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HOSPITAL-BASED INPATIENT DETOXIFICATION - PDF
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1 MEDICAL ASSISTANCE ADMINISTRATION Division of Provider Services HOSPITAL-BASED INPATIENT DETOXIFICATION Billing Instructions August 19942 TABLE OF CONTENTS Hospital Based Inpatient Detoxification DESCRIPTION PAGE Preface... ii Definition Guide... 1 Medical Assistance Administration - General Information and Policy... 5 Division of Alcohol and Substance Abuse (DASA) Programs... 8 Section I: Alcohol Detoxification Services... 9 Section II: Drug Detoxification Services Section III: Alcohol/Drug Detoxification for Clients Detained or Involuntarily Committed Physician Billing Instructions for Completing the UB-92 Claim Form Completed Sample Form UB-92: Alcohol Detox Claim... 20A Completed Sample Form UB-92: Drug Detox Claim... 20B Instructions for Completing the HCFA-1500 Claim Form Completed Sample Form HCFA-1500: Physician Billing... 24A Completed Sample Form A-19: Involuntary Commitment and Treatment... 24B (August 1994) - i -3 PREFACE This publication supersedes all previous Hospital-Based Inpatient Detoxification Billing Instructions. Send claims for services provided to Washington State Medical Assistance clients, except for Involuntary Treatment Act (ITA) Extended Detoxification, to the Department of Social and Health Services, Medical Assistance Administration (MAA): UB-92 Claim Forms: HCFA-1500 Claim Forms: DIVISION OF PROVIDER SERVICES DIVISION OF PROVIDER SERVICES PO BOX 9246 PO BOX 9248 OLYMPIA WA OLYMPIA WA Send claims for Involuntary Treatment Act (ITA) extended detoxification services to the address below, and/or for questions regarding policy and/or payment for (ITA) Detoxification, or to obtain A-19 forms call: DIVISION OF ALCOHOL AND SUBSTANCE ABUSE FISCAL SECTION PO BOX OLYMPIA WA (360) If you have questions regarding MAA policy, payments, denials, or have general questions regarding claims processing call: PROVIDER INQUIRY HOTLINE Toll Free: For questions regarding private insurance and third-party liability call: For information on electronic billing call: THIRD-PARTY RECOVERY PROGRAM Toll-Free: CLAIMS CONTROL (360) Or (360) (August 1994) - ii -4 DEFINITION GUIDE Hospital Based Inpatient Detoxification The Definition Guide contains definitions, abbreviations, and acronyms used in these billing instructions which relate to the Medical Assistance Program. ADATSA - Alcohol and Drug Addiction Treatment and Support Act. Persons eligible under the ADATSA program are entitled to medical care services. Participation in this program will be indicated on the medical ID card with a W legend. ALCOHOL ABUSE - Use of alcohol in amounts hazardous to individual health or safety. ALCOHOLISM - A disease characterized by a dependence on alcoholic beverages or the consumption of alcoholic beverages; loss of control over the amount and circumstances of use; symptoms of tolerance; physiological or psychological withdrawal, or both, if use is reduced or discontinued; and impairment of health or disruption of social or economic functioning. ALCOHOLISM AND/OR ALCOHOL ABUSE TREATMENT - The provision of medical social services to an eligible client designed to mitigate or reverse the untoward effects of alcoholism or alcohol abuse and to reduce or eliminate alcoholism or alcohol abuse behaviors and restore normal social, physical, and psychological functioning. Alcoholism or alcohol abuse treatment is characterized by the provision of a combination of alcohol education sessions, individual therapy, group therapy, and related activities to detoxified alcoholics and their families. CATEGORICALLY NEEDY PROGRAM - A program providing maximum benefits to persons who qualify for Medical Assistance. Participation in this program will be indicated on the medical ID card with the CNP legend. CHEMICAL DEPENDENCY - An alcohol or drug addiction, or dependence on alcohol and one or more other psychoactive chemicals. CLIENT - A person who has been determined to be eligible for one of the Medical Assistance Administration's medical care programs. CODE OF FEDERAL REGULATIONS (CFR) - A codification of the general and permanent rules published in the federal register by the executive departments and agencies of the federal government. COMMUNITY SERVICES OFFICE(S) (CSO) - Field offices of the Department of Social and Health Services located in communities throughout the State which administer various services of the department at the community level. (August 1994) - 1 -5 CORE PROVIDER AGREEMENT - A basic contract that the Medical Assistance Administration (MAA) holds with medical providers serving MAA clients. The provider agreement outlines and defines terms of participation in the Medicaid program. (WAC ) DASA - The Division of Alcohol and Substance Abuse within DSHS. DEPARTMENT or DSHS - The Washington State Department of Social and Health Services. DIAGNOSIS, PRINCIPAL - The condition established after study to be chiefly responsible for necessitating the admission of a client to a health care facility. DRUG ABUSE - The use of a drug in amounts hazardous to a person's health or safety. DRUG ADDICTION - A disease characterized by a dependency on psychoactive chemicals; loss of control over the amount and circumstances of use; symptoms of tolerance; physiological or psychological withdrawal, or both, if use is reduced or discontinued; and impairment of health or disruption of social or economic functioning. DRUG ADDICTION AND/OR DRUG ABUSE TREATMENT - The provision of medical and rehabilitative social services to an eligible client designed to mitigate or reverse the effects of drug addiction or drug abuse and to reduce or eliminate drug addiction or drug abuse behaviors and restore normal physical and psychological functioning. Drug addiction or drug abuse treatment is characterized by the provision of a combination of drug and alcohol