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EDI UB-04 Claims Processing Procedures (Part 4)

Edi ub-04 claims procedures (security health plan).

EDI UB-04 Claims processing procedures: EDI UB-04 Claims completion for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies and other institutional providers ( Continuation).

51. Health plan ID   – Providers’ current Medicare Provider Number.

52. Release of information certification indicator – This field indicates whether the provider has on file a signed statement from the beneficiary permitting the provider to release data to other organizations in order to adjudicate the claim. (Required)

53. Assignment of benefit certification indicator – This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service.

54. Prior payments – payers and patient – The amount the hospital has received toward payment of this bill prior to the billing date for the payer indicated in field 50 on lines a., b., and c. for outpatient claims and all other third-party payers. (Required)

55. Estimated amount due – An estimate by the hospital of the amount due from the indicated payer in field 50 on lines a., b., and c., or from the patient (estimated responsibility less any prior payments).

56. NPI   – National Provider Identifier (Type 2 for organization required).

57.   Other Provider ID – This field is not used for provider reporting. For National use only.

58.   Insured’s name – Name of the patient or insured individual in whose name the insurance is issued as qualified by the payer organization listed in field 50 on lines a., b., and c. (Required)

59. Patient’s relationship to insured – This field contains the code that indicates the relationship of the patient to the insured individuals identified in field 58 on lines a., b., and c. (Required) when Medicare is the secondary or tertiary payer.

60. Certificate/Social Security Number/health insurance claim/identification number – The insured’s identification number assigned by the payer organization. This field allows 19 alphanumeric characters in three lines. (Required)

61.   Insured group name – The group or plan through which the health insurance coverage is provided to the insured. (Required)

62. Insurance group number   – The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered.

63. Treatment authorization codes   – A number or other indicator that designates that the treatment covered by this bill has been authorized by the payer indicated in field 50 on lines a., b., and c. (Required)

64. Document control number   – Not required.

65. Employer name of the insured   – Name of the employer that provides health care coverage for the insured individual identified in field 58 on lines a., b., and c. This field allows for 24 alphanumeric characters on each of three lines. (Required)

UB-04 Claims Processing Procedures (Part 1) 

UB-04 Claims Processing Procedures (Part 2)

UB-04 Claims Processing Procedures (Part 3)

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  Enter Other Payer

In addition to NY Medicaid, you may enter additional payers who are responsible for this claim. Remember that all elements marked with an asterisk ( * ) are required when entering a Payer. Not all claims will have Other Payer information. Note: A maximum of 10 Other Payer records may be entered per claim.

Other Payer Information

Other Payer Name: Select the name of the desired payer from the provided list. If the Other Payer you are looking for is not listed, contact your Administrator to add the Payer to the Support File of valid Payers. Required for all Other Payers. Payer Sequence Number: Select the value that represents the order in which payment was received from other payers. Payers may be entered in any sequence and displayed in any sequence. Required for all Other Payers.

Payer Type: A code identifying the type of Payer. Enter or select a value from the list of available codes.

Other Payer Paid Amount: This field is required when this payer has adjudicated the claim. If the Other Payer denied the claim, enter 0. If the Other Payer has not adjudicated the claim, leave blank. If a value is entered, the Date Claim Paid must be entered as well.

Other Payer Claim Control Number:  Enter the claim control number of the other payer.

Date Claim Paid: Date on which the Other Payer Paid Amount was received. This date may not be greater than the current date. The format is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.

Other Subscriber

Last Name/First Name: If entering an Other Payer, you must enter the First and Last Name of the Subscriber for the Payer. The Subscriber may or may not be the Client.

Primary ID: The Other Insured Identifier as assigned by the Payer. This is required when entering the Subscriber for the Other Payer.

Address Line 1/2: The street address of the Subscriber, if known.

City: Enter city name of the Subscriber.

State: State in which the Subscriber lives. Select value from the list of available valid state abbreviations, defaults to 'NY'.

Zip Code: Enter the postal Code associated with the Subscriber's address.

Country: Country in which the Subscriber lives. Select value from the list of available countries, defaults to 'US'.

Other Subscriber Information

Relationship: Code indicating the relationship between the Client/Patient and the Subscriber for this Payer. Enter or select a value from the list of available codes. A relationship is required if a Subscriber is entered.

