Claim Submission and Processing

1 INDIANA HEALTH COVERAGE PROGRAMS. PROVIDER REFERENCE MODULE. Claim Submission and Processing LIBRARY REFERENCE NUMBER: PROMOD00004. PUBLISHED: JANUARY 23, 2018. POLICIES AND PROCEDURES AS OF JULY 1, 2017. VERSION: Copyright 2018 DXC Technology Company. All rights reserved. Revision History Version Date Reason for Revisions Completed By Policies and procedures as of New document FSSA and HPE. October 1, 2015. Published: February 25, 2016. Policies and procedures as of Scheduled update FSSA and HPE. July 1, 2016. Published: December 15, 2016. Policies and procedures as of CoreMMIS update FSSA and HPE. July 1, 2016. (CoreMMIS updates as of February 13, 2017). Published: May 23, 2017. Policies and procedures as of Scheduled update: FSSA and DXC. July 1, 2017 Edited and reorganized text for clarity Published: January 23, 2018 Added a note encouraging providers to submit claims electronically Changed Hewlett Packard Enterprise references to DXC Technology Clarified as needed throughout that Medicare Replacement Plan claims are a type of crossover Claim Updated the Fee-for-Service Billing for Carved-Out Services section as follows: Added crisis intervention and Hepatitis C pharmacy services as carve-outs Removed dental and pharmacy as carve-outs for Hoosier Healthwise (moved to note box for past DOS.)

2 Billing only). Added the Provider Signatures section to apply to all Claim types and removed corresponding outdated text from the institutional billing section Updated the number of Claim notes accepted for Portal dental claims and 837D. transaction in the Claim Notes section Added introductory text for the Surgery Billed with Related Postoperative or Preoperative Care section Added the Partial Sterilization section Removed the outdated crosswalk sequence for how the system identifies a one-to-one match in the National Provider Identifier and One-to-One Match section Library Reference Number: PROMOD00004 iii Published: January 23, 2018. Policies and procedures as of July 1, 2017. Claim Submission and Processing Revision History Version Date Reason for Revisions Completed By Removed the ICD-9 code in the ICD Codes section Updated the billing information in the National Drug Codes section and its subsections In the Place of Service Codes section, updated the web link for the Place of Service Code Set page Updated the Visit and Encounter Definitions section Corrected examples in the Calendar-Year Versus 12-Month Monitoring Cycle section Added IHCP provider type and specialty numbers to Table 3 Types of Services Billed on Institutional Claims and moved LTAC facility from the LTC provider to the hospital provider Updated the Revenue Codes Not Reimbursable for Outpatient Billing section Added the Revenue Code 724 Labor Room/Delivery Birthing Center section (per corresponding table on code document).

3 Combined revenue linkages for 905 and 906 with newly added managed care linkages into the Revenue Code Linkages for Managed Care Billing Only section Updated Table 4 UB-04 Claim Form Fields: Removed 99 from Admission Hour codes (field 13). Updated descriptions for patient status codes 04 and 62 (field 17). Removed note about using occurrence code 51 for date of death prior to 1/1/16 (fields 31a 34b). Updated NDC instructions and added milligram as an option (field 43). Updated instructions for fields 50A . 55C and 58A 65C to better reflect the procedures for indicating primary, secondary, and tertiary insurers Added an end-date for use of ICD-9. codes (field 66). Updated the reference and link for the POA exemption list (field 67 and 67A Q). Removed statement that attending physician's taxonomy is required in field 81 CCb (field 76).

4 Iv Library Reference Number: PROMOD00004. Published: January 23, 2018. Policies and procedures as of July 1, 2017. Version: Revision History Claim Submission and Processing Version Date Reason for Revisions Completed By Changed field 81CC from optional to required, if applicable, changed b to not applicable, and added not applicable for c and d Added IHCP provider type and specialty numbers to Table 5 Types of Services Billed on Professional Claims and made updates including the following: Removed case manager Added MRT. Added asterisks and a table note for specialties with restricted code sets Updated the Billing Guidance for Dates of Service section Updated Table 6 CMS-1500, Version 02/12, Claim Form Fields: Added an end-date for use of ICD-9. codes (fields 21A L). Updated NDC instructions and added milligram as an option (fields 21A L).

5 Updated reference and link for the POA exemption list (field 24B). Changed the emergency indicator on the CMS-1500 from required if applicable to required (field 24C, bottom half). Corrected the format for entering the NDC quantity (field 24D, top half). Added IHCP provider type and specialty numbers to Table 7 Types of Services Billed on Dental Claims Updated Table 8 ADA 2006 Claim Form Field Descriptions: Corrected instructions for field 3. Added Member ID to replace RID. Updated field 16 to not applicable Updated field 17 to optional Changed physicians to dentists in the note box in field 54. Updated Section 6 heading and introduction to reflect benefit plans instead of programs Specified Professional Fee Schedule in the Medical Review Team Billing section Updated the information about billing outpatient claims in Table 10 Package E.