education sessions, individual therapy, group therapy and related activities to detoxified addicts and their families. ELECTRONIC MEDIA CLAIMS (EMC) - Medical claim data, client eligibility data, thirdparty insurance data, and remittance data transmitted between Medical Assistance providers, or their intermediaries, and the MAA Division of Provider Services by means of personal computer, magnetic tape, mainframe, and the direct entry system. EXPLANATION OF BENEFITS (EOB) - A coded message on the Medical Assistance Remittance and Status Report (RA) that gives detailed information regarding the claim associated with that report. When EOB is referred to in relation to third-party liability instructions, it is most likely referencing the insurance payor's Explanation of Benefits the result of the provider's having billed a third party. MAA's Third Party Recovery (TPR) Program requires a copy of an insurance company's EOB prior to paying a claim's balance. (August 1994) - 2 -6 FRAUD - A deliberate, intentional, and willful act with the specific purpose of deceiving the department with respect to any material fact, condition, or circumstance affecting eligibility or need. (WAC ) FREE-STANDING DETOX CENTER - A facility that is not attached to a hospital and in which care and treatment is provided to persons who are recovering from the transitory effects of acute or chronic intoxication or withdrawal from alcohol or other drugs. MAXIMUM ALLOWABLE - The maximum dollar amount for which a provider may be reimbursed by MAA for specific services, supplies, or equipment. MEDICAID - The federal aid Title XIX program under which medical care is provided to: (a)categorically needy as defined in chapters and WAC; or (b)medically needy as defined in chapter WAC. (WAC ) MEDICAL ASSISTANCE ADMINISTRATION (MAA) - The unit within the department of social and health services authorized to administer the Title XIX Medicaid and the state-funded medical care programs. (WAC ) MEDICALLY NECESSARY - A term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions in the client that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section `course of treatment' may include mere observation or, where appropriate, no treatment at all. (WAC ) PARTICIPATING HOSPITAL - A hospital that is: (1) located outside of a selective contracting area (SCA); or (2) located within a SCA and the facility and/or services it provides are considered exempt; or (3) located within a SCA and the facility has a contract with DSHS. PATIENT IDENTIFICATION CODE (PIC) - An alphanumeric code assigned to each Medical Assistance client which consists of: a) First and middle initials (or a dash (-) if the middle initial is not indicated). b) Six-digit birthdate, consisting of numerals only (MMDDYY). c) First five letters of the last name (and spaces if the name is fewer than five letters). d) Alpha character (tie breaker). (August 1994) - 3 -7 PROVIDER or PROVIDER OF SERVICE - An institution, agency, or person: (1) Having a signed agreement with the department to furnish medical care and goods and/or services to clients; and (2) Eligible to receive payment from the department. (WAC ) PROVIDER SERVICES, DIVISION OF (DPS) - The division within the Medical Assistance Administration which processes claims for payment under the Title XIX (federal) program and state-funded programs. RATIO OF COST-TO-CHARGE (RCC) - The RCC payment method is used to reimburse peer group A hospitals for their costs and other DRG exempt services. RCCs are updated annually. Out-of-state hospitals are paid a weighted average of in-state hospitals' RCC. REMITTANCE AND STATUS REPORT (RA) - A report produced by the claims processing system in the MAA Division of Provider Services that provides detailed information concerning submitted claims and other financial transactions. REVISED CODE OF WASHINGTON (RCW) - Washington State laws. THIRD PARTY - Any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a State plan. (CFR ) USUAL & CUSTOMARY FEE - This is the rate that may be billed to the department for a certain service or equipment. This rate shall not exceed (1) the usual and customary charge that you bill the general public for the same services, or (2) if the general public is not served, the rate for the same services normally offered to other contractors. WASHINGTON ADMINISTRATIVE CODE (WAC) - Codified rules of the State of Washington. (August 1994) - 4 -8 MEDICAL ASSISTANCE ADMINISTRATION (MAA) GENERAL INFORMATION AND POLICY I.BILLING TIME LIMIT: State law requires that you present your final bill to MAA for reimbursement no later than 365 days after providing medical services. II.PAYMENT: MAA may be billed only after you provide a service to an eligible client. Delivery of a service does not guarantee payment. For example, MAA will not make payment when: The request for payment is not presented within the 365-day billing limit; The service is not medically necessary or is not covered by MAA; OR A third party pays as much as, or more than, MAA allows. If you provide services to a person who is not eligible for a medical program and who is later determined to be eligible, you may be paid by MAA when: The service is determined to be medically necessary, it is within MAA's scope of care, and it is a service covered by MAA policy; AND The client provides you with a medical ID card which covers the date of service and that covered service is billed within 365 days of the date it was provided; OR Your claim is presented within 365 days from the retroactive or delayed certification date indicated on the MAA medical ID card. The delayed certification legend appears on the medical ID card when a person applies for a medical program prior to the month of service and a delay occurs in the processing of the application. Because of this delay, the eligibility determination date becomes later than the month of service. When the retroactive certification legend