UB-04 Billing

Premera follows national credentialing standards regarding the staff in a hospital system who must be credentialed. See the Credentialing and Contracting section of this manual for more information.

• Inpatient admissions – Nonemergency, elective, or scheduled admissions (including mental health and chemical dependency)
• Skilled nursing facility and acute rehabilitation admissions
• Acute care hospitals
• Inpatient hospice
• Mental health and chemical dependency residential treatment centers

Prior authorization is required instead of admit notification for the following intermediate levels of care:

• Long term acute care hospital
• Inpatient rehabilitation facility/unit (IPR)
• Skilled nursing facility (SNF)
• Residential Treatment Center (RTC)

• Notify us of urgent/emergent admissions within 48 hours of the admission.
• To notify us of an inpatient admission, sign in and use our prior authorization tool or complete an admission notification fax form and fax it to 888-742-1487.
• Some planned procedures, surgeries, and other services require prior authorization and/or medical necessity and inpatient admission and discharge notification. See our code list for requirements
• If the procedure or condition is subject to medical necessity review, a request for a prior authorization review should be submitted before the member is admitted to the hospital.

Call 877-342-5258, option 3, with questions.

Please have the following information available when you notify us of an admission:

• Facility name
• Facility phone number
• Member name and/or identification number
• Health plan product
• Actual date of admission
• Attending physician or other provider
• If available, admitting procedure code (English or ICD/CPT code)

A discharge planner notifies Care Management about the possibility of a patient facility transfer. When this occurs, Care Management helps facilitate a transfer to a contracted facility whenever medically appropriate.

Prior to all non-emergent transfers, please confirm with Customer Service that the facility is contracted for the health plan and contracted for the proposed services. Some facilities have contracts limited to special or limited services and are not contracted for all services they provide.

Some member contracts will allow the use of a non-contracted facility at a lower benefit level. For non-emergent transfers, contact Customer Service to determine if the member contract allows for the lower level of reimbursement. Medically necessary services that cannot be reasonably provided at a contracted facility within the product-specific network will be prospectively assessed for possible authorization of non-contracted provider use at the maximum benefit level.

In an emergency, members may be hospitalized at non-contracted facilities. We will assess each member's situation for appropriateness of a transfer to a contracted facility. Transfer decisions are made based on our policy for medical stability, attending physician or other provider agreements, member and/or family agreement to transfer, and expected duration of stay.

To contact Care Management, please call 877-342-5258, 800-596-3382, 800-722-4714, option 3.

When the audit is complete, the auditor will meet with a hospital auditor to review the findings. This could result in refunds and/or the reprocessing of claims to pay additional benefits. For questions about Calypso processes, please call 800-364-2991.

Type of Bill (form locater 4): 0NNN

The type of bill (TOB) provides specific information about the bill.  The TOB is made up of four digits, the first digit is always a zero.  The second digit indicates the type of facility (hospital, SNF, home health, clinic, etc.).  The third digit classifies the type of care being billed (inpatient, outpatient, lab service, swing bed, etc.).  The fourth digit identifies the sequence of the bill for a specific episode of care (admit through discharge, first and continuing interim claim, last interim claim, etc.).

Patient Discharge Status (form locater 17): The patient discharge status code is a required item and must be available to identify transfer situations. This code represents the patient’s disposition or discharge status at the ending date of service for the period of care.

Condition Codes (form locators 18-26): these codes provide additional information on the condition of the patient that may affect processing of the claim.

Occurrence Codes (form locaters 31 - 36): Occurrence codes and dates should be completed for all accident, maternity, and illness claims.

Value Codes and Amounts (form locater 39, 40, 41): These fields contain codes and related dollar amounts that are necessary to process and reimburse the claim correctly. Entries in these fields can represent semi-private room rates, blood deductibles, coinsurance amounts, dialysis charges to name a few.

Revenue Codes (form locator 42): Revenue codes represent a specific accommodation and/or ancillary service. The revenue code must be four digits. Revenue codes may affect reimbursement, particularly for outpatient claims based on contract reimbursement terms.

