Claim Billing Requirements - L.A. Care Health Plan

Clean Claim Edits – UB04DescriptionProvider’s name, address and telephonenumber1RequiredRequiredAction ifMissingRejectPay-to Name and Address2Not RequiredNot requiredPassPass2010ABPatient control numberMedical/ Health Record lRejectPass/Reject23002300Type of bill code4RequiredRequiredRejectReject if blankMissing Patient Control NumberSituational - Requiredwhen the provider needsto identify for futureinquiries.Reject if blank or invalid Missing Bill Type Invalid Bill TypeProvider’s federal tax ID number5RequiredRequiredRejectReject if blank or invalid(needs to be 9 digits)Missing Provider Tax ID NumberInvalid Provider Tax ID Number2010AABeginning and ending date of claim period6RequiredRequiredRejectReject if blankMissing Beginning/End Dates ofService2300Not usedPatient’s name78Not usedRequiredNot usedRequiredRejectPassReject if blankMissing Patient's NameN/A2010CAPatient’s address9RequiredRequiredRejectReject if blankMissing Patient Address2010CAPatient’s date of birth10RequiredRequiredRejectReject if blankMissing Patient DOB2010CAPatient's gender11RequiredRequiredRejectReject if blankMissing Patient Gender2010CA04/25/19Field #Medi-CalMedicareCommentReject if blank or ifaddress is not a physicaladdress (PO BOX, LockBOX, etc is not valid). 9Digit billing provider zipcode is required.1 of 6Reject Reason DescriptionLoopMissing physician/Provider Billing name 2010AAand physical address and/or Missing orinvalid Service Billing Provider 9 digitZip Code2300SegmentNM101 85 (Billing Provider)NM102 2 (Non-Person Entity)NM103 Organizational NameN301, N302 Provider AddressN401 Provider CityN402 Provider StateN403 Provider Zip CodeN404 Country CodePER04,REF02,NM101 87 (Pay to Provider)NM102 2 (Non-Person entity)N301, N302 Provider AddressN401 Provider CityN402 Provider StateN403 Provider Zip CodeN404 Country CodeCLM01 Patient Control NumberREF01 EA (Medical Record ID Number)REF02 Medical Record NumberCLM05-1 Facility Type CodeCLM05-2 A (UB-04 bill type)CLM05-3 Claim Frequency CodeREF01 EI (Employers ID Number)REF02 Billing provider tax id numberDTP01 434 (Statement Dates)DTP02 RD8 (Ranges of Dates)DTP03 Statement from and To DateN/ANM101 QC (Patient)NM102 1 (Person)NM103 Patient Last NameNM104 Patient First NameNM105 Patient Middle Name / InitialNM107 Patient SuffixN301 Patient Address Line 1N302 Patient Address Line 2N401 Patient City NameN402 Patient StateN403 Patient Zip codeN404 PatientDMG01 D8DMG02 Patient's Date of BirthDMG03 Patient Gender CodeF, M or U

Clean Claim Edits – UB04DescriptionField #Medi-CalMedicareAction ifMissingPass/RejectCommentReject Reason DescriptionDate of admission12SituationalSituationalRequired forinpatient,home healthand hospiceclaimsAdmission hour13SituationalSituationalPass/Reject Required for Types of Bill: Missing Admission Hour11X, 12X, 18X, 21X, 22X,32X, 33X, 41X, 81X, 82Xwhere X is any numberinpatient claims exceptfor SNF inpatient TOB012XType of admission14SituationalSituationalSource of admission code15SituationalSituationalDischarge hour16SituationalSituationalPass/Reject Required for InpatientTypes of Bill: 011X, 012X,018X, 021X, 022X, or041X where X is anynumber Reject if blank orinvalidPass/Reject Required for all TOBexcept 014X. Reject ifinvalid.Pass Required on finalinpatient claims.Patient-status-at-discharge code17RequiredRequiredCondition t State29SituationalSituationalPassNot usedOccurrence codes and dates3031-34Not usedSituationalNot usedSituationalPassPass/RejectOccurrence span code35-36SituationalSituationalPass/RejectNot usedResponsible PartyValue code and amounts373839-41Not usedNot usedSituationalNot usedNot ired for Types of Bill: Missing Date of Admission Invalid Date 2300011X, 012X, 018X, 021X, of Admission022X, 032X, 033X, 041X,081X, 082X where X isany number Reject ifinvalid date2300DTP01 435 (Admission)DTP02 D8 or DTDTP03 Admission date and hourDTP03 Admission date and hour (militarytime)Missing Type of Admission Invalid Type 2300of AdmissionCL101 Priority (type) of admission or visitcodeInvalid Source of Admission2300CL102 Point of origin for admission or visitHours are indicated in military timeusing two- characters.2300DTP01 096 (Discharge)DTP02 TM (Time expressed in HHMM)DTP03 Discharge TimeCL103 Patient Status CodePass/Reject Required for all Medicare Missing Patient Status Discharge Code 2300claims. For Medi-calInvalid Patient Status Discharge Codeclaims, only required forinpatient claims.Not required, but if one is Invalid Condition Codesprovided, reject if invalidNot required, but if one is Invalid Occurrence Codes and Datesprovided, reject if invalid2300HI01-1 BG (Condition)HI01-2 Condition code2300REF01 LU (Location number)REF02 State or providence code whereaccident occurred2300HI01-1 BH (Occurrence)HI01-2 Occurrence codeHI01-3 D8 (Date qualifier)HI01-4 Occurrence DateFor Medicare- requiredInvalid Occurrence Span Codesfor Inpatient ClaimsNot required, but if one isprovided, reject if invalidRequired when there is a Invalid Value Codes and Amountsvalue code that applies tothe claim.2 of 6SegmentHI01-1 BI (Occurrence Span)HI01-2 Occurrence Span codeHI01-3 RD8 (Date qualifier)HI01-4 Occurrence Span code date2300Not mappedHI01-1 BE (Value)HI01-2 Value CodeHI01-5 Amounts