appears on a medical ID card, it indicates that the applicant received a service and applies in a later month for a medical program. Upon approval of the application, the person was found to be eligible for the medical program at the time he or she received the service. (Refer to the MAA General Information Booklet for more specific information on medical ID card legends.) (August 1994) - 5 -9 III.FEES: Bill MAA your usual and customary fee (the fee you bill the general public). MAA's payment will be the lower of the billed charges, or MAA's maximum allowable rate, and is payment in full. State law allows you to bill clients for MAA medical programs' emergency medical expense requirement (EMER) and/or spend-down requirements. MAA does not cover certain services. If you provide any noncovered service, the client is responsible for payment only under conditions defined in the MAA General Information Booklet section entitled "Billing the Medical Assistance Client." IV.THIRD PARTY LIABILITY: Although the billing time limit for MAA is 365 days, an insurance carrier's time limit for claim submissions may be different. It is your responsibility to meet the insurance carrier's requirements relating to billing time limits, as well as MAA's, prior to any payment by MAA. If you would like assistance in identifying an insurance carrier in order to obtain information from them on their time limitations, you may call the Third Party Recovery Program at You must bill any insurance carrier indicated on the medical ID card. The MAA 365-day billing time limit must be met even though you may not have received notification of action by the insurance carrier. If your claim is denied due to any existing third party liability, refer to the corresponding MAA Remittance and Status Report for insurance information appropriate for the date of service. If you receive an insurance payment and the carrier pays you less than the maximum amount allowed by MAA, or if you have reason to believe that MAA may make an additional payment, submit a completed claim form to MAA. Attach the insurance carrier's statement. If rebilling, also attach a copy of the MAA Remittance and Status Report showing the previous denial. If you are rebilling electronically, list the claim number (ICN) of the previous denial in the comments field of the Electronic Media Claim (EMC). If you have any questions regarding third party liability, refer to the General Information Booklet or call the Third Party Recovery Program at V.CHARTS/RECORDS: You must maintain legible, accurate, and complete charts and records in order to support and justify the services you provide. Chart means a compendium of medical records on an individual patient. Record means dated reports supporting claims submitted to the Washington Medical Assistance Administration for medical services provided in an office, home, nursing facility, hospital, outpatient, emergency room, or other place of service. (August 1994) - 6 -10 Records of service shall be entered in chronological order by the practitioner who rendered the service. For reimbursement purposes, such records shall be legible and shall include but not be limited to: 1. Date(s) of service. 2. Patient's name and date of birth. 3.Name and title of person performing the service, when it is someone other than the billing practitioner. 4.Chief complaint or reason for each visit. 5.Pertinent medical history. 6.Pertinent findings on examination. 7. Medications and/or equipment/supplies prescribed or provided. 8.Description of treatment (when applicable). 9.Recommendations for additional treatments, procedures, or consultations. 10.X-rays, tests, and results. 11. Plan of treatment/care/outcome. Records must be available to DSHS and to the U.S. Department of Health and Human Services upon request. Documentation must be timely, complete, and consistent with the bylaws and medical policies of the facility where the service is provided. DSHS conducts provider audits in order to determine compliance with the various rules governing its medical programs. (WAC ) VI.ADVANCE DIRECTIVES: All Medicare-Medicaid certified hospitals, nursing facilities, home health agencies, personal care service agencies, hospices, and managed health care organizations are federally mandated to give all adult patients written information about their rights, under state law, to make their own health care decisions. The patient's rights include: the right to accept or refuse medical treatment, the right to make decisions concerning their own medical care, and the right to formulate an advance directive, such as a living will or durable power of attorney, for their health care, except when a patient is detained under the provisions of RCW, relating to ITA (Involuntary Treatment Act). (August 1994) - 7 -11 DIVISION OF ALCOHOL AND SUBSTANCE ABUSE (DASA) PROGRAMS The following information is intended to assist hospital and physician billing staff working with clients receiving hospital-based alcohol and/or drug detoxification services in counties where no free-standing detoxification centers are available. NOTE: If your facility is certified to treat pregnant women under a Chemically Using Pregnant (CUP) Women agreement, do not use Hospital Based Inpatient Detoxification Billing Instructions. You should bill for those services using the instructions in the MAA Chemically Using Pregnant (CUP) Women Billing Instructions, which are available through the MAA Division of Provider Services. ELIGIBILITY Hospital-based alcohol and/or drug detoxification services are available to all eligible Medical Assistance clients. If the person is not currently eligible for Medical Assistance but may qualify, the hospital must contact the local DSHS Community Services Office (CSO) on the first working day following admission to initiate an application. Reimbursement cannot be made until eligibility is established. REIMBURSEMENT RATES Reimbursement for all