Group Number: Enter the Subscriber’s group number for the other payer when applicable.

Group Name: The Group Name associated with the Group Number above.

Claim Adjustments

If the other payer reported claim adjustments at the claim level, enter the adjustment information here. Otherwise, this information will be blank. Claim adjustment group codes and reason codes are from the remittance of the other payer.

Claim Adjustment Group: Enter the Group Code as received from the other payer. A maximum of 5 Claim Adjustment Groups are allowed per claim and the values are to be entered. Reason Code: Enter the Claim Adjustment Reason Code as received from the other payer. The Claim Adjustment Group/Reason Code combination may not be entered more than once. If an Adjustment Amount or Adjustment Quantity is entered, a Reason Code is required. Adjustment Amount: Enter the Adjustment Amount as received from the other payer. Adjustment Quantity: Enter the Quantity Adjusted as received from the other payer.

Other Insurance Coverage Information

Assignment of Benefits?: The Benefits Assignment Certification Indicator. 'Yes' indicates insured or authorized person authorizes benefits to be assigned to the provider while 'No' indicates that no authorization has been given. This value will default to 'Yes' and is required if an Other Payer Name is selected.

Patient Signature Source: Enter or select the Patient Signature Source Code, indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. An entry is required if an Other Payer Name is selected.

Release of Information?: Indicates whether the provider has a signed statement by the patient authorizing the release of medical data to other organizations. This value is required if an Other Payer Name is selected.

Remaining Patient Liability: This is the amount the provider believes is due and owing after the Other Payer’s adjudication.

Non-Covered Charge Amount: Enter the dollar value of the claim in this field if the other payer was not billed, and documentation is on file that the other payer would not have paid the claim.

Once all the information for the Payer has been added, another payer may be added by clicking the Next Payer>> control at the top or bottom of the tab. This will return you to the top of the page with all the values cleared out and a new Payer Number listed at the top of the page. Clicking View All Other Payers will display the Other Payers Summary page.

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  • Medicare Overview of Billing and Claims Payment Policy
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ConnectiCare will process Medicare claims according to Medicare payment rules and specialty society guidelines, unless specified otherwise in a provider contract. If a billing or claims payment policy for a particular service is not addressed in this section, follow procedures that are considered standard rules of the Centers for Medicare & Medicaid Services (CMS). This information is available at the CMS website . ConnectiCare applies the CMS National Correct Coding Initiative (NCCI) edits for claims editing. Certain inpatient evaluation and management procedures are identified in the NCCI manual as not being separately reimbursable, even if a modifier such as modifier 25 is added to the procedure code. NCCI edits apply to claims from all providers in the same specialty and group. There are no exceptions to these edits based on sub-specialty or different diagnoses. Please refer to the CMS NCCI manual regarding reporting of evaluation and management services as needed.

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If you have any questions, please call Provider Services at 860-674-5850 or 800-828-3407.

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Claim Edits

ConnectiCare evaluates medical billing information and coding for accuracy and appropriateness. This practice is designed to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures.

In addition, ConnectiCare’s claims payment system will adjudicate claims based on CMS (Centers for Medicare & Medicaid Services) and NCCI (National Correct Coding Initiative) edits. ConnectiCare considers coding edits that are based on industry sources, including but not limited to CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there are conflicts between sources, ConnectiCare will apply edits that ConnectiCare determines are most appropriate.

For questions about why a particular claim was denied based on a coding edit, refer to your remittance, or call Provider Services at 877-224-8230 .

Medicare PPM/2.10

ConnectiCare has policies in place that reflect billing or claims payment processes unique to our health plans. Current billing and claims payment policies apply to all our products, unless otherwise noted. ConnectiCare will inform you of new policies or changes in policies through updates to the Provider Manual and/or provider news. If a billing or claims payment policy for a particular service is not addressed in this outline, follow procedures that are considered standard throughout the health care industry. Most of ConnectiCare’s billing and claims payment policies are standard in the health insurance industry, and you should follow industry standard procedures for issues that are not specifically addressed in the Provider Manual.  

We also evaluate medical billing information to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures. ConnectiCare reserves the right to audit physician documentation in order to verify coding and billing accuracy.  