Clean Claim Edits – UB04DescriptionRevenue codeField #42Medi-CalSituationalMedicareRequiredAction ifMissingRejectCommentReject if blank or invalidReject Reason DescriptionMissing Revenue Code InvalidRevenue CodeLoopSegment2400SV201 Service Line Revenue CodeFor Medi- Cal- Requiredfor Inpatient claims onlyRevenue/service description43SituationalSituationalPassService Code2400SV202-7 DescriptionNDC or UPN Codes43SituationalSituationalPassReport NDC, UP ordesignated qualifer.2410LIN*02 QualiferN4 National Drug CodeUP Consumer Package Code U.P.C.EN European Article Number (EAN)EO GTIN EAN/UCCHI Health Care Industry Bar Code (HIBC)UK U.P.C./EAN Shipping Container CodeON Customer Order NumberCTP04 QuantityCTP05-01 Code QualifierSV202-1 HC or HPSV202-2 Procedure CodeSV202-3 thru SV202-6 ModifiersN4 followed by the 11digit National Drug lPass/RejectHCPCS and HIPPS not Invalid HCPCS or HIPPSrequired for Inpatientclaims, but if one isprovided reject if invalid.All other claim types maybe required. Please referto CMS and/or Medi-CalguidelinesService date45SituationalSituationalPass/RejectUnits of service46RequiredRequiredRejectRequired for Types of Bill: Missing Service Date Invalid Service 2400012X, 013X, 014X, 022X, Date023X, 032X, 033X,0324X, 071X, 072X,075X, 076X, 077X,081X, 082X, 083X and085X where X is anynumber Reject if invaliddateReject if blankMissing Units of Service2400Total chargeNon-covered charges4748RequiredNot RequiredRequiredNot requiredRejectPassNot usedPayer Name4950aNot usedRequiredNot usedRequiredPassRejectPayer NameHealth Plan IDHealth Plan nalRequiredRequiredPassPassPass04/25/19Reject if blankMissing Total Charges2400240024002010BB3 of 6DTP01 472 Service DateDTP02 D8 or RD8D8 Date expressed in CCYYMMDDRD8 Ranges of datesSV204 Units or basis of measureDA DaysUN UnitsSV205 Service Unit CountSV203 Line Item Charge AmountSV207 Line Item Denied Charge or NonCovered Charge AmountNM101 PRNM102 2NM103 Payer NameNM108 Payer IDNM109REF01 Payer Secondary IDREF02

Clean Claim Edits – UB04DescriptionRelease of Info Certification52 a-cRequiredRequiredAction ifMissingRejectAssignment of Benefit Certification53 a-cNot RequiredNot requiredPassPrior payments54SituationalSituationalPassEstimated Amount Due55Not RequiredNot Required PassNPI number56RequiredRequiredRejectOther Provider ID57SituationalNot requiredPass2010AAInsured's NamePatient Relationship58 a-c59 BA2000BA2000CInsured's Unique ID60 a-cRequiredRequiredPass2000BAGroup NameGroup Insurance NumberTreatment Authorization Codes61 a-c62 ument Control Number64SituationalSituationalPass2300Employer nameDiagnosis and Procedure Code Qualifier6566Not RequiredRequiredNot requiredRequiredPassRejectPrincipal Diagnosis Codes67RequiredRequiredPass/RejectOther Diagnosis Codes67a-qSituationalSituationalPass/RejectPresent on Admission Indicator67, 67a-q SituationalSituational04/25/19Field #Medi-CalMedicareCommentReject if blankReject Reason DescriptionMissing Release of InformationCertificationLoop23002300SegmentCLM09 Release of information codeY Yes Provider has signed statementI Informed Consent to Release MedicalInformationCLM07 Plan ParticipationA- AssignedB Assigned accepted on clinical lab servicesonlyC- Not AssignedCLM08 Benefits assignment certificationindicatorY- Benefits AssignedN- Benefits not assignedW- Not applicableRequired when the indicated payer has 2320 Claim Levelpaid an amount to the provider towards 2430 Line levelbillReject if blank or invalidNPI (check sum logic)Reject if blank9 ICD 90 ICD 10Required for Types of Bill:11X, 12X, 13X, 14X, 21Xwhere X is any number,reject if invalidMissing NPI Number Invalid NPINumber2010AANM108 Billing Provider IdentifierNM109 ID numbersNM108 Billing Provider IdentifierNM109 ID numbers01 Spouse18 Self19 Child20 Employee21 Unknown39 Organ Donor40 Cadaver Donor53 Life PartnerG8 Other RelationshipNM108 Billing Provider IdentifierNM109 ID numbersSBR04 Insured groups nameSBR03 Insured's group numberREF01 Qualifier9F Referral NumberG1 Authorization NumberREF02 Prior Authorization or referralnumberREF01 F8REF02 Payer Claim Control NumberNot mappedHI01 ICD qualifierMissing Diagnosis or Procedure CodeQualifier2300Missing Diagnosis Codes InvalidDiagnosis Codes2300HI01-1 ABK or BKHI01-2 Principal Diagnosis CodeRequired only if