Referring provider, Ordering provider and billing provider - CMS 1500 & UB04 form FAQ

Q: What is the difference between an “ordering/referring provider” and a “billing provider”?

A: An ordering/referring provider is the individual who orders or refers an item or service for a Medicare beneficiary (e.g., laboratory diagnostic tests, imaging services, specialty services, durable medical equipment) that will be furnished and billed by another provider or supplier (e.g., laboratory, imaging center, specialist, DME supplier).

The billing provider is the individual or organization that furnishes and bills Medicare for the ordered/referred service provided to the beneficiary.


Q: Where do I indicate referring or ordering provider’s information on my claim?

A: Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

• Report the name of the referring or ordering practitioner of a service in Item 17 (837P 2310A loop, segment NM1) and the appropriate qualifier to the left of the dotted line on the CMS-1500 (02/12) claim form: DN (referring provider) or DK (ordering provider)

• No information should appear in Item 17a (837P 2310A loop, segment REF02). Item 17a was formerly used to report the Unique Physician Identification Number (UPIN), which is no longer used -- leave this item blank. Information appearing in this item or loop will cause your claims to be returned as unprocessable and rejected electronically.

• Report the National Provider Identifier (NPI) of the referring/ordering provider in Item 17b or the 837P 2310A Referring Provider Loop, segments NM101 using qualifier DN (referring provider) or DK (ordering provider), NM103-NM105 [Name], NM108 using [XX] qualifier and NM109 [NPI].
• Note: When a service is referred or ordered by another practitioner, a valid NPI is required and must be reported. Your claims will be returned as unprocessable if the NPI is required and is missing, invalid or submitted in the wrong item (e.g., a valid NPI submitted in Item 17a).


Q: When responding to a CERT request for medical records, can records from a referring or consulting physician be included?

A. Yes. It is the responsibility of the provider who was reimbursed by Medicare for the service to procure any documentation necessary from another party.

Q: Where do I indicate my billing entity’s provider number on my claim?

A: The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form.

Important note: The NPI of the billing provider is required on all claims. Paper claims will be returned as unprocessable and electronic claims may be rejected if:

• Any information appears to be missing or invalid in the 837P 2010AA loop, REF02. Item 33b of the paper form should be left blank.
• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. If billing services for an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.

Q: What are the requirements for a provider to be eligible to order or refer items or services for a Medicare beneficiary?

A: According to the Centers for Medicare & Medicaid Services’ (CMS’) change request (CR) 6417 external pdf file, a provider is eligible to order or refer items or services for a Medicare beneficiary only if he or she meets both of the following criteria:

• The ordering/referring provider must be enrolled in Medicare and have a current enrollment record in the Provider Enrollment, Chain and Ownerships System (PECOS).
• The ordering/referring provider must be classified as a provider who is eligible to order or refer:
• Doctor of medicine or osteopathy
• Dental medicine
• Dental surgery
• Podiatric medicine
• Optometry
• Physician’s assistant
• Certified clinical nurse specialist
• Nurse practitioner
• Clinical psychologist
• Certified nurse midwife
• Clinical social workers
Note: Only Medicare-enrolled physicians and non-physician practitioners that meet the above criteria are eligible to order/refer services for Medicare beneficiaries.

UB-04 Reminder: 

National Provider Identifier for Attending or Referring Providers Here are several reminders: • Indicate the Attending Provider Name and Identifiers for the patient’s medical care and treatment on institutional claims for any services other than non-scheduled transportation claims.

 • Also send the Referring Provider NPI and name on outpatient claims when the Referring Provider for the services is different than the Attending Provider.

• As of Jan. 1, 2013, claims must include the NPI of the attending provider in the Attending Provider Name and Identifiers Fields (UB-04 FL76 or electronic equivalent) of your claims. That NPI must not be your billing NPI or an organizational NPI; it must an individual provider NP


CMS-1500 Form:

The Form CMS-1500 is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from physicians and suppliers. With the transition of the medical community to electronic data interchange and the proliferation of data element definitions among various payers, it became essential that an organization be established to maintain uniformity and standardization in these areas. The NUCC (National Uniform Claim Committee) is responsible for maintaining the integrity of the data sets and physical layout of the hard copy 1500 Claim Form.1

UB-04 (formerly UB-82 and UB-92) Form:

The members of the NUBC endorsed the UB-82 as the uniform bill. The UB-82 format and data specifications were finalized at the May 1982 NUBC meeting. The focus then shifted to the state level for implementation of the UB-82. Consequently, State Uniform Billing Committees (SUBC's)  were created to handle state implementation and to disseminate state UB-82 manuals. The UB-82 manuals reflect the national guidelines and unique state billing requirements. Virtually all states adopted the use of the UB-82 data set specifications.