ConnectiCare's claims system will process claims based on Centers for Medicare & Medicaid Services (CMS) and National Correct Coding Initiative (NCCI) edits. ConnectiCare follows coding edits that are based on industry sources, including, but not limited to, CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there appears to be conflicts between sources, we will apply the edits we determine are appropriate. ConnectiCare uses industry-standard claims editing software products when making decisions about appropriate claim editing practices. Upon request, we will provide an explanation of how ConnectiCare handles specific coding issues.

If you have any questions, please call Provider Services at 860-674-5850 or 800-828-3407 .

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COMMENTS

  1. PDF CMS Manual System

    authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for

  2. CMS 1500 Claim Form Instructions Tool

    CLM08 - Certification Indicator: Loop 2320 - OI03 - Benefits assignment: Item 14. Enter the date of the current illness, injury or pregnancy. For Chiropractic services, enter the date of the initiation of the course of treatment. Loop 2300 - DTP01 - 439 qualifier:

  3. PDF ) Crosswalk for Paper/Electronic Claims

    CLM08- Certification Indicator Loop 2320 - OI03- Benefits assignment 14 Enter the date of the current illness, injury or pregnancy. For Chiropractic services, enter the date of the initiation of the course of treatment. Loop 2300 - DTP01- 439 qualifier DTP03- Accident Date DTP01- 431 qualifier

  4. PDF UB-04 Facility Claim Form Instructions

    Assignment of Benefits Certification Indicator. This field conveys that the provider has a signed form from the patient authorizing the payer to remit payment directly to the provider. Valid entries are Y (Yes) and N (No). Line A Required Lines B and C Conditional 54 PRIOR PAYMENTS

  5. Paper to Electronic Claim Crosswalk (5010)

    Indicator's must equal one of the following values: 12,13,14,15,16,41,42,43 or 47 if 2000B SBR01 = "T" or "S" ... Assignment of Benefits Indicator. QI06. Release of information code. 14. Date of current illness, injury or pregnancy. 2300. DTP01. ... CLIA Certification number. Ambulance point of pickup. 2310E. NM101. Entity identifier ...

  6. EDI CMS-1500 Crosswalk ANSI 837P

    2300 CLM10 175 Benefits assignments Certification indicator Benefits Assignment Indicator is required. Y = Yes; N = No 2320 O103 345 Benefits Assignment Indicator is required. Y = Yes; N = No 14 Date of current: illness, injury, pregnancy 2300 DTP03 (439) 194 Accident date Required if Related Cause code (CLM11-1, -2 or -3) = Auto Accident

  7. PDF National Uniform Claim Committee

    2300 CLM08 Titled Benefits Assignment Certification Indicator in the 837P. 14 Date of Current Illness, Injury, Pregnancy (LMP) 2300 DTP01 DTP03 Titled in the 837P: Date - Onset of Current Illness or Symptom Date - Last Menstrual Period . Version 3.3 8/18 5 1500 Form Locator 837P Notes Item

  8. EDI UB-04 Claims Processing Procedures (Part 4)

    Assignment of benefit certification indicator - This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service. 54. Prior payments - payers and patient - The amount the hospital has received toward payment of this bill prior to the billing date for the payer ...

  9. PDF HRSA COVID-19 Uninsured Claim Companion Guide

    The Benefit Assignment Certification Indicator must be set to Y (Yes) indicating the uninsured individual has assigned the benefits to the provider. Any other value will result in a rejected claim. *Please note: Individual claims cannot exceed 400 SVC segments. Please split a single claim that contain s more than 400 SVC segments into multiple ...

  10. Prof Enter Other Payer

    The Benefits Assignment Certification Indicator. 'Yes' indicates insured or authorized person authorizes benefits to be assigned to the provider while 'No' indicates that no authorization has been given. This value will default to 'Yes' and is required if an Other Payer Name is selected. Patient ...

  11. Medicare Part B CMS-1500 Crosswalk for 5010 Electronic Claims

    Benefits Assignments Certification Indicator . This item authorizes payment of medical benefits to the physician. 2320 . QI03 . Assignment of Benefits Indicator . N No; W Not applicable. Use code "W" when the patient refuses to assign benefits; Y Yes . Item No. Claim Description . Loop .

  12. PDF 1500 Form Mapping to 837 Claim Transaction

    2300 CLM08 Titled Benefits Assignment Certification Indicato 14 rrent y, 2300 DTP03 1. Onset of current illness or injury date. 2. Acute manifestation 4. Last menstrual period date. ... Titled Emergency Indicator in the 837P. 24D or upplies 400 (2-6) itled Product/Service ID and Procedure Modifier in the 837P. Procedures, Services, S 2400 2 SV101 T

  13. Claim Status Codes

    Payment made to entity, assignment of benefits not on file. Usage: This code requires use of an Entity Code. Start: 01/01/1995 | Last Modified: 07/01/2017 ... Certification Condition Indicator Start: 10/31/2004: 528: Certification Period Projected Visit Count Start: 10/31/2004: 529: Certification Revision Date

  14. PDF medicare assignment not accepted

    These updates will allow payments to be issued to the provider when the "Provider Accept Assignment Code" indicator in the CLM07 (Loop 2300) states "C" (Non-Assigned) and the "Benefit Assignment Certification" indicator in the CLM08 (Loop 2300) states "Y" (Yes), indicating that the insured/member authorizes benefits to be ...

  15. Medicare-Coordination of Benefits

    I. Getting Started—Preparing to Test Medicare NCPDP D.0 COB Claims. As a COBA trading partner representative that is preparing your organization for testing NCPDP D.0 COB claims with the Coordination of Benefits Contractor (COBC), your first step is to complete the ―Technical Readiness Assessment Document.‖. This document may be referenced.

  16. PDF Rationale Behind X12's Health Care Good Faith Estimate (X370)

    • Examples include a diagnosis code, the Benefits Assignment Certification Indicator, admission type, and patient discharge status • If the billing provider is a group practice or organization, the rendering provider may or will not be known when the GFE is submitted. • There isn't a date segment defined for the period of care.

  17. Claim Rejection

    BENEFITS ASSIGNMENT CERTIFICATION INDICATOR. Definition. This rejection occurs when the assignment of benefits is not set to the correct entity (Patient/Facility) Resolution. An Assignment of Benefits Based Rejection is due to the Assignment of Benefits Indicator missing or invalid on the claim. This field indicates whether or not the insured ...

  18. Submitting corrected claims

    Select "Claims & Payments" from the navigation bar at the top. Select "Claim Status" and search for the claim you want to correct. If you don't see the "Claim Status" option, contact your Availity Essentials administrator to request access to this tool. If the claim can be corrected, a "Correct this Claim" button will display ...

  19. Reimbursement Policies

    ConnectiCare, in compliance with the 5010 standard, will pay the provider or member based on what the provider submitted under the Benefits Assignment Certification Indicator on the claim. If the provider wants the payment to be sent to the member, the provider should enter "N" under the Benefits Assignment Certification Indicator.

  20. Box 53a, 53b, 53c

    Box 53a, 53b, 53c - Assignment of Benefits Certification Indicator June 16, 2023 15:04; Box Description. This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service. The form contents will either be Y or N. ... To update the benefits assignment, update the patient's ...

  21. CMS-1500 Crosswalk to ANSI 837P

    Benefits Assignment Indicator is required. Y = Yes; N = No authorized 2320personʹs Benefits signature Certification: O103 345 Benefits assignments indicator Assignment Indicator is required. Y =Yes; N No 2300 DTP03 (439) 194 Accident date Required if Related Cause code (CLM11‐1, ‐2 or ‐3) = Auto

  22. Assignment and Nonassignment of Benefits

    The second reimbursement method a physician/supplier has is choosing to not accept assignment of benefits. Under this method, a non-participating provider is the only provider that can file a claim as non-assigned. When the provider does not accept assignment, the Medicare payment will be made directly to the beneficiary.

  23. EZClaim

    CLM08 - Benefits Assignment Certification Indicator. CLM09 - Release of Information Code. CLM10 - Patient Signature Source Code. CLM11 - RELATED CAUSES INFORMATION. ... CRC02 - Certification Condition Indicator. CRC03 - Homebound Indicator. CRC*E1 - PATIENT CONDITION INFORMATION: VISION. DTP*439 - DATE - ACCIDENT. DTP01 - Qualifier.