value Codes and Amounts	This category is used to identify any other payments made on this claim prior to the creation of this particular bill. If a code is entered, it must be valid per National Uniform Billing Committee (NUBC) guidelines.
Block 42 Mandatory	Rev. CD. (Revenue Code)	Enter four-digit uniform billing revenue code(s) to describe each type of accommodation and ancillary service billed. We accept HIPAA-compliant revenue codes.

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 43 Mandatory	Description (Revenue Description)	Enter the narrative description or a standard abbreviation for each revenue code. Show narrative on adjacent line using HCPCS/CPT-4, when possible. Revenue code descriptions must match revenue codes in block 42.
Block 44 Mandatory	HCPCS/Rates	When coding HCPCS (ex., outpatient surgery, outpatient or non-patient clinical diagnostic lab, radiology, and other diagnostic services), enter the common HCPCS/CPT-4 procedure code(s). Include the appropriate modifier, as necessary.
Block 45 Mandatory	Serv. Date (Service Date)	Enter the date of service using MMDDCCYY.
Block 46 Mandatory	Serv. Units (Units of Service)	Enter the number of units of service by day, visit, hour, or minutes, as applicable, for each service rendered on each reported line. Inpatient claims- enter number of days. Ancillary services- enter number of units, when applicable. Outpatient services- Enter number of units, when applicable.
Block 47 Mandatory	Total Charges	Enter the charge amount for each line item reported.
Block 48 Mandatory	Non-Covered Charges	Enter any non-reimbursable charges for the primary payer pertaining to the related revenue code.
Block 49 Not Applicable	Future Use	Not applicable.

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 50 a-c Mandatory	Payer (Payer Identification)	List all health insurance carriers on file. If applicable, attach an EOB from other carriers. Line a- Enter the name of the primary insurance carrier. Line b- Enter the name of the secondary insurance carrier. Line c- Enter the name of any other insurance carrier.
Block 51 a-c Mandatory	Health Plan ID	Health Plan Id assigned to the insurer.
Block 52 a-c Mandatory	Rel Info (Release of Information)	Enter “yes” or “no” for each insurance carrier.
Block 53 a-c Mandatory	Asg Ben (Assignment of Benefits)	For each insurance carrier, enter “Y” if assignment of benefits is on file or “N” if no assignment of benefits is on file.
Block 54 a-c Mandatory	Prior Payments (Payer and Patient)	Report all prior payment for the claim. Attach an EOB from the other carrier(s), when applicable.
Block 55 Optional	Est. Amount Due (Estimated Amount Due)
Block 56 Mandatory	NPI (National Provider Identifier)	Enter the provider number assigned to you.
Block 57	Other Provider ID	Optional for the provider legacy number

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 58 a-c Mandatory	Insured’s Name	Enter the name of the member (last name, first name) for each insurance indicated in block 50 a-c.
Block 59	P. Rel (Patient’s Relationship to Insured)	Enter patient’s relationship to insured. For the Plan this is always Self.
Block 60 a-c Mandatory	Insured’s Unique ID	Enter the ID number assigned to the member by the insurance carrier. Line a- enter the primary insurer’s member ID number (if the Plan is primary, enter the member ID number as shown on the member’s Plan ID card.) Line b- Enter the secondary insurer’s member ID number. Line c- Enter any other insurer’s member ID number.
Block 61	Group Name	Enter the name of the group or plan through which the member has insurance.
Block 62	Insurance Group No.	Enter the ID number, control number, or code assigned by the carrier or administrator to identify the group though which the member is covered.
Block 63	Treatment Authorization Codes	Enter the Plan’s prior authorization number for services or treatment.
Block 64 Mandatory (If Applicable)	Document Control #	The control number assigned to the original bill by the health plan or health plan’s fiscal agent as part of their internal control.
Block 65 a-c Mandatory (If Applicable)	Employer Name	If there is a higher priority insurance coverage than the Plan, and the other insurance is handled through an employer, the employers name must be listed in Block 65
Block 66 Mandatory	DX (Diagnosis Version Qualifier)	The qualifier that denotes the version of ICD (International Classification of Diseases) being reported. 9 = ninth edition; 0 = tenth edition

