Tuesday, July 26, 2016

CLIA Number on UB 04 form


 
“CLIA”  - The Clinical Laboratory Improvement Act and CMS implementing regulations and processes.  

A paper claim for laboratory testing requires the presence of the CLIA number of the lab performing the testing in field 64 on UB04 form

  If a valid and appropriate CLIA number is not included with the claim as provided in this letter, the entire claim will not be considered a clean claim and will be rejected as incomplete. This process is consistent with the procedure followed by CMS and is applicable to all products offered by MHS.

•    Physician office laboratory services follow CLIA regulations and are required to bill the CLIA or Waiver number on each appropriate service.

•    A list of CLIA laboratories can be found at www.cdc.gov/clia/Resources/LabSearch.aspx



Electronic Claim Submission to Carriers

American National Standards Institue (ANSI) X12N 837 (HIPAA version) format electronic claims: 

CLIA number: 
An ANSI claim for laboratory testing will require the presence of the performing (and billing) laboratory’s CLIA number; if tests are referred to another laboratory, the CLIA number of the laboratory where the testing is rendered must also be on the claim.  

An ANSI electronic claim for laboratory testing must be submitted using the following format: 


ANSI Electronic claim: the billing laboratory performs all laboratory testing.

The independent laboratory submits a single claim for CLIA-covered laboratory tests and reports the billing laboratory’s number in: 
X12N 837 (HIPAA version) loop 2300, REF02.   REF01 = X4 

ANSI Electronic claim: billing laboratory performs some laboratory testing; some testing is referred to another laboratory.

The ANSI electronic claim will not be split; CLIA numbers from both the billing and reference laboratories must 
be submitted on the same claim.  The presence of the ‘90’ modifier at the line item service identifies the referral 
tests.  Referral laboratory claims are only permitted for independently billing clinical laboratories, specialty code 69. 

The billing laboratory submits, on the same claim, tests referred to another (referral/rendered) laboratory, with 
modifier 90 reported on the line item and reports the referral laboratory’s CLIA number in: 
X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4 

Sunday, July 24, 2016

What is Re-credentialing, delegated credentialing and facility credentialing

Re-Credentialing

All providers must be re-credentialed every three years to continue their participation with the 1199SEIU Benefit Funds. Re-credentialing allows us to re-evaluate qualifications and performance and ensure compliance with the 1199SEIU Benefit Funds’ criteria. Providers may be re-credentialed off-cycle for disciplinary actions, a suspended license, cancellation of professional liability coverage, loss of privileges, suspected fraudulent behavior and quality-of-care or member dissatisfaction concerns.

Any fraudulent or erroneous information submitted to the 1199SEIU Benefit Funds, including at the time of the original credentialing, can be cause for a provider to immediately lose his or her participation status with the 1199SEIU Benefit Funds. Providers are obligated  to immediately notify the 1199SEIU Benefit Funds of changes to any information submitted as part of the credentialing and re-credentialing processes.


Delegated Credentialing

In certain instances, providers may be credentialed through “delegated credentialing,” whereby an outside entity authorized by the 1199SEIU Benefit Funds (generally a hospital) will credential the provider. That provider still must sign a contract directly with the 1199SEIU Benefit Funds and pass the 1199SEIU Benefit Funds’ onsite auditing process. However, the 1199SEIU Benefit Funds retain the final authority to approve, terminate or suspend a provider at their sole discretion. The 1199SEIU Benefit Funds may delegate credentialing to contracted facilities, organizations or provider groups who demonstrate the ability, through a pre-delegation assessment, to meet the performance requirements of the 1199SEIU Benefit Funds. Approved delegates may be evaluated annually to monitor continued compliance with the
1199SEIU Benefit Funds’ current credentialing criteria.


 Facility and Ancillary Provider Credentialing

The 1199SEIU Benefit Funds have established facility and ancillary criteria for evaluating and appointing providers to its network. This facility and ancillary application assesses and gathers appropriate certification data and also verifies the extensive list of services provided by our
facilities for areas such as behavioral health, mental health, substance abuse, durable medical equipment, orthotics and prosthetics, home health/hospice, freestanding ambulatory surgery,  and rehabilitation and dialysis.

Please contact the Provider Relations Department to speak to one of our representatives about applying to be a participating Ancillary Provider.

The 1199SEIU Benefit Funds are committed to protecting the confidentiality of all provider information obtained during the credentialing process.

Please note that participating hospitals, treatment centers, ancillary facilities, group and individual providers should notify the Provider

Relations Department of new providers joining  (and leaving) existing practices.