6 Billing Instructions Changed HIP Link references to HIP. Employer Link in the HIP Employer Link Billing section Library Reference Number: PROMOD00004 v Published: January 23, 2018. Policies and procedures as of July 1, 2017. Version: Claim Submission and Processing Revision History Version Date Reason for Revisions Completed By Added the Medicaid Inpatient Hospital Services Only Billing section Updated the link for the OPR search tool in the Verifying OPR Enrollment section Added region code 28 to Table 14 . Region Codes Updated examples in the Internal Control Number/ Claim ID Examples section Added the TA1 Interchange Acknowledgement bullet to the 837. Electronic Transaction Claim Processing section Updated Section 10: Crossover Claims and its subsections, including: Extensively edited, reorganized, and updated information throughout as needed Updated the formulas for calculating the payment for crossover claims (replaced spend-down references with waiver liability, removed outdated reference to psychiatric adjustments, and specified Medicaid or Medicare where appropriate for clarity).

7 Clarified that the timely filing exemption for crossover claims also applies to Medicare Replacement Plan claims Removed references to home health crossover claims Added mailing instructions for CMS-1500 crossover claims Updated instructions for submitting claims that did not cross over automatically Replaced the Medicare Exhaust Claims section with a reference to the Inpatient Hospital Services module vi Library Reference Number: PROMOD00004. Published: January 23, 2018. Policies and procedures as of July 1, 2017. Version: Table of Contents Section 1: Introduction to IHCP Claim Submission and Processing .. 1. Fee-for-Service Billing for Carved-Out Services .. 2. Paper Claim 2. Ordering Claim Forms .. 3. Paper Claim Submission Guidelines .. 3. Claim Submission Addresses .. 4. Provider Signatures .. 4. Electronic Claims .. 4. Electronic Standards.

8 4. Paper Attachments for Electronic Claims .. 5. Claim Notes .. 8. General Billing and Coding Information .. 10. National Provider Identifier and One-to-One Match .. 10. Diagnosis and Procedure Coding Systems .. 11. Procedure Codes That Require Claim Attachments .. 12. National Correct Coding Initiative .. 12. Units of Service .. 12. 12. National Drug Codes .. 15. Place of Service 15. Date of Service Definition .. 16. Visit and Encounter 16. Calendar-Year Versus 12-Month Monitoring Cycle .. 16. Section 2: Institutional Billing and UB-04 Claim Form Instructions .. 19. Types of Services Billed on Institutional Claims .. 19. Admission and Duration Requirements for Institutional Claims .. 20. Using Modifiers for Outpatient Hospital Billing .. 20. Using ICD Procedure Codes for Inpatient Billing .. 20. Revenue 21. Revenue Codes Not Reimbursable for Outpatient Billing.

9 21. Using Treatment Room Revenue Codes for Therapeutic and Diagnostic Injections .. 21. Revenue Codes Linked with Specific Procedure Codes .. 21. Guidelines for Completing Institutional Claims Electronically .. 23. UB-04 Claim Form Field-by-Field Instructions .. 24. Billing a Continuation Claim Using the UB-04 Claim Form .. 35. Section 3: Professional Billing and CMS-1500 Claim Form Instructions .. 37. Types of Services Billed on Professional Claims .. 37. Using Modifiers on Professional Claims .. 39. Billing Guidance for Dates of Service .. 39. Billing and Rendering Provider Numbers .. 39. Guidelines for Completing Professional Claims Electronically .. 40. CMS-1500 Claim Form Field-by-Field Instructions .. 40. Section 4: Dental Billing and ADA 2006 Claim Form Instructions .. 47. Types of Services Billed on Dental Claims .. 47.

10 Rendering NPI Required on Dental Claims .. 47. Dental Procedure Codes .. 47. Date of Service Definition .. 48. Guidelines for Submitting Dental Claims Electronically .. 48. ADA 2006 Claim Form Field-by-Field Instructions .. 48. Library Reference Number: PROMOD00004 vii Published: January 23, 2018. Policies and procedures as of July 1, 2017. Claim Submission and Processing Table of Contents Section 5: Coordination of Benefits .. 53. Reporting Other Insurance Information on IHCP Claims .. 53. 837 Transactions .. 53. Provider Healthcare Portal Claims .. 54. Paper Claims .. 54. Zero-Paid TPL Claims .. 55. Section 6: Special Billing Instructions for Specific IHCP Benefit Plans .. 59. Medical Review Team Billing .. 59. Emergency Services Only (Package E) Billing .. 60. HIP Employer Link Billing .. 60. Medicaid Inpatient Hospital Services Only Billing.