UB-04 Billing

  • Credentialing

  • Premera follows national credentialing standards regarding the staff in a hospital system who must be credentialed. See the Credentialing and Contracting section of this manual for more information.

  • Admission Notification

    • Inpatient admissions – Nonemergency, elective, or scheduled admissions (including mental health and chemical dependency)
    • Skilled nursing facility and acute rehabilitation admissions
    • Acute care hospitals
    • Inpatient hospice
    • Mental health and chemical dependency residential treatment centers
    • Notify us of urgent/emergent admissions within 48 hours of the admission.
    • Maternity admissions related to delivery do not require admission notification for the first 48 hours for vaginal delivery or the first 96 hours for C-section. Inpatient stays beyond the first 48 hours for vaginal delivery or the first 96 hours for C-section require admission notification.
    • The admission notification process should be completed prior to admission for other scheduled, elective procedures.
    • If the procedure or condition is subject to medical necessity review, a request for a benefit advisory/prior authorization review should be submitted before the member is admitted to the hospital.

    Complete the Admission Notification form; fax contact numbers are noted on the form. You may also fax in the hospital census to 800-866-4198.

    Call 800-596-3382, option 3, with questions.

    Please have the following information available when you report a medical, mental health or chemical dependency inpatient or residential treatment admission:

    • Facility name
    • Facility phone number
    • Member name and/or identification number
    • Health plan product
    • Actual date of admission
    • Attending physician or other provider
    • If available, admitting procedure code (English or ICD/CPT code)
  • Medical Necessity Criteria

    We use American Society of Addiction Medicine criteria and plan medical policy to determine the medical necessity of each member admission and length of stay for all medical, mental health, and chemical dependency facility-based treatments.

    Transfers

  • A discharge planner notifies Care Management about the possibility of a patient facility transfer. When this occurs, Care Management helps facilitate a transfer to a contracted facility whenever medically appropriate.

    Prior to all non-emergent transfers, please confirm with Customer Service that the facility is contracted for the health plan and contracted for the proposed services. Some facilities have contracts limited to special or limited services and are not contracted for all services they provide.

    Some member contracts will allow the use of a non-contracted facility at a lower benefit level. For non-emergent transfers, contact Customer Service to determine if the member contract allows for the lower level of reimbursement. Medically necessary services that cannot be reasonably provided at a contracted facility within the product-specific network will be prospectively assessed for possible authorization of non-contracted provider use at the maximum benefit level.

    In an emergency, members may be hospitalized at non-contracted facilities. We will assess each member's situation for appropriateness of a transfer to a contracted facility. Transfer decisions are made based on our policy for medical stability, attending physician or other provider agreements, member and/or family agreement to transfer, and expected duration of stay.

    To contact Care Management, please call 877-342-5258, 800-596-3382, 800-722-4714, option 3.

  • Hospital Bill Audits

    Calypso provides investigation and recovery services for us and our subsidiaries and affiliates. Calypso administers the hospital bill audit process on our behalf. The purpose of the audit is to:

    • Compare the provider’s billed charges to documentation in the medical records and ensure that services to our members are ordered, documented, administered, coded, and billed correctly.
    • Compare the provider’s coding on a claim against the provider’s contract.
    • Compare the provider’s billed charges to our contract exclusion list for inpatient services.
  • When the audit is complete, the auditor will meet with a hospital auditor to review the findings. This could result in refunds and/or the reprocessing of claims to pay additional benefits. For questions about Calypso processes, please call 800-364-2991.

  • UB-04 (CMS 1450) billing guidelines

    The Centers for Medicare and Medicaid Services (CMS) form 1450, referred to as the UB-04, is the standard claim form used to bill facility services to us and our affiliates. Submitting the claim form with all required fields will assist us in paying your claim in a timely manner. Claim forms that are missing one or more of the required fields may be rejected or denied.

    It is necessary to follow the guidelines provided in the National Uniform Billing Manual when completing this form for all facility services rendered to a member. It is also necessary to follow the established definitions and guidelines for each type of diagnosis or procedure code used (i.e., CPT, ICD, and HCPCS).