When the NUBC established the UB-82 data set design and specifications, it also imposed an eight-year moratorium on changes to the structure of the data set design. In light of the expiration of the moratorium, the NUBC embarked on a process to evaluate how well the UB-82 data set performed. After numerous state surveys, the NUBC sought to implement improvements to the UB-82 design. Consequently, the UB-92 was created, incorporating the best of the UB-82 along with other changes that further improve on the previous data set design. These improvements further reduce the need for attachments. Today the UB-92 is the institutional claim standard with, more than 98% of hospital claims submitted electronically to the Medicare program using this form.


Definitions:

CMS-1500 Form:


The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim.3 UB-04 Form:

An electronic format of the CMS-1450 paper claim form that has been in general use since 1993.4

This policy was written to document correct use of CMS forms. Professional providers should submit claims using the CMS-1500 forms and institutional providers should submit claims using the UB-82 form.


 Uniform Billing with Form CMS-1450 (Rev. 2922, Issued: 04-03-14, Effective: 04-18-14, Implementation: 04-18-14)

This form, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Because it serves many payers, a particular payer may not need some data elements. The National Uniform Billing Committee (NUBC) maintains lists of approved coding for the form. Medicare Administrative Contractors servicing both Part A and Part B lines of business (A/B MACs (A) and (HHH)) responsible for receiving institutional claims also maintain lists of codes used by Medicare. All items on Form CMS-1450 are described. The A/B MAC (A) or (HHH) must be able to capture all NUBC-approved input data described in section 75 for audit trail purposes and be able to pass coordination of benefits data to other payers with whom it has a coordination of benefits agreement.

Disposition of Copies of Completed Forms

The provider retains the copy designated “Institution Copy” and submits the remaining copies of the completed Form CMS-1450 to its A/B MAC (A) or (HHH), managed care plan, or other insurer. Where it knows that a managed care plan will pay the bill, it sends the bill and any necessary supporting documentation directly to the managed care plan for coverage determination, payment, and/or denial action. It sends to the A/B MAC (A) or (HHH) bills that it knows will be paid and processed by the A/B MAC (A) or (HHH).

General Instructions for Completion of Form 

This section contains Medicare requirements for use of codes maintained by the NUBC that are needed in completion of the Form CMS-1450 and compliant Accredited Standards Committee (ASC) X12 837 institutional claims. Note that the internal claim record used for processing is not being expanded. Instructions for completion are the same for inpatient and outpatient claims unless otherwise noted. The A/B MAC (A) or(HHH) does not need to search paper files to annotate missing data unless it does not have an electronic history record. It does not need to obtain data that is not needed to process the claim.

Effective June 5, 2000, CMS extended the claim size to 450 lines. For the Form CMS1450, this simply means that the A/B MAC (A) or (HHH) accepts claims of up to 9 pages. The following layout describes the data specifications Form CMS-1450.

What are the 837I and Form CMS-1450?

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. In addition to billing Medicare, the 837I and Form CMS1450 may be suitable for billing various government and some private insurers. Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).

Medicare Billing: 837I and Form CMS-1450

ANSI ASC X12N 837I

The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional) Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.

ANSI = American National Standards Institute

ASC = Accredited Standards Committee

X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions

837 = Standard format for transmitting health care claims electronically

I = Institutional version of the 837 electronic format Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.

The National Uniform Billing Committee (NUBC) makes their UB-04 manual available through their website. This manual contains the updated specifications for the data elements and codes included on the CMS-1450 and used in the 837I transaction standard. MACs may include a crosswalk between the ASC X12N 837I and the CMS-1450 on their websites.

Elements of a Clean Claim

1. Clean claim defined: A clean claim has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and claims for individual professional procedures and services are to be submitted on the CMS-1500. State guidelines may supersede these requirements. In addition, claims may be submitted electronically through a contracted clearinghouse or on Magellan’s  webbased claims submission application. Magellan does not typically, but may require attachments or other information in addition to these standard forms (as noted  below). Magellan may request treatment records for review.

2. Required clean claim elements: The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate provider reimbursement. The required elements of a clean claim must be complete, legible and accurate.

CMS-1500

In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the CMS-1500 claim form. For more information about the CMS-1500 form, visit the National Uniform Claim Committee’s website. Note that Magellan can only accept the current version of the CMS-1500 form.