detoxification services addressed in these billing instructions will be based on rates set by applying the allowable Ratio of Cost-to-Charge (RCC) percentage for each hospital (see page 4 for a definition of RCC). Physicians will be reimbursed according to the current Medical Assistance Resource Based Relative Value Scale (RBRVS) Billing Instructions and Fee Schedule. (August 1994) - 8 -12 SECTION 1: ALCOHOL DETOXIFICATION SERVICES Description:Alcohol Detoxification provides up to three days of inpatient hospital detoxification services. These services must be performed in a participating hospital enrolled with the Medical Assistance Administration. Billing:Hospitals must submit their claims on the UB-92 claim form. Send claims to: DIVISION OF PROVIDER SERVICES PO BOX 9246 OLYMPIA WA Diagnosis You must use one or more diagnosis codes for alcohol detoxification when Codes:completing the UB-92 claim form. Use the code that most closely describes the diagnosis. The following diagnoses relate to alcohol detox Alcohol withdrawal delirium Alcohol induced persisting amnestic disorder Alcohol induced persisted dementia Alcohol induced psychotic disorder with hallucinations Idiosyncratic alcohol intoxication Alcohol induced psychotic disorder with delusions Alcohol withdrawal Other specified alcohol induced mental disorders Unspecified alcohol induced mental disorder Acute alcoholic intoxification Other and unspecified alcohol dependence Alcohol abuse Excessive blood level of alcohol ADD THE APPROPRIATE FIFTH-DIGIT ICD-9-CM SUBCLASSIFICATION BELOW TO CATEGORIES 303 AND 305: 0 UNSPECIFIED 1 CONTINUOUS 2 EPISODIC 3 IN REMISSION (August 1994) - 9 -13 SECTION 2: DRUG DETOXIFICATION SERVICES Description:Drug Detoxification provides up to five days of inpatient hospital detoxification services. These services must be performed in a participating hospital enrolled with the Medical Assistance Administration. Billing: Hospitals must submit their claims on the UB-92 claim form. Send claims to: DIVISION OF PROVIDER SERVICES PO BOX 9246 OLYMPIA WA Diagnosis You must use one or more diagnosis codes for drug detoxification Codes: when co detox Drug withdrawal Drug induced psychotic disorder with delusions Drug induced psychotic disorder with hallucinations Pathological drug intoxication Drug induced delirium Drug induced persisting amenstic disorder Drug induced mood disorder Other specified drug induced mental disorders Unspecified drug induced mental disorder Opioid type dependence Sedative, hypnotic or anxiolytic dependence Cocaine dependence Cannabis dependence Amphetamine and other psychostimulant dependence Hallucinogen dependence Other specified drug dependence Combinations of opioid type drug with any other Combinations of drug dependence excluding opioid type drug Unspecified drug dependence Cannabis abuse Hallucinogen abuse Sedative, hypnotic or anxiolytic abuse Opioid abuse Cocaine abuse (August 1994)14 305.7 Amphetamine or related acting sympathomimetic abuse Antidepressant type abuse Other, mixed, or unspecified drug abuse ADD THE APPROPRIATE FIFTH-DIGIT ICD-9-CM SUBCLASSIFICATION TO CATEGORIES 304 AND 305: 0 UNSPECIFIED 1 CONTINUOUS 2 EPISODIC 3 IN REMISSION (August 1994)15 SECTION 3:ALCOHOL/DRUG DETOXIFICATION FOR CLIENTS DETAINED OR INVOLUNTARILY COMMITTED Description:Protective Custody/Detention of Persons Incapacitated by Alcohol or Other Drugs: RCW 70.96A.120 provides for the protective custody and emergency detention of persons who are found to be incapacitated or gravely disabled by alcohol or other drugs in a public place. Providers of services to clients who are (1) detained under the protective custody provisions of RCW 70.96A.120, and (2) are not being judicially committed to further care, must follow the instructions outlined in the Hospital-Based Inpatient Alcohol/Drug Detoxification sections. See Sections 1 & 2, pages Involuntary Commitment for Chemical Dependency: RCW 70.96A.140 provides for the involuntary commitment (ITA) of persons incapacitated by chemical dependency. When a Petition for Commitment to Chemical Dependency Treatment or a Temporary Order for Treatment is invoked on a client under care in a hospital, there may be a need to hold the client beyond the three- to five-day limitations described on pages 9-11 in these instructions. Therefore, if a Petition is filed or a Temporary Order for Treatment is invoked, the three-/five-day limitations may be extended up to an additional six days. In this event, DASA will reimburse up to a maximum of nine days for Alcohol ITA Extended Detoxification or eleven days for Drug ITA Extended Detoxification. Rates are set by applying the allowable RCC (Ratio of Cost-to-Charge) percentage for a given hospital. Billing:All billings for ITA extended detoxification are to be submitted to: DIVISION OF ALCOHOL AND SUBSTANCE ABUSE FISCAL SECTION PO BOX OLYMPIA WA (August 1994)16 Submit the following forms, in addition to the completed UB-92 claim form, in order to receive payment: 1.An A-19 billing form with a statement on the form that the services are ITA Extended Detoxification; and 2.A copy of the cover page from the client's Temporary Order for Treatment or Petition for Commitment to Chemical Dependency Treatment. Diagnosis Codes: Use the diagnosis codes listed under Sections 1 or 2: Alcohol Detoxification Services (page 9) or Drug Detoxification Services (page 10-11). (August 1994)17 PHYSICIAN BILLING HOSPITAL INPATIENT ALCOHOL OR DRUG DETOXIFICATION SERVICES A. DETOXIFICATION - VOLUNTARY (NON-ITA) Description: Physicians billing for services rendered to inpatient alcohol or drug detox clients must complete a HCFA-1500 claim form using the appropriate procedure codes from the MAA RBRVS (Resource Based Relative Value Scale) Billing Instructions and Fee Schedule. To receive reimbursement for these services, the appropriate alcohol or drug diagnosis codes listed under the DASA Program (pages 9-11) section must also be