HCPCS/Rate/HIPPS Codes (form locator 44): Enter a HCPCS code applicable for the ancillary service for outpatient claims, a HIPPS rate code, or the inpatient accommodation rate. A HCPCS code is required when a drug or biological is reported. An accommodation rate is required when a room and board revenue code is billed (revenue codes 0100s through 0219)

Service Date (form locator 45): The dates for when the service indicated was provided.

• Outpatient Claims: This is a mandatory field and must be populated.
• Inpatient Claims: Room and board lines must be itemized-one line for each date of service.

Diagnosis Codes (form locators 67, 67a – 67q, 69): Enter ICD-10 CM diagnosis codes.

• Field 67 – Principal Diagnosis Code: the patient condition established after inpatient discharge or outpatient procedure. The ICD-10 CM code can be up to seven digits without a decimal, include an appropriate present on admission (POA) indicator for each diagnosis code listed for inpatient claims.
• Fields 67a-67q – Other Diagnosis Codes: corresponding conditions existing at the time of the inpatient admission or outpatient procedure.  Include an appropriate present on admission (POA) indicator for each diagnosis code listed for inpatient claims.
• Field 69 – The patient’s diagnosis at the time of admission.

Procedure Codes (form locator 74, 74a – 74e):

• Field 74 – Principal Procedure Code and Date:  the principal procedure performed for the period represented on the claim (from – through dates); ICD-10 PCS procedure codes (seven digits in length) are required for inpatient claims and CPT procedure codes are required for outpatient claims.
• Fields 74a-74e – Other Procedure Codes and Dates: up to five additional PCS procedure codes (Inpatient) and CPT procedure codes (Outpatient) along with date of service when the procedure was rendered

Remarks (form locater 80): Additional information needed to help in the processing of the claim.

• When billing for secondary coverage, document the level of care in the Remarks field.
• When billing for non-covered days, enter a description of the non-covered days

Special facility billing scenarios

Maternity Claims:

• All mother/baby bills should be submitted as two separate claims, batched together for either paper or electronic submission.

• Per ICD-10 CM Official Coding Guidelines when claims are submitted for deliveries, a diagnosis that identifies the outcome of the delivery using an ICD-10 CM diagnosis code is required.

Age of Patient and Age Bands of Diagnosis codes or Procedure Codes: The age of a patient should match the same age band of a diagnosis code or procedure code:

• ICD-10-CM diagnosis code Z00.111 - Health examination for newborn 8 to 28 days old and the patient age is 5 years old.
• CPT procedure code 99385 – Preventive medicine examination, 18-39 years and the patient age is 47 years old

Please submit interim bills for lengths of stay in excess of 30 days with the following criteria. Interim bills submitted with lengths of stay less than 30 days will be returned to the facility.

• Initial interim claim: bill type 0112
• Subsequent interim claim(s): bill type 0113
• The admission date should be the same on all related claims. The beginning and ending dates must reflect the dates of service being billed for each subsequent claim.
• The interim claims must be billed in date sequential order.
• The discharge status code (form locator 17) should be “30-still a patient”  if the patient is “still a patient” during the interim billing, whether Inpatient or outpatient
• Final claim: bill type 0114. The final claim must include all ICD-10 CM diagnosis and ICD-10 PCS procedure codes related to the entire stay. The beginning and ending dates must reflect the admission and discharge date (entire stay).

Each interim claim will be processed based on the computed DRG, APDRG or MS-DRG for inpatient claims and outpatient payment methodology for outpatient claims. The final bill (bill type 0114) will determine whether additional reimbursement or an adjustment will be made. If the final bill is being replaced in its entirety, the bill type must be 117 to represent a replacement of prior claim(s).

Supplemental claims should be submitted when an additional charge is realized after the final claim has been submitted. If you are submitting a late charge, indicate the additional charges and the beginning and ending dates of service. Late charges are added to the original claim and processed according to contractual agreements. Change the “bill type” (field 4) to represent late charges only (bill type 0115).