Thursday, July 21, 2016

Check list for provider credentialing and re-credentialing - documents


 Credentialing Criteria

At a minimum, eligible providers must meet the criteria listed below before they can participate in the 1199SEIU Benefit Funds’ network:

1. A valid, current, unencumbered license to practice issued by the state education department within the state of practice.

2. Graduation from an accredited medical school, professional school, college of osteopathy or a foreign medical school recognized by the World Health Organization and completion of a residency program.

3. Foreign medical school graduates must submit an ECFMG certification (if licensed after 1986).

4. Current, active medical staff privileges (if applicable) in good standing at a participating hospital.

5. Evidence of at least five years of work history. (“Work” includes time spent in the past five years – post-fellowship, military service, etc.).

6. Professional liability insurance in the amount of $1 million per incident/$3 million aggregate per annum.

7. Current Drug Enforcement Agency (DEA) registration, where applicable.

8. For MDs and DOs only, board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association. For an applicant who is not board-certified, sufficient work history (the practitioner must be in practice for 20 or
more years) and evidence of significant network need in a local area will be considered. The credentialing committee will make this determination on a case-by-case basis.

9. For MDs only, current and unencumbered participation in the Medicaid and Medicare programs or proof that such non-participation is entirely voluntary and not due to current or past debarment from the programs.

10. Absence of a physical or mental impairment or condition that may impede the provider’s performance of essential functions of his/her clinical responsibility. If the provider does have a physical or mental impairment, he or she must submit adequate evidence that a physical or mental impairment or condition does not render the provider unable to perform the essential functions without threatening the health or safety of others.

11. Absence of a current chemical dependency or substance abuse problem. For an applicant with this history, the provider must submit adequate evidence that a past chemical  dependency or substance abuse problem does not adversely affect the provider’s ability to
competently and safely perform essential functions.

12. Absence of a history of professional disciplinary actions or absence of any other information that may indicate provider is engaged in unprofessional misconduct. Unprofessional misconduct can be defined as, but not limited to, sexual misconduct (e.g., with patients), sexual harassment of his or her patients or fraudulent billing practices.
An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

13. Absence of a history of felony criminal conviction or indictment. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

14. Absence of falsification of the credentialing application, requested documents or material omission of information requested in the  pplication.

At the Time of Re-Credentialing:

15. Absence of information to indicate a pattern of inappropriate utilization of medical resources.

16. Absence of substantiated member complaints. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

17. All criteria applicable to original credentialing must still be true.

Sunday, July 17, 2016

UB 04 - Provider identifying field instruction


FL 76. Attending Provider Name and Identifiers.

a. The UPIN must be present on inpatient Part A bills with a “Through” date of January 1, 1992, or later. For outpatient and other Part B services, the UPIN must be present if the “From” date is January 1, 1992, or later. This requirement applies to all provider types and all Part B bill types. Effective May 23, 2007, providers are required to submit NPI.

b. An institutional provider may not submit their own NPI, except for Institutional billing of influenza and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of influenza and pneumococcal vaccinations and their administrations, self-referred screening mammography as the only billed service on a claim, or where the provider only has a type-1 NPI as a physician/practitioner owned sole-proprietor.


FL 77. Operating Physician Name and Identifiers

a. Effective May 23, 2007, providers are required to submit NPI. NPI must be present if:
• Bill type is 11X and a procedure code is shown in FL 74;
• Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or
• Bill type is 85X and HCPCS code is in the range of 10000 through 69979.
b. If required:
• NPI, last name and first initial must be present; and
• Left justified.

FL 56. National Provider Identifier – Billing Provider
a. Effective May 23, 2007, providers are required to submit their NPI.
b. Left justified.

UB 04 - Provider identifying field instruction


FL 76. Attending Provider Name and Identifiers.

a. The UPIN must be present on inpatient Part A bills with a “Through” date of January 1, 1992, or later. For outpatient and other Part B services, the UPIN must be present if the “From” date is January 1, 1992, or later. This requirement applies to all provider types and all Part B bill types. Effective May 23, 2007, providers are required to submit NPI.

b. An institutional provider may not submit their own NPI, except for Institutional billing of influenza and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of influenza and pneumococcal vaccinations and their administrations, self-referred screening mammography as the only billed service on a claim, or where the provider only has a type-1 NPI as a physician/practitioner owned sole-proprietor.


FL 77. Operating Physician Name and Identifiers

a. Effective May 23, 2007, providers are required to submit NPI. NPI must be present if:
• Bill type is 11X and a procedure code is shown in FL 74;
• Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or
• Bill type is 85X and HCPCS code is in the range of 10000 through 69979.
b. If required:
• NPI, last name and first initial must be present; and
• Left justified.

