part ii policies and procedures for rural health clinic services

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FL 42FL 43FL 44FL 46FL 47Revenue CodeEnter Revenue Code 521 for rural health clinic services, revenue code 522 forhome visit services, revenue code 527 for Visiting Nurse services, Revenue code636 for injectable drugs and revenue code 001 for the total charges.Revenue DescriptionEnter a narrative description of the related revenue categories included on this bill.Abbreviations may be used. The description and abbreviations should correspondwith the revenue codes as defined in the Georgia Uniform Billing Manual.CPT/HCPCSCPT codes must be entered in the FL 44 adjacent to the appropriate revenue codeto identify all services provided. The clinic must select the HCPCS code whichbest describes the service provided. Revenue codes as described in FL 42 andCPT codes for the appropriate level of encounter/service must be used.Units of ServiceUnits of service must always be a “1”.Total Charges (by Revenue Category)Enter the total charges pertaining to the related revenue code for the currentbilling period as entered in the “statement covers period”. Only charges relating tothe covered eligibility dates should be included in total charges. The figures in thisfield add up to a total that is reported in this FL using revenue code 001.NOTE:Lines A, B, and C are used for FL 50 through 66 to indicate primary (A), secondary (B) andtertiary (C) payers. For example: If Medicaid is the primary payer listed on line A of FL50,Medicaid information must be listed on line A through FL 66.FL 50 PayerA, B, C Enter payer name and carrier code of any liable third party payer other thanMedicare. (*Carrier codes are located in the Third Party Insurance CarrierListing.)A reasonable effort must be made to collect all benefits from other third partycoverage. Federal regulations require that Medicaid be the payer of last resort.(See Chapter 300 of the Policies and Procedures Manual applicable to allMedicaid providers.)When a liable third-party carrier is identified on the card, the provider must billthe third party.FL 51 Provider NumberA, B, C Enter the number assigned to the provider by the payer indicated.January 2012 Rural Health Clinic Services E-13
FL 54 Prior PaymentsA, B, C Enter the amount that the hospital has received toward payment of this bill fromthe carrier.FL 58Insured‟s NameEnter the insured‟s last name, first name, and middle initial. Name mustcorrespond with the name on the Medicaid card. If the name on the Medicaid cardis incorrect, the member or the member‟s representative should contact the localDFCS to have it corrected immediately.FL 60 Certification/SSN/HIC/ID No.A, B, C Enter the Medicaid Member Client Number exactly as it appears on the Medicaidcard.FL 61 Insured Group NameA, B, C Enter the name of the group or plan through which the insurance is provided tothe insured. Medicaid requires the primary payer information on their primarypayer line when Medicaid is secondary.FL 62 Insurance Group NumbersA, B, C Enter the identification number, control number, or code assigned by the carrier oradministrator to identify the group under which the individual is covered.FL 63 Treatment Authorization Code (Precertification)A, B, C A number or other indicator that designates that the treatment covered by this billhas been authorized by the DMA. Enter the twelve-digit authorization number asrequired for inpatient hospital admissions and selected outpatient procedures, ifapplicable.FL 63 Employment Status CodeA, B, C Enter the code as defined by the National Uniform Billing Committee used todefine the employment status of the individual identified in FL 58.FL 65 Employer NameA, B, C Enter employer name that might or does provide health care coverage for theindividual in FL 58.FL 66 Employer LocationA, B, C Enter the specific location of employer of the insured individual identified in FL58.FL 67Principle Diagnosis CodeEnter the ICD-9-CM code for the principal diagnosis appearing in FL 76.January 2012 Rural Health Clinic Services E-14
Page 2 and 3: PART II - POLICIES AND PROCEDURESFO
Page 4 and 5: Rev. 01/09APPENDIX AAPPENDIX BAPPEN
Page 6: . 01/09Rev. 01/09Rev. 01/09Rev. 07/
Page 10 and 11: PART II - CHAPTER 800PRIOR APPROVAL
Page 12 and 13: Rev 01/09Payments specified as the
Page 14 and 15: 902.1 ICD-9-CMCodes deleted from pr
Page 16 and 17: 903.3 Laboratory ServicesRev 01/09R
Page 18 and 19: COS 600 ID. The procedure codes for
Page 20 and 21: 904 Other Ambulatory Clinics Servic
Page 22 and 23: 4. ResidentialRev 01/09Clinics may
Page 24 and 25: 1001. Reimbursement MethodologyPART
Page 26 and 27: health clinics, and the UB-04 claim
Page 28 and 29: APPENDIX BSTATEMENT OF PARTICIPATIO
Page 30 and 31: Rev 01/09Rev 01/09Rev 01/09Example
Page 32 and 33: APPENDIX EBILLING INSTRUCTIONS AND
Page 34 and 35: PLACE OF SERVICE CODES11 - Office12
Page 36 and 37: Completion of the Health Insurance
Page 38 and 39: OrEnter the Prior Authorization Num
Page 40 and 41: enter the date.Unsigned invoice for
Page 42 and 43: Completion of the National Uniform
Page 46 and 47: FL 68thru 75Codes prefixed in „E
Page 48 and 49: Established Patient 99391 - 99395Ne
Page 50 and 51: APPENDIX HVACCINE FOR CHILDREN PROG
Page 52 and 53: (5) A request for review of a chang

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