used and entered in field 24E. Do not use diagnosis code The RBRVS detox procedure codes are listed below: PROCEDURE MAXIMUM CODE DESCRIPTION ALLOWABLE 0025M Detox - Hospital Admit $ M Detox - Hospital Follow-ups $15.90 For alcohol detoxification services, the Department will allow: (a) one Detox - Hospital Admit (0025M) per admission and (b) two Detox - Hospital Follow-ups (0026M) per admission. For drug detoxification services, the Department will allow: (a) one Detox - Hospital Admit (0025M) per admission and (b) four Detox - Hospital Follow-ups (0026M) per admission. Billing: Submit claims to: DIVISION OF PROVIDER SERVICES PO BOX 9248 OLYMPIA WA (August 1994)18 B. DETOXIFICATION - INVOLUNTARY COMMITMENT (ITA) Hospital Based Inpatient Detoxification Description: When billing for services to clients being committed for further treatment, submit claims directly to DASA. Submit the following forms in addition to the completed HCFA-1500 claim form: 1. An A-19 billing form with a note that the services are for ITA Extended Detoxification; and 2. A copy of the cover page from the client's Temporary Order for Treatment or Petition for Commitment to Chemical Dependency Treatment. Use the following procedure codes when billing: PROCEDURE MAXIMUM CODE DESCRIPTION ALLOWABLE 0025M Detox - Hospital Admit $ M Detox - Hospital Follow-ups $15.90 Only one Detox - Hospital Admit (0025M) and up to ten Detox Hospital Follow-ups (0026M) will be allowed per admission. Billing: Submit claims for ITA extended detoxification services to: DIVISION OF ALCOHOL AND SUBSTANCE ABUSE FISCAL SECTION PO BOX OLYMPIA WA (August 1994)19 INSTRUCTIONS FOR COMPLETING THE UB-92 CLAIM FORM The numbered boxes on the UB-92 are called form locators. Only form locators that pertain to MAA are addressed here. FORM LOCATOR NAME AND INSTRUCTIONS FOR COMPLETION: 1.PROVIDER NAME, ADDRESS & TELEPHONE NUMBER - Enter the provider name, address, and telephone number as filed with DPS. 3.PATIENT CONTROL NUMBER - Enter an alphanumeric ID number, i.e., a medical record number or patient account number. This number will be printed on your Remittance and Status Report under the heading Patient Control Number. 4.TYPE OF BILL - Enter a code indicating the specific type of bill. 6.STATEMENT COVERS PERIOD - Enter the beginning and ending dates of the service(s) covered by this bill. 12.PATIENT NAME - Enter the client's last name, first name, and middle initial as shown on his/her medical ID card. 13.PATIENT'S ADDRESS - Enter the client's address. 14.PATIENT'S BIRTHDATE - Enter the client's birthdate. 17.ADMISSION DATE - Enter the date of admission (MMDDYY). 18.ADMISSION HOUR - Enter the hour the client was admitted. Use the two-character codes shown below: CODE TIME (A.M.) CODE TIME (P.M.) CODE TIME 00 12:00-12:59 (Midnight) 12 12:00-12:59 (noon) 99 Hour Unknown 01 01:00-01: :00-01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11:59 (August 1994)20 19.TYPE OF ADMISSION - Enter type of admission: 1 - Emergent 2 - Urgent 3 - Elective 4 - Newborn 20.SOURCE OF ADMISSION - Enter Source of admission: 1 - Physician Referral 2 - Clinic Referral 3 - HMO Referral 4 - Transfer from a Hospital 5 - Transfer from a Skilled Nursing Facility 6 - Transfer from Another Health Care Facility 7 - Emergency Room 8 - Court/Law Enforcement 9 - Information Not Available 21.DISCHARGE HOUR - Enter the hour of discharge. Use the two-character coding shown on form locator PATIENT STATUS - Enter one of the following codes to describe the client at discharge: CODE DESCRIPTION 01 Discharged to home or self care (routine discharge) 02 Discharged/transferred to another short-term general hospital for inpatient care 03 Discharged/transferred to skilled nursing facility (SNF) 04 Discharged/transferred to an intermediate care facility (ICF) 05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 06 Discharged/transferred to home under care of home health service organization 07 Left against medical advice or discontinued care 08 Discharged/transferred to home under care of a Home IV provider 09 Admitted as an inpatient to this hospital Discharge to be defined at state level, if necessary 20 Expired Expired to be defined at state level, if necessary 30 Still patient or expected to return for outpatient services Still patient to be defined at state level, if necessary 42.REVENUE CODE - Enter the appropriate revenue code(s). (August 1994)21 43.REVENUE OR PROCEDURE DESCRIPTION - Enter a narrative description of services performed. 44. HCPCS/RATES - Enter the accommodation rate for hospital bills or the HCFA code applicable to ancillary service and outpatient bills. 46.UNITS OF SERVICE - Enter the number of days of service (up to 3 days for alcohol detoxification and up to five days for drug detoxification). 47.TOTAL CHARGES - Enter the charge for each line. After all line charges, enter the total of all charges. 48.NONCOVERED - Enter the noncovered charge, if any, for each line. After all line charges, enter the total of all noncovered charges. 50.PAYER IDENTIFICATION: A/B/C - Enter name of insurer(s) if other health insurance benefits are available. 51.MEDICAID PROVIDER NUMBER - Enter the provider number issued to you by DPS for hospital-based detox services. This is the seven-digit provider number which appears on your Remittance and Status Report. 54.PRIOR PAYMENTS: A/B/C - Enter the amount due or received from other insurance. 55.ESTIMATED AMOUNT DUE: A/B/C - Total charges minus any amount(s) entered in form locator(s) 48 and 54 (other insurance). 58.INSURED'S NAME: A/B/C - If other insurance benefits are available and coverage is under another name, enter the insured's name here. (August 1994) View more
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INSTITUTIONAL billing module UB-92 Billing Module Basic Rules... 2 Before You Begin... 2 Reimbursement and Co-payment... 2 How to Complete the UB-92... 5 1 Basic Rules Instructions for completing the UB-92 More information ICD 9 to ICD 10 Code Conversions Based on 2014 GEMs Alcohol and Drug Abuse Programs Approved ICD 10 Codes 3/21/2014
