Institutions should bill using the standardized ANSI 837I electronic transaction or on a standardized UB-04 form using four-digit type of bill, four-digit revenue codes and applicable CPT and/or HCPCS codes. All applicable fields on the UB-04 should be completed in compliance with Medicare guidelines. For accurate payment, please include both admitting/presenting AND discharge diagnoses.
Submit claims for hospital-based inpatient and outpatient services, associated durable medical equipment, and home health services via the ANSI 837I or on a UB-04. In addition, written descriptions, itemized statements, and invoices may be required for specific types of claims.
Incomplete claims may result in rejection, delayed payment or may be returned to the provider for additional information.
Any charges for required diagnostic services rendered to a member within 72 hours of an inpatient admission and/or ambulatory surgery are included in the case rate paid for that admission/surgery. No additional compensation will be paid with the exception of charges for CT scans and MRIs. (Note: This does not pertain to those facilities paid on a per diem basis).
The name and NPI of the attending physician must be indicated in the appropriate 837I field or field 82 of the UB-04. Claims that lack this information cannot be processed.
The name and NPI of the operating physician must appear in field 83 of the UB-04 when the following conditions are met:
If the Bill Type is '011x or 012x' and a principal procedure code is indicated in field 4 & 80 of the UB-04; or
If the Bill Type is '013x or 083x', a surgery code of 10040-69979 in indicated in field 44 AND Revenue Code(s) 036x, 049x, or 075x is/are indicated in field 42 of the UB-04 (Exception: This information is NOT required if the ICD9 code is V64.1-V64.3).
Claims for inpatient hospital stays should be submitted with an appropriate Diagnostic Related Grouping (DRG) in addition to pertinent Revenue Codes and CPT codes. Please indicate the authorization number in field 63.
Hospitals must also include the proper Value Code in fields 39 indicating private versus semi-private room availability. Hospitals with semi-private rooms available should use a Value Code of '01' with the semi-private room rate indicated. Hospitals with only private rooms available (e.g. labor/delivery/post-partum suites) should use a Value Code of '02.' These Value Codes ensure that the claim is processed correctly and the member is not held inadvertently responsible for a private room rate when there is no other option available.
Private rooms for infectious disease reasons must be requested at the time of initial authorization of the stay or at the time of decision during an approved stay currently in process.
Charges for on-going services may be submitted in 30-day increments on interim claims. Charges for services that are reimbursed as a one-time case rate, (e.g., inpatient admissions reimbursed based on DRG rates) must be submitted on one claim, at the end of treatment.
When billing for patients who have transferred to another facility, please be sure to indicate the appropriate disposition code. This allows MHP to correctly price the claim. MHP employs Medicare transfer payment guidelines unless otherwise outlined in the provider’s contract.
Readmissions to a hospital within the timeframes specified by Medicare’s DRG methodology will be considered an extension of the original admission.
Claims must be submitted with both the appropriate CPT code in field 44 of the UB-04 and the ICD9 procedure code(s) in field 67 for the surgery performed. Indicate the name of the operating physician in fields 82 and 83. Please indicate the authorization number, if applicable, in field 63.
Claims must be submitted with both a revenue code and CPT emergency room evaluation and management code based on the level of treatment provided. It is imperative that both the presenting and discharge diagnoses are indicated on the claim. When transition is made from the Emergency Room, prior authorization requirements apply.
If the hospital renders a service at a higher level of care than was authorized, MHP will deny the claim.
MHP does not reimburse claims for clinic fees separately unless indicated in the contract. Providers may not bill members for these charges.
MHP does not reimburse additionally for 'stat' lab fees. Payment is made for the actual lab test performed ONLY.
While not all forms of educational services are covered benefits, MHP does recognize the health benefits of certain programs sponsored by participating hospitals and associations.
Please use the following minimum coding parameters in addition to standard Medicare requirements:
Revenue Code 0942
Type of Bill 0131
One of the following CPT codes based on the nature of the session:
99404 - Preventive Medicine Counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) approximately 60 minutes
99412 - Preventive Medicine Counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure) approximately 60 minutes
When billing for Nutritional Counseling: Use specific the ICD9 code for the reason for nutritional counseling.
When billing for Smoking Cessation Programs: Use ICD9 diagnosis code of 305.1. Commercial members have a one-time co-payment.
When billing for Natural Family Planning (when a covered benefit): Use ICD9 diagnosis code of either V25.09 or V26.4. Claims should be submitted for the initial evaluation, supplies and on-going sessions at the time the member enrolls in the program. Claims should be billed under the female unless she is not a covered member. In the latter instance, the claim may be submitted under the male. The covered member is responsible for a one-time co-payment payable at the time of enrollment. There should be no more than one claim associated with each member accessing this benefit. This benefit is limited to once per lifetime.
When billing for Prenatal Classes for Pregnant Women: Use ICD9 diagnosis code V22.1. Members may have a limited benefit. There is no applicable CPT code. Indicate 'Lamaze classes - 8 weeks' in Field 43 of the UB-04.