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 67 Mandatory	Principal Diagnosis Code	Enter the primary diagnosis code. Use ICD-9-CM coding protocols to sequence diagnoses shown to be chiefly responsible for the admission or the outpatient services. Code must be to the fourth or fifth digit specification, if applicable. If the diagnosis is accident-related, an occurrence code accident date is required.
Block 67 a-q Mandatory	Other Diagnosis Codes	Enter the ICD-9-CM for any additional secondary diagnoses if they co-existed at the time of the admission or developed subsequently. The codes must be to the fourth or the fifth digit specification, if applicable. If another diagnosis applies to a member, it must be listed.
Block 69 Mandatory if inpatient	Admit Dx (Admitting Diagnosis)	Enter the ICD-9-CM diagnosis code provided by the physician at the time of admission.
Block 70	Patient Reason Dx	Patient’s reason for the visit.
Box 71 Mandatory For Inpatient	PPS (Prospective Payment System) Enter DRG here	The diagnosis related group number is required for all inpatient claims.
Block 72 Mandatory for Applicable Services Only	ECI (External Cause of Injury)	Enter the ICD-9-CM code for the external cause of an injury, poisoning, or adverse effect. The E-code range E930-E949 (drugs, medicinal, and biological substances causing adverse effects in therapeutic use) are required, if applicable.
Block 73	Reserved

Block # and Requirement	Information	Instructions for the UB-04 Form
Block 73 Mandatory	Untitled	Enter the hospital assigned DRG group number for all inpatient bills. Inpatient acute care bills submitted without a DRG will be denied.
Block 74 Mandatory if applicable	Principal Procedure (Code and Date)	Enter the ICD-9-CM procedure code to the fourth or fifth digit specifications, if applicable, to describe the principal procedure performed for the service billed. This is required for all inpatient and outpatient surgeries. Enter the date (MMDDCCYY) of the procedure.
Block 76 Mandatory	Attending (Attending, Ordering, Referring Physician)	Enter the ordering physician’s NPI, qualifications, physician’s last name, first name and middle initial. In the absence of an ordering physician, enter the attending physician’s information. Do not enter generic information.
Block 77 Mandatory, if applicable	Operating (Operating Physician)	Enter the operating physician’s NPI, qualification, physician’s last name, first name, and middle initial.
Blocks 78/79 Mandatory, if applicable	Other (Any other servicing physicians)	Enter the other(s) physician’s NPI, qualifications, physician’s last name, first name, and middle initial.
Block 80	Remarks	Enter any additional information pertaining to the claim.
Block 81	Code-code field	Required. Providers submitting claims for their primary facility and its subparts will report their taxonomy code on all their claims submitted. The taxonomy code will assist in cross walking from the NPI of the provider to each of its subparts when a provider has chosen not to apply for a unique national provider number for those subparts individually.

2.18 Bill Type Codes for Block 4 of the UB-04 Form

Type of Bill
A. Must not have spaces B. Must be a valid code for hospital billing. Valid codes are:
First Digit- Type of Facility
1	Hospital
Note: Hospital based multi-unit complexes may also have use for the following first digits when billing non-hospital services:
2	Skilled Nursing
3	Home Health
4	Christian Science (Hospital)
5	Christian Science (Extended Care)
7	Clinic- See special coding for second digit below
8
Second Digit - Classification (if first digit is 1-5)
1	Inpatient (Part A)
2	Inpatient (Part B)- Includes HHA visits under a Part B plan of treatment
3	Outpatient- Includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment
4	Other (Part B)- Includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnosis clinical laboratory services for "non-patients"
8	Swing bed
Second Digit- Classification (first digit is 7)
1	Rural Health
2	Freestanding Renal Dialysis Center
3	Independent Provider-Based Federally Qualified Health Centers
4	Other Rehabilitation Facility (ORF) or Community Mental Health Center (CMHC)
5	Comprehensive Rehabilitation Facility (CORF)
Second Digit - Classification (first digit is 8)
1	Hospice (Non-hospital based)
2	Hospice (Hospital based)
3	Hospital Outpatient (ASC procedure)
Third Digit - Frequency
0	No payment
1	Full billing (payment)
2	First interim
3	Continuing interim
4	Final interim
5	Late charge
7	Correction
8	Void/Cancel

2.18.1 Sample UB-04 Form

Sample UB-04 Form

2.19 Sample BMC HealthNet Plan Remittance Advice

BMCHP Sample Remittance Advice