291 Alcohol induced mental disorders 291.0 Alcohol withdrawal delirium F10.231 Alcohol dependence with withdrawal delirium F10.121 Alcohol abuse with intoxication delirium F10.221 Alcohol dependence with More information Home Health Services Billing Manual
Home Health Services Billing Manual F245-424-000 (07-2015) Home Health Services Billing Instructions About Billing Instructions... 1 Where can you find help with L&I billing procedures?... 1 About Labor More information Instructions for Completing the UB-04 Claim Form
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All related services performed by an ambulatory surgery center must be billed on the UB04 claim form following the instructions listed below. Tips Claim Form Completion Claims for ASC covered services More information Instructions for Completing the CMS 1500 Claim Form
Instructions for Completing the CMS 1500 Claim Form The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. The form is used by Physicians and Allied More information Substance Use Disorder Services to be a Benefit of Texas Medicaid
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professional billing module Professional CMS-1500 Billing Module Coding Requirements...2 Evaluation and Management Services...2 Diagnosis...2 Procedures...2 Basic Rules...3 Before You Begin...3 Modifiers...3 More information To submit electronic claims, use the HIPAA 837 Institutional transaction
3.1 Claim Billing 3.1.1 Which Claim Form to Use Claims that do not require attachments may be billed electronically using Provider Electronic Solutions (PES) software (provided by Electronic Data Systems More information Premera Blue Cross Medicare Advantage Provider Reference Manual
Premera Blue Cross Medicare Advantage Provider Reference Manual Introduction to Premera Blue Cross Medicare Advantage Plans Premera Blue Cross offers Medicare Advantage (MA) plans in King, Pierce, Snohomish, More information -- No equivalent DSM-IV code disorders 303 Alcohol dependence syndrome -- No equivalent DSM-IV code 303.9 [0-3]*
Substance Use Disorder Covered Diagnoses ICD-9 DSM-IV Alcohol Use Disorders 291 Alcohol-induced mental -- No equivalent DSM-IV code s 303 Alcohol syndrome -- No equivalent DSM-IV code 303.9 [0-3]* Other More information CMS 1500 Training 101
CMS 1500 Training 101 HP Enterprise Services Learning Objective Welcome, this training presentation will educate you on how to complete a CMS 1500 claim form; this includes a detailed explanation of all More information UB-04 Billing Instructions
UB-04 Billing Instructions 11/1/2012 The UB-04 is a claim form that is utilized for Hospital Services and select residential services. Please note that these instructions are specifically written to correlate More information CHAPTER 1223. OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES
CHAPTER 1223. OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES GENERAL PROVISIONS Sec. 1223.1. Policy. 1223.2. Definitions. 1223.11. Types of services covered. 1223.12. Outpatient services. 1223.13. Inpatient More information MEDICAL POLICY Treatment of Opioid Dependence
POLICY........ PG-0313 EFFECTIVE......11/11/14 LAST REVIEW... 07/14/15 MEDICAL POLICY Treatment of Opioid Dependence GUIDELINES This policy does not certify benefits or authorization of benefits, which More information Glossary of Frequently Used Billing and Coding Terms
Glossary of Frequently Used Billing and Coding Terms Accountable Care Organization (ACO) Accounts Receivable Reports All Inclusive Fees Allowances and Adjustments Capitation Payments Care Coordination More information OSCAR Health Insurance Frequently Asked Questions/General Information
Q: What is the relationship between Oscar and ValueOptions? A. ValueOptions administers the mental health and substance abuse benefits for Oscar Health Insurance. They have contracted with ValueOptions, More information Appendix A. Glossary
Glossary The following provides brief definitions and descriptions of terms, abbreviations, and acronyms often used in the conjunction with the Medicaid program. AI is an indicator in the CAP block on More information UB-04, Inpatient / Outpatient
UB-04, Inpatient / Outpatient Hospital (Inpatient and Outpatient), Hospice (Nursing Home and Home Services), Home Health, Rural Health linic, Federally Qualified Health enter, IF/MR, Birthing enter, and More information You must write REHAB at the top center of the claim form!
CMS 1500 (02/12 INSTRUCTIONS FOR REHABILITATION CENTER SERVICES You must write REHAB at the top center of the claim form! Locator # Description Instructions Alerts 1 Medicare / Medicaid / Tricare Champus More information Request for Proposal (RFP) Chemical Dependency Outpatient Treatment Services
Request for Proposal (RFP) Chemical Dependency Outpatient Treatment Services 1. Introduction Island County Board of County Commissioners is requesting proposals to provide Outpatient Chemical Dependency More information Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS)
Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure More information Current Status: Active PolicyStat ID: 1361644. Financial Assistance/Charity Care
Current Status: Active PolicyStat ID: 1361644 Original Approval: 8/17/2001 Approval: 2/6/2015 Next Review: 1/30/2016 Owner: Jonathan Tingstad: VP & Chief Financial Officer Policy Area: Finance References: More information Frequently Asked Questions About Your Hospital Bills
Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of More information HOSPICE INFORMED CONSENT
HOSPICE INFORMED CONSENT PATIENT NAME: INSTRUCTIONS: This form is used to acknowledge receipt of our Orientation Booklet and confirm your understanding and agreement with its contents. Your signature below More information Column1 Substance Abuse Diagnosis Exclusion Codes ICD-9: Description 291.0 Alcohol withdrawal delirium 291.1 Alcohol-induced persisting amnestic
