Texas Hospitals and Facilities Claims Submitted Using UB92 Forms ...

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Aetna Clean Claim Requirements: Hospitals and Facilities Page 2 of 5 Claims Submitted Using UB92 Forms March 28, 2003 likewise, it requires that a DRG be present if the ZZ value exists. Box 42 – A code that identifies a specific accommodation, ancillary service or billing calculation for the related service(s) provided. This is required for all claims. Please follow the guidelines specified in the National Uniform Billing Data Element Specifications or St. Anthony’s UB92 editor for code values. Note: For outpatient services, most revenue codes will require a HCPCS code attachment. Box 43 – Revenue Description Box 44 – This field must be valued when reimbursement is based on HCPCS codes. Box 45 – For HMO claims, the service date is required for all outpatient claims when the statement covers period from and through dates are not equal. Box 46 – Number of Units Box 47 – Total Charges Box 50 – Payer Name Box 54 – Prior Payments (applicable only if payment has been made to the provider) Box 58 – Insured’s Name Box 59 – Patients’ Relationship to Insured Box 60 – Member/Insured’s ID Number Box 62 – The identification number, control number or code assigned by the carrier administrator to identify the group for which the individual is covered. Copyright 2003 Aetna All Rights Reserved Box 67 – Principal Diagnosis Code Box 68, 69, 70, 71, 72, 73, 74 and 75 – Other Diagnosis Codes (Applicable only if there are diagnoses other than the principal diagnosis) Box 76 – Admission Diagnosis Code Box 78 – DRG Code Box 79 – Principal Procedure Code (Applicable only if the patient has undergone a surgical procedure.) Box 80 – Other Procedure Codes (Applicable only if additional surgical procedures were performed) Box 82 – Attending Physician ID Number Box 84 – This field is designated for use in limited situations when supplementary data is required from health care providers that the format and data set do not provide for them. Box 85 – Provider Representative (signature or signature on file) Box 86 – Date Bill Submitted Other – In the event that an “H” precedes the patient identification number, the “H” should be omitted for electronic submissions. Line charges greater than $9,999.99 should be submitted on paper. Total claim charges greater than $99,999.99 should be split and submitted electronically, if possible. Claims spanning 2 calendar years must be separated. NDC codes should be submitted in the remarks field. Principal procedure code required for specific revenue codes. Error message will indicate “Principal procedure code for services rendered”. Revenue codes – some require an HCPCS code when billed. In order for a claim to be a clean claim the following additional documents are required. Modifiers There are situations in which a claim must be submitted using a CPT modifier. The use of modifiers can indicate an unusual event occurred or that the procedure or service was altered in some way. When billing with certain CPT modifiers you must provide a complete description of the service performed including supporting documentation such as operative report, or anesthesia notes. Relevant information should include adequate description of the nature and events that occurred during the procedure or at the time of service.
Aetna Clean Claim Requirements: Hospitals and Facilities Page 3 of 5 Claims Submitted Using UB92 Forms March 28, 2003 Modifier-22 Unusual Procedural Service Submit complete description of the procedure including operative report. Modifier-23 Unusual Anesthesia Submit complete description of the procedure including operative report and anesthesia notes. All Unlisted/Unspecified Codes Include a complete written description of the procedure and written report for all unlisted/unspecified codes. See the requirements below for the following specific codes. All Unlisted Anesthesia Codes For example: CPT 01999-Unlisted anesthesia procedure. Submit complete description of the procedure including operative report. All Unlisted Surgical Procedures For example: CPT 19499-Unlisted procedure, breast. Submit complete description of the procedure including operative report. All Unlisted Radiology/Imaging Procedures For example: CPT 78799-Unlisted genitourinary procedure, diagnostic nuclear medicine. Submit complete description of the procedure including imaging report. All Unlisted Laboratory Procedures For example: CPT 84999-Unlisted chemistry procedure. Submit complete description of the procedure including report. All Unlisted Medical Procedures & Supplies For example: CPT 93799-Unlisted cardiovascular service or procedure; CPT 99070-Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). Submit complete description of procedure including office notes and report. All Unclassified Drug Codes For example: HCPCS J3490-Unlisted drugs. State the NDC code, name of drug, manufacturer's name, dose, number of doses and number of doses administered. Submit complete description of the service including itemized invoice. All Other Unlisted, Non-specific HCPCS Codes For example: HCPCS A0999-Unlisted ambulance service; HCPCS E1399-Durable medical equipment, miscellaneous; HCPCS A4649-Surgical supply, miscellaneous. Submit complete description of the service, including itemized invoice. All Non-specific ICD-9 Codes For example: ICD-9 799.8-ILL-Define condition nec. ICD-9 794.9-ABN Function study nec. Submit complete description of the diagnosis including office notes and history & physical Interim Billing: When interim billing, stop loss must be indicated in the remarks box when cumulative charges meet or exceed stop loss threshold. Copyright 2003 Aetna All Rights Reserved
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Texas Hospitals and Facilities Claims Submitted Using UB92 Forms ...

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