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

  • Admission notification is required for the following:

    • All acute care hospital admissions and discharges.
    • Free-standing psychiatric hospital admissions and discharges.
    • Maternity admission after 48 hours for vaginal delivery and after 96 hours for cesarean delivery.
    • Neonatal Intensive Care Unit (NICU)

    Prior authorization is required instead of admit notification for the following intermediate levels of care:

    • Long term acute care hospital
    • Inpatient rehabilitation facility/unit (IPR)
    • Skilled nursing facility (SNF)
    • Residential Treatment Center (RTC)
    • Notify us of urgent/emergent admissions within 48 hours of the admission.
    • To notify us of an inpatient admission, sign in and use our prior authorization tool or complete an admission notification fax form and fax it to 888-742-1487.
    • Some planned procedures, surgeries, and other services require prior authorization and/or medical necessity and inpatient admission and discharge notification. See our code list for requirements
    • If the procedure or condition is subject to medical necessity review, a request for a prior authorization review should be submitted before the member is admitted to the hospital.

    Call 877-342-5258, option 3, with questions.

    Please have the following information available when you notify us of an 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 Change Healthcare InterQual® criteria, American Society of Addiction Medicine criteria and plan medical policy to determine the medical necessity of member admission and length of stay for all medical, surgical, 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 by the National Uniform Billing Committee (NUBC) in the most current Official UB-04 Data Specifications 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 field on the claim form.

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

    For additional information you can reference:

  • There are 81 data fields on a UB-04 claim form. Careful attention should be paid to the following items on the UB-04 will assist in processing your claim accurately and promptly. The examples provided below do not represent ALL the 81 fields but some of the most critical fields and some of the most common examples:

    Type of Bill (form locater 4): 0NNN

    • The first digit is always a zero
    • The second digit indicates the type of facility:
      • 1 - Hospital
      • 2 - Skilled Nursing Facility
      • 3 - Home Health
      • 7 - Clinic
      • 8 - Special facility or ASC Surgery
    • The third digit is the bill classification:
      • 1 – Inpatient
      • 3 – Outpatient
      • 4 – Lab Services
      • 8 – Swing Beds
    • The fourth digit indicates the frequency of the bill:
      • 0 – Non-payment claim
      • 1 – Admit through Discharge claim
      • 2, 3 – Interim Claim- first and continuing interim claim respectively
      • 4 – Last Interim claim
      • 7 – Replacement claim

    Patient Discharge Status (form locater 17): The patient discharge status code is a required item and must be available to identify transfer situations. This code represents the patient’s disposition or discharge status at the ending date of service for the period of care such as:

    • 01 – Discharged home
    • 02 - Transfer to a short-term hospital
    • 03 – Transfer to a Skilled Nursing Home
    • 07 - Left against medical advice
    • 20 – Patient expired
    • 30 - Still a patient

    Condition Codes (form locators 18-26): these codes provide additional information on the condition of the patient that may affect processing of the claim.

    • 21 – Billing for denial notice
    • 38 – Semi-private room not available
    • 39 – Private room per medical necessity
    • 44 – Inpatient admission changed to an Outpatient

    Occurrence Codes (form locaters 31 - 36): Occurrence codes and dates should be completed for all accident, maternity, and illness claims.

    Value Codes and Amounts (form locater 39): These fields contain codes and related dollar amounts that are necessary to process and reimburse the claim correctly. Entries in these fields can represent semi-private room rates, blood deductibles, coinsurance amounts, dialysis charges to name a few.

    Revenue Codes (form locator 42): Revenue codes represent a specific accommodation and/or ancillary service. The revenue code must be four digits.

    HCPCS/Rate/HIPPS Codes (form locator 44): Enter a HCPCS code applicable for the ancillary service for outpatient claims, a HIPPS rate code, or the inpatient accommodation rate. A HCPCS code is required when a drug or biological is reported. An accommodation rate is required when a room and board revenue code is billed (revenue codes 0100s through 0219)

    Service Date (form locator 45): The dates for when the service indicated was provided.

    • 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.

    Diagnosis Codes (form locators 67, 67a – 67q, 69): Enter ICD-10 CM diagnosis codes.

    • Field 67 – The patient condition established after inpatient discharge or outpatient procedure
    • Fields 67a-67q – Corresponding conditions existing at the time of the inpatient admission or outpatient procedure
    • Field 69 – The patient’s diagnosis at the time of admission

    Procedure Codes (form locator 74, 74a – 74e):

    • Field 74 – the principal procedure performed for the period represented on the claim (from – through dates); ICD-10 PCS procedure codes are required for inpatient claims and CPT procedure codes are required for outpatient claims
    • Fields 74a-74e – up to five additional PCS procedure codes (Inpatient) and CPT procedure codes (Outpatient) along with date of service when the procedure was rendered

    Remarks (form locater 80): Additional information needed to help in the processing of the claim.

    • When billing for secondary coverage, document the level of care in the Remarks field.
    • When billing for non-covered days, enter a description of the non-covered days

    Special facility billing scenarios

    Maternity Claims:

    • All mother/baby bills should be submitted as two separate claims, batched together for either paper or electronic submission.
    • Claims submitted for deliveries should also be coded with a diagnosis that identifies the “outcome” of the delivery using an ICD-10 CM diagnosis code

    Age of Patient and Age Bands of Diagnosis codes or Procedure Codes: The age of a patient should match the same age band of a diagnosis code or procedure code:

    • ICD-10-CM diagnosis code Z00.111 - Health examination for newborn 8 to 28 days old and the patient age is 5 years old.
    • CPT procedure code 99385 – Preventive medicine examination, 18-39 years and the patient age is 47 years old
  • 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 interim claim: Bill type 112
    • Subsequent interim 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.
    • The discharge status code (form locator 17) should be “30-still a patient”  if the patient is “still a patient” during the interim billing, whether Inpatient or outpatient
    • Final claim: Bill type 114. The final claim must include all diagnosis and ICD-10 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 for inpatient claims and outpatient payment methodology for outpatient claims.. The final bill (bill type 114) will determine whether additional reimbursement or an adjustment will be made. If the final bill is being “replaced” in its entirety, the bill type must be 117 to represent a replacement of prior claim(s).

    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. Change the “bill type” (field 4) to represent “late charges only” (bill type 115).

  • 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 ASC APC methodology, are paid a facility fee modeled after CMS. We supplement the list with additional procedures. Reference the facility agreement to confirm your specific billing, reimbursement methodology, and reimbursement rates.

    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.