Column1 Substance Abuse Diagnosis Exclusion Codes ICD-9: Code Description 291.0 Alcohol withdrawal delirium 291.1 Alcohol-induced persisting amnestic disorder 291.2 Alcohol-induced persisting dementia More information Administrative Code. Title 23: Medicaid Part 306 Third Party Recovery
Administrative Code Title 23: Medicaid Part 306 Third Party Recovery Table of Contents Title 23: Division of Medicaid... 1 Part 306: Third Party Recovery... 1 Part 306 Chapter 1: Third Party Recovery... More information HEALTH INSURANCE CLAIM FORM APPROVED BY THE BERMUDA HEALTH COUNCIL 10/09
HEALTH INSURANCE CLAIM FORM APPROVED BY THE BERMUDA HEALTH COUNCIL 10/09 1. NAME OF INSURANCE COMPANY PLEASE PRINT OR TYPE IN UPPERCASE LETTERS 1a. INSURED S CERTIFICATE NUMBER ARGUS BF&M COLONIAL FM GEHI More information The Healthy Michigan Plan Handbook
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Medicare Intermediary Manual Part 3 - Claims Process Department of Health and Human Services (DHHS) HEALTH CARE FINANCING ADMINISTRATION (HCFA) Transmittal 1795 Date: APRIL 2000 CHANGE REQUEST 1111 HEADER More information CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS
CHAPTER 7 (E) DENTAL PROGRAM CHAPTER CONTENTS 7.0 CLAIMS SUBMISSION AND PROCESSING...1 7.1 ELECTRONIC MEDIA CLAIMS (EMC) FILING...1 7.2 CLAIMS DOCUMENTATION...2 7.3 THIRD PARTY LIABILITY (TPL)...2 7.4 More information TRANSITIONING FROM ICD-9 to ICD-10 CODES. Presented by: Michael Langer, Office Chief, Behavioral Health and Prevention
TRANSITIONING FROM ICD-9 to ICD-10 CODES Presented by: Michael Langer, Office Chief, Behavioral Health and Prevention September 25, 2015 2 TOPICS Coding and System Changes Understanding the ICD-10 Format More information The Healthy Michigan Plan Handbook
The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). The Healthy Michigan Plan provides health More information OUTPATIENT SUBSTANCE USE DISORDER SERVICES FEE-FOR-SERVICE
OUTPATIENT SUBSTANCE USE DISORDER SERVICES FEE-FOR-SERVICE Brief Coverage Statement Outpatient Substance Use Disorder (SUD) Fee-For-Service (FFS) Treatment Services are available for the treatment of substance More information Current Status: Active PolicyStat ID: 333621. Charity Care
Current Status: Active PolicyStat ID: 333621 Effective Date: 07/2002 Approved Date: 01/2013 Last Revised: 03/2012 Expiration Date: 01/2014 Owner: Symonds, Jana: Director of Patient Financial Services Department: More information CMS-1500 Billing Guide for PROMISe Audiologists
CMS-1500 Billing Guide for PROMISe udiologists Purpose of the document Document format The purpose of this document is to provide a block-by-block reference guide to assist the following provider types More information FAILURE TO PROVIDE VALID INFORMATION MATCHING THE INSURED S ID CARD COULD RESULT IN A REJECTION OF YOUR CLAIM.
FAILURE TO PROVIDE VALID INFORMATION MATCHING THE INSURED S ID CARD COULD RESULT IN A REJECTION OF YOUR CLAIM. Enter in the white, open carrier area the name and address of the payer to whom this claim More information SECTION 4. A. Balance Billing Policies. B. Claim Form
SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing More information GEORGIA MEDICAID TELEMEDICINE HANDBOOK
OUTPATIENT SUBSTANCE USE DISORDER SERVICES FEE-FOR-SERVICE BRIEF COVERAGE STATEMENT This benefit coverage standard describes outpatient Substance Use Disorder services (known as SUD Fee-For-Service (FFS) More information Section Eleven. Referrals and Pre-Authorization REFERRAL PROCESS
REFERRAL PROCESS Physician Referrals within Plan Network Physicians may refer members to any Specialty Care Physician (Specialist) or ancillary provider within the Fidelis Care network. Except as noted More information MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT CLAIM FORM
MENTAL HEALTH / SUBSTANCE ABUSE TREATMENT CLAIM FORM DIRECTIONS FOR COMPLETION If you are in treatment with a non-participating ValueOptions provider and your provider has indicated that you will be responsible More information Maryland Data as of July 2003. Mental Health and Substance Abuse Services in Medicaid and SCHIP in Maryland
Mental Health and Substance Abuse Services in Medicaid and SCHIP in Maryland As of July 2003, 638,662 people were covered under Maryland's Medicaid/SCHIP programs. There were 525,080 enrolled in the Medicaid More information Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005
Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005 Welcome to the AIG Companies family of customers. We appreciate that you had a choice when placing your insurance and More information Completing a Paper UB-04 Form
Completing a Paper UB-04 Information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport Connect S. For UnitedHealthcare s related policies/procedures, More information Ambulance and Involuntary Treatment Act (ITA) Transportation
Health and Recovery Services Administration (HRSA) Ambulance and Involuntary Treatment Act (ITA) Transportation Billing Instructions [Chapter 388-546 WAC] Copyright Disclosure Current Procedural Terminology More information INSTRUCTIONS FOR COMPLETING THE UB-92 CLAIM FORM
INSTRUCTIONS FOR COMPLETING THE UB-92 CLAIM FORM All entries on a UB-92 are made in a field called the Form Locator (FL). All Form Locators (FL) are assigned a number. For example, Form Locator 67 is referred More information Clarification of Patient Discharge Status Codes and Hospital Transfer Policies
The Acute Inpatient Prospective Payment System Fact Sheet (revised November 2007), which provides general information about the Acute Inpatient Prospective Payment System (IPPS) and how IPPS rates are More information MITS WEB PORTAL BILLING GUIDE FOR DENTAL CLAIMS
MITS WEB PORTAL BILLING GUIDE FOR DENTAL CLAIMS Revised 2011.12.21 Fields marked with an asterisk (*) require an entry. Information entered into a field must be "recorded" before the system can use it. More information ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim
ebilling Support ebilling Support webinar: ebilling terms ebilling enrollment Lifecycle of a claim 2 Terms EDI Electronic Data Interchange Flow of electronic information, specifically claims information More information 1500 Claims Processing Manual DHMP Health Insurance Claim Form CMS-1500
DENVER HEALTH MEDICAL PLAN, INC. 1500 Claims Processing Manual DHMP Health Insurance Claim Form CMS-1500 Box 1 Medicare, Medicaid, Group Health Plan or other insurance Information Show the type of health More information Place of Service Codes for Professional Claims Database (updated November 1, 2012)
Place of Codes for Professional Claims Database (updated August 6, 2015) Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity More information Willamette University Long-Term Care Insurance Outline of Coverage
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Hospice care services Summary of change: Effective February 1, 2015, hospice services will be a covered benefit covered by Amerigroup Louisiana, Inc. Amerigroup Louisiana, Inc. recognizes the importance More information CMS 1500 (02/12) CLAIM FORM INSTRUCTIONS
February 6, 2014 UB-04 Billing Guide for PROISe mbulatory Surgical Purpose of the Document Document at Font Sizes The purpose of this document is to provide a block-by-block reference guide to assist the More information Place of Service Codes
Place of Service Codes Code(s) Place of Service Name Place of Service Description 01 Pharmacy** A facility or location where drugs and other medically related items and services are sold, dispensed, or More information Medicare Coding and Billing Part 1
Medicare Coding and Billing Part 1 Medicare Fee ScheduleMedicare has released next year s fee schedule There is a 27% cut in fees. This will be in effect until Congress takes action to delay it again. More information THE DIVISION OF ALCOHOL AND SUBSTANCE ABUSE. Chemical Dependency Treatment Options for Minors Under Age 18. A Guide for Parents
THE DIVISION OF ALCOHOL AND SUBSTANCE ABUSE Chemical Dependency Treatment Options for Minors Under Age 18 A Guide for Parents Answers to Frequently Asked Questions September 2002 THE DIVISION OF ALCOHOL More information COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS
COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS If you are filing for the medical expense benefit only under your accident policy, a claim form may not be needed More information UB-04 Billing Guide for PROMISe Inpatient Rehabilitation Hospitals & Facilities
February 6, 2014 Hospitals & Facilities Purpose of the Document Document at Font Sizes Signature pproval The purpose of this document is to provide a block-by-block reference guide to assist the following More information Connecticut Data as of July 2003
Mental Health and Substance Abuse Services in Medicaid and SCHIP in Connecticut As of July 2003, 378,961 people were covered under Connecticut Medicaid/SCHIP programs. There were 364,692 enrolled in the More information HOW TO SUBMIT OWCP - 1500 BILLS TO ACS
HOW TO SUBMIT OWCP - 1500 BILLS TO ACS The services performed by the following providers should be billed on the OWCP-1500 Form: Physicians (MD, DO) Radiologists Independent Laboratories Audiologists/Speech More information NURSING FACILITY SERVICES
MARYLAND MEDICAID NURSING FACILITY SERVICES UB-04 BILLING INSTRUCTIONS Issued: February 5, 2013 Applicable for Dates of Service beginning July 1, 2012 UB-04 BILLING INSTRUCTIONS FOR NURSING FACILITY SERVICES More information Please follow these suggestions in order to facilitate timely reimbursement of claims and to avoid timely filing issues:
Claims/Payment Section K-1 New Claims Submissions All claims must be submitted and received by Molina Healthcare of New Mexico, Inc. (Molina Healthcare) within ninety (90) days from the date of service More information (d) Ambulance services means advanced life support services or basic life support services.
Initial Proposal DRAFT 6/21/12 1 Readopt with amendment He-W 572, effective 5/30/06 (Document #8638), as amended effective 7/1/12 (Document #10139), to read as follows:] PART He-W 572 AMBULANCE SERVICES More information Section 6. Medical Management Program
Section 6. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs. More information Florida Medicaid Recipients With Other Medical Insurances. April 2013
Florida Medicaid Recipients With Other Medical Insurances April 2013 1 Section 1 The Basics 2 What is Third Party Liability? Third Party Liability (TPL) is the obligation of any entity other than Medicaid More information The policy of Island Hospital is to provide charity care consistent with the requirements of the Washington Administrative Code (WAC) Chapter 246-453.
POLICY STATEMENT CHARITY CARE Island Hospital Admin Page 1 of 6 The policy of Island Hospital is to provide charity care consistent with the requirements of the Washington Administrative Code (WAC) Chapter More information CMS-1500 Billing Guide for PROMISe Renal Dialysis Centers
CMS-1500 Billing Guide for PROMISe Renal Purpose of the document Document format The purpose of this document is to provide a block-by-block reference guide to assist the following provider types in successfully More information DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare is denying an increasing number of claims, because providers are not identifying the correct primary payer prior More information UB-04 Billing Guide for PROMISe Joint Commission on Accreditation of HealthCare Organizations (JCAHO) RTFs
February 6, 2014 UB-04 Billing Guide for PROISe Joint Commission on ccreditation of HealthCare Organizations (JCHO) RTFs Purpose of the Document Document at Font Sizes Signature pproval The purpose of More information CMS-1500 Billing Guide for PROMISe Certified Registered Nurse Anesthetists (CRNAs)
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