    When completing the form be sure to include information regarding other insurance coverage, the facility tax identification number, itemized dates of service, procedure codes, and revenue codes to assist in proper and timely payment of all claims.

    For additional information you can reference:

    • The National Uniform Billing Manual at nubc.org.
    • The Medicare Hospital Manual at cms.hhs.gov in the Regulations and Guidance & Standards - Manuals section (reference Paper-Based Manuals).
    • Diagnosis and procedure code guidelines at cms.hhs.gov/home/medicare.asp in the Coding section.
  • Careful attention to the following items on the UB-04 will also assist us in processing your claim accurately and promptly:

    • Type of Bill (form locater 4): The third digit of the type of bill indicates whether the bill is a final, interim, corrected, or supplemental claim. This affects the benefit payment so be sure to use the appropriate code to avoid incorrect payment and subsequent reprocessing of a claim.
    • Patient Status (form locater 17): The patient status code is a required item and must be available to identify transfer situations.
    • Condition Codes (form locators 18-26): Condition Code 38 should be billed when a semi-private room was not available. Condition Code 39 should be billed when a private room was medically necessary.
    • Occurrence Codes (form locaters 31 - 36): Occurrence codes and dates should be completed for all accident, maternity, and illness claims.
    • Room Rate (form locater 39): Indicate the semi-private room rate. Facilities that do not have a semi-private room rate for the service should include the private room rate dollar value in this field.
    • Revenue Codes (form locator 42): Revenue codes must be four digits.
    • Service Date (form locator 45):
      • Outpatient Claims: This is a mandatory field and must be populated.
      • Inpatient Claims: Room and board lines must be itemized-one line for each date of service.
    • Skilled Nursing Facility Claims (form locater 80): When billing for secondary coverage, document the level of care in the remarks field.
    • Maternity Claims: All mother/baby bills should be submitted as two separate claims, batched together for either paper or electronic submission.
  • Reimbursement

    Reimbursement is subject to the terms defined in the contract between the facility and us. Final payment is subject to our fee schedule and payment policies, a member’s eligibility, coverage and benefit limits at the time of service, and claims adjudication edits common to the industry and/or adopted as our Payment Policy.

  • Please submit interim bills for lengths of stay in excess of 30 days with the following criteria. Interim bills submitted with lengths of stay less than 30 days will be returned to the facility.

    • Initial claim: Bill type 112
    • Subsequent claim(s): Bill type 113
    • The admission date should be the same on all related claims. The beginning and ending dates must reflect the dates of service being billed for each subsequent claim.
    • The interim claims must be billed in date sequential order.
    • Final claim: Bill type 114 or 117. The final claim must include all diagnosis and ICD procedure codes related to the entire stay. The beginning and ending dates must reflect the admission and discharge date (entire stay).

    Each interim claim will be processed based on the computed DRG, APDRG or MS-DRG. The final bill (bill type 114 or 117) will determine whether additional reimbursement or an adjustment will be made.

    Supplemental claims should be submitted when an additional charge is realized after the final claim has been submitted. If you are submitting a late charge, indicate the additional charges and the beginning and ending dates of service. Late charges are added to the original claim and processed according to contractual agreements.

  • Ambulatory Surgery Centers

    An Ambulatory Surgery Center (ASC) is a freestanding facility, other than a physician or other provider's office, where surgical and diagnostic services are provided on an ambulatory basis.

    Ambulatory Payment Classification Methodology

    Most ASCs contracted with us use a payment methodology modeled after the CMS Ambulatory Payment Classification (APC) methodology for ASCs, with services billed on a CMS-1500 claim form. ASCs, whose payment is based on the Medicare APC methodology, are paid a facility fee modeled after CMS. We supplement the list with additional procedures.

    Note: The physician or other provider who performs the surgery in an ASC is also paid for his or her professional services. A claim is filed for the physician or other provider services, separate from the ASC facility services.

    Note: Reference the facility agreement to confirm your specific billing, reimbursement methodology, and reimbursement rates.