BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 [18]
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 UB-04 INFORMATION UB-04 claim completion is for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies and other institutional providers. The data elements are listed as fields on the claim form. Required information must be filled in completely, accurately, and legibly. If the information is inaccurate or incomplete, your claim cannot be processed and will not be considered a “clean claim”. A clean claim has all the necessary data elements, such as timely filing on industry standard paper forms (CMS-1500 or UB-04, or their successor forms), or by electronic format, with no defect or impropriety. A submission which does not include all the necessary information, or for which GHC must request additional information (for example, medical records, other coverage information, or subrogation information) is not a clean claim until GHC receives the needed information. A clean UB04 claim is considered to have the following data elements (numbered as shown on claim form): 1. Complete provider information to include name, address, city, state, zip code +4 and telephone number 3. Patient's account number 4. Type of bill 5. Federal tax ID number 6. Date(s) of service 8. Patient's complete name (to include middle initial when appropriate) 9. Patient's complete address 10. Patient's birth date 13. Admission hour 14. Type 15. SRC (Source of Admission) 16. Discharge hour 17. Discharge status 18-28. Condition codes 29. Accident Status 31-34 Occurrence codes & dates 42. Revenue codes 43. Revenue code description (optional) 44. HCPCS/CPT code corresponding to Rev Code in element 42* 45. Service Date 46. Days or units 47. Total Charges 50. Other insurance information (if applicable) 54. Amount Paid Prior 55. Balance Due (optional) 56. NPI 58. Insured's name 60. Patient Identification Number (ForwardHealth, Social Security or GHC six digit ID Number) 66. Principle Diagnosis 67A-Q. Diagnosis or nature of illness or injury Present on Admission indicator (POA) 71. DRG number (only on inpatient claims) 72. E-Codes – External Cause of Injury (when appropriate) 76-79. Attending Provider’s NPI 81cc. Taxonomy NOTE: Please utilize the appropriate claims form and follow standard Medicaid submission guidelines for your INDUSTRY AND/OR PROVIDER type. *This requirement is effective for claims received on or after July 1, 2010 regardless of date of service. Refer to ForwardHealth Update No. 2010-22 for a list of Revenue codes that are exempt from this requirement. [19]
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Therapy Request Form Please indicat
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Speech Therapy Request Form Patient
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Discharge Information Request Form
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Intensive In-Home Therapy Request F
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Neuro/Psychological Testing Request
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BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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