FL 56. National Provider Identifier – Billing Provider
a. Effective May 23, 2007, providers are required to submit their NPI.
b. Left justified.

Wednesday, July 13, 2016

UB 04 - Condition code, occurence code and date fields

FLs 18 thru 28. Condition Codes.
a. Each code is two numeric digits.
b. If code 07 is entered, type of bill must not be hospice 81X or 82X.
c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.
d. If code 40 is entered, the “From” and “Through” dates in FL 6 must be equal, and there must be a “0” or “1” in FL 7 (Covered Days).
e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.


FLs 31, 32, 33, and 34. Occurrence Codes and Dates
a. All dates must be valid.
b. Each code must be accompanied by a date.
c. All codes are two alphanumeric positions.
d. If code 20 or 26 is entered, the type of bill must be 11X or 41X. If code 21 or 22 is entered, the type of bill must be 18X or 21X.
e. If code 27 is entered, the type of bill must be 81X or 82X.
f. If code 28 is entered, the first digit in FL 4 must be a “7” and the second digit a “5.”
g. If code 42 is entered, the first digit in FL 4 must be “8” and the second digit “1” or “2” and the third digit “1 or 4.”
h. If 01 - 04 is entered, Medicare cannot be the primary payer, i.e., Medicare-related entries cannot appear on the “A” lines of FLs 58-62.
i. If code 20 is entered:
• Must not be earlier than “Admission” date (FL 17) or later than “Through” date (FL 6).
• Must be less than 13 days after the admission date (FL 17) if “From” date is equal to admission date (less than 14 days if billing dates cover the period December 24 through January 2).
j. If code 21 is entered:
• Cannot be later than “Statement Covers Period” Through date; or
• Cannot be more than 3 days prior to the “Statement Covers Period” From date.
k. If code 22 is entered, the date must be within the billing period shown in FL 6.


FL 35 and 36. Occurrence Span Codes and Dates
a. Dates must be valid.
b. Code entry is two alphanumeric positions.
c. Code must be accompanied by dates.
d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.
e. If code 71 is entered, the first digit of FL 4 must be “1,” “2,” or “4” and the second digit must be “1.”
f. If code 72 is entered, the type of bill must be 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, or 85X.
g. If code 74 is entered, the type of bill must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 74X, 75X, 81X, or 82X.
h. If code 75 is entered, the first digit of FL 4 must be “1” or “4” and the second digit must be “1.”
i. If code 76 is entered, occurrence code 31 must be present (inpatient only).
j. If code 76 is entered, occurrence code 32 must be present (outpatient only).
k. If code 76, 77, or M1 is present, the bill type must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 73X, 74X, 75X, 81X, 82X, or 85X.
l. Neither the “From” nor the “Through” portion can exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions of each field.
m. If code M2 is present, the bill type must be 81X or 82X.
n. Code 79 is for payer use only. Providers do not report this code.

Saturday, July 9, 2016

Filling UB 04 FORM - Field 6 - FL 17

FL 6. Statement Covers Period (From - Through)
a. Cannot exceed eight positions in either “From” or “Through” portion allowing for separations (nonnumeric characters) in the third and sixth positions.
b. The “From” date must be a valid date that is not later than the “Through” date.
c. The “Through” date must be a valid date that is not later than the current date.
d. With the exception of Home Health PPS claims, the statement covers period may not span 2 accounting years.


FL 09. Patient’s Address
a. The address of the patient must include:
City
State (P.O. Code)
ZIP
b. Valid ZIP Code must be present if the type of bill is 11X, 13X, 18X, or 83X or 85X.
c. Cannot exceed 62 positions.


FL 10. Birthdate
a. Must be valid if present.
b. Cannot exceed 10 positions allowing for separations (nonnumeric characters) in the third and sixth positions.


FL 11. Sex
a. One alpha position.
b. Valid characters are “M” or “F.”
c. Must be present.

FL 12. Admission Date
a. Must be valid if present.
b. Cannot exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions.
c. Present only if the type of bill is 11X, 12X, 18X, 21X, 22X, 32X, 33X, 41X, 81X or 82X.

FL 14. Priority (Type) of Admission or Visit
a. One numeric position.
b. Required only if the type of bill is 11X, 12X, 18X, 21X, 22X, or 41X.


FL 15. Point of Origin for Admission or Visit.
a. One numeric position
b. Must be present

FL 17. Patient Discharge Status.
a. Two numeric positions
b. Present on all Part A inpatient, SNF, hospice, home health agency, and outpatient hospital services. Types of bill: 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, or 85X.