• Subscriber’s/patient’s plan ID number (field 1a);
• Patient’s name (field 2);
• Patient’s date of birth and gender (field 3);
• Subscriber’s name (field 4);
• Patient’s address (street or P.O. Box, city, zip) (field 5);
• Patient’s relationship to subscriber (field 6);
• Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7);
• Whether patient’s condition is related to employment, auto accident, or other accident (field 10);
• Subscriber’s policy number (field 11);
• Subscriber’s birth date and gender (field 11a);
• HMO or preferred provider carrier name (field 11c);
• Disclosure of any other health benefit plans (field 11d);
• Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 12);
• Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 13);
• Date of current illness, injury, or pregnancy (field 14);
• First date of previous, same or similar illness (field 15);
• Name of referring provider or other source (field 17);
• Referring provider NPI number (field 17b);
• Diagnosis codes or nature of illness or injury (current ICD-10 codes are required effective 10/1/15) (field 21);
• Date(s) of service (field 24A);
• Place of service codes (field 24B);
• EMG – emergency indicator (field 24C);
• Procedure/modifier code (current CPT or HCPCS codes are required) (field 24D);
• DX Pointer – diagnosis code (ICD-10 codes are required effective 10/1/15) by specific service (field 24E);
• Charge for each listed service (field 24F);
• Number of days or units (field 24G);
• Rendering provider NPI (field 24J);
• Physician’s or provider’s federal taxpayer ID number (field 25);
• Total charge (field 28);
• Signature of physician or provider that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31);
• Name and address of facility where services rendered (if other than home or office) (field 32);
• The service facility Type 1 NPI (if different from main or billing NPI) (field 32a);
• Physician’s or provider’s billing name and address (field 33); and
• Main or billing Type 1 NPI number (field 33a).

UB-04

The UB-04 form captures essential data elements for providers of services in institutional/inpatient/facility settings. The form can be used to bill Medicare fiscal intermediaries, Medicaid state agencies and health plans/insurers. The required elements of a clean claim must be complete, legible and accurate. For more information about the UB-04 form, visit the National Uniform Billing Committee’s website. Contact your claim forms vendor to obtain full-color versions of the UB-04.

In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the UB-04 claim form.

• Provider’s name, address and telephone number (field 1);
• Patient control number (field 3a);
• Type of bill code (field 4);
• Provider’s federal tax ID number (field 5);
• Statement period (beginning and ending date of claim period) (field 6);
• Patient’s name (field 8);
• Patient’s address (field 9);
• Patient’s date of birth (field 10);
• Patient’s gender (field 11);
• Date of admission (field 12), required for inpatient and home health;
• Admission hour (field 13);
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14), required for inpatient;
• Source of admission code (field 15);
• Patient-status-at-discharge code (field 17);
• Value code and amounts (fields 39-41);
• Revenue code (field 42);
• Revenue/service description (field 43);
• HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
• Units of service (field 46);
• Total charge (field 47);
• HMO or preferred provider carrier name (field 50);
• Main NPI number (field 56);
• Subscriber’s name (field 58);
• Patient’s relationship to subscriber (field 59);
• Insured’s unique ID (field 60);
• Diagnosis qualifier (field 66);
• Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
• Admit diagnosis (field 69);
• Provider name and identifiers (field 76-79).

3. Situational clean claim elements: Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.

(1) Other insured’s or enrollee’s name (CMS-1500, field 9), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(2) Other insured’s or enrollee’s policy/group number (CMS-1500, field 9a), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(3) Other insured or enrollee date of birth (CMS-1500, field 9b), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(4) Other insured or enrollee plan name (employer, school, etc.) (CMS-1500, field 9c), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(5) Other insured or enrollee HMO or insurer name. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(6) Subscriber’s plan name (employer, school, etc.) (CMS-1500, field 11b) isapplicable if the health benefit plan is a group plan;
(7) Prior authorization number (CMS-1500, field 23), is applicable when prior authorization is required;
(8) Whether assignment was accepted (CMS-1500, field 27), is applicable when assignment has been accepted;
(9) Amount paid (CMS-1500, field 29), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan (Commercial or Medicare). When applicable, a copy of the primary plan’s EOB is required;
(10) Balance due (CMS-1500, field 30), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber;
(11) Pay To name, address and ID (UB-04, field 2), required when the Pay To information is different than Billing provider info in field 1;
(12) Medical/ health record number (UB-04, field 3b), not the same as 3a;
(13) Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation;
(14) Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition;
(15) Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB04 manual contains an occurrence code appropriate to the patient’s condition;
(16) Occurrence span code, from and through dates (UB-04, field 35-36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the patient’s condition;
(17) Non-covered charges (UB-04, field 48), required when applicable;
(18) Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or subscriber, on behalf of the patient or subscriber, or by a primary plan;
(19) Diagnoses codes other than principle diagnosis code (UB-04, fields 67A-Q), is applicable if there are diagnoses other than the principle diagnosis and ICD-10 code is required effective 10/1/15;
(20) Principal procedure code and date (UB-04, field 74), required on inpatient claims when a procedure was performed; Other procedure codes and dates (UB-04, field 74a-e), required on inpatient claims when additional procedures must be reported;
(21) Ambulance trip report, submitted as an attachment to the claim; and
(22) Anesthesia report is applicable to report time spent on anesthesia services.

Additional clean claim elements: In the event information not specified herein is required to make an accurate determination of proof of loss, the provider will be notified in writing within the applicable regulatory or contractual prompt payment standards. The notice will identify the specific claim or portion of a claim that is being reviewed and the information required. The review is completed within the applicable prompt payment standard following receipt of the information requested from the provider.

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