Online Claim Entry UB-04

1. Online Claim Entry UB-04 Presented by: Xerox State Healthcare, LLC Provider Relations

2. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

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

4. Important State Websites STATE WEBSITES: PROGRAM POLICY MANUAL • http://www.hsd.state.nm.us/mad/policymanual.html BILLING INSTRUCTIONS • http://www.hsd.state.nm.us/mad/billinginstructions.html REGISTERS AND SUPPLEMENTS: • http://www.hsd.state.nm.us/mad/registers/2012.html

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

6. Claim Form Instructions

7. Where to get a copy of claim form instructions Click Forms , Publications, and Instructions under Provider Information

8. Where to get a copy of claim form instructions Scroll down Open file

9. Timely Filing

10. What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= Credit 91308700085000001 The first digit indicates what the claim “media” is: 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim 9 = Web portal claim entry Batch number The last two digits of the year the claim was received The claim number within the batch. The numeric day of the year. This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87th day of 2013, or March 28, 2013

11. Timely Filing Denials Re-filing Claims and Submitting Adjustments UB-04 form: Put the TCN in block 64 on the paper form. 1 1 8,100 00 0001 082807 123456789 MEDICAID CONNIE CLIENT

12. NCCI National Corrective Coding Initiative

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

14. NCCI (National Corrective Coding Initiative) • RA EOB Codes: • 6501 or 6502 - Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service. • 6503 through 6505 - Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit. • Please visit the link below for any additional information: • http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html

15. New Hospital Outpatient Payment Method

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

17. New Hospital Outpatient Payment Method for New Mexico Medicaid • The following resources are available on the HSD/MAD website located at: • http://www.hsd.state.nm.us/mad/PFeeSchedules.html • Hospital Outpatient Payment Method FAQ • Hospital Outpatient Payment Method Revenue Codes • Hospital Outpatient Payment Method Procedure Codes • Notice of Hospital Outpatient Prospective payment System Rates • Explanation of Simulation Spreadsheet for Outpatient services

18. Add/Manage Templates

19. UB-04 - Add Claim Template Please note template are limited to 25 per user. HINT: think about use procedure code, or dates (billing range dates) The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice.

20. UB-04 - Add Claim Template Fill out any information you would like included in your template

21. UB-04 - Add Claim Template Fill out any information you would like included in your template

22. UB-04 - Add Claim Template Fill out any information you would like included in your template

23. UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text. View next slide for additional fields.

24. UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with Red Text.

25. UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with RedText.

26. UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with RedText.

27. UB-04 - Add Claim Template Fill out any information you would like included in your template. Sections can be expanded by checking all sections with RedText.

28. UB-04 - Manage Claim Template Edit or Delete created templates

29. Medicaid Primary Claim Forms

30. Online Claims Entry To begin the claim submission, all field with a RED asterisk (*) must be completed

31. Online Claims Entry Primary Claim (Cont.) Click on the RedText for the UB-04 Claim form instructions

32. Additional Information Option Sections can be expanded by selecting all sections with Red Text

33. Online Claims Entry Primary Claim (Cont.) Sections can be expanded by selecting all sections with Red Text

34. Online Claims Entry Primary Claim (Cont.) Sections can be expanded by selecting all sections with Red Text

35. Online Claims Entry Primary Claim (Cont.) Click upload

36. Online Claims Entry Primary Claim (Cont.) Review the Uploading Attachments Restrictions. You can attach files up to 10 MB Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files.

37. Online Claims Entry Primary Claim (Cont.) All field with a RedAsterisk (*)are REQUIRED fields Diagnosis codes do not require a period(.) Only enter the numeric value

38. Online Claims Entry Primary Claim (Cont.) Indicate the Total charge x Verify Total charge is correct If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits.

39. Medicaid Third Party Liability (TPL) Claim

40. Third Party Liability (TPL) Tips • TPL is commercial insurance • TPL must be billed primary to Medicaid • Medicaid does not consider Medicare TPL

41. Third Party Liability (TPL) Tips • Always enter the amount paid in the “Paid Amount” field provided in the “Other Insurance Info” section of claim. • If Medicaid requires a PA for the service, then a PA issued by Medicaid Utilization Review is always required when TPL is involved, no matter if TPL paid or denied the service. • Attach the TPL EOB showing the payment/denial with the claim. • Always include the explanation page of the EOB along with the page of the EOB that shows payment/denial.

42. MedicaidTPLClaimExample Indicate Paid Amount

43. MedicaidTPLClaimExample Indicate the Total charge TPL Payment Co-pay/Co-insurance/ Deductible x Verify Total charge is correct If total change is missing or does not match up with the line item provided on the claim, the claim will deny or post additional edits.

44. Medicaid Co-payment Claim Forms

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

46. HMO Co-pay Claim Example Indicate Copay amount

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

48. Medicare Replacement Plan Claim Forms

49. Medicare Replacement Plan Indicate “Medicare Advantage” for Medicare Replacement Plan

50. Medicare Replacement Plan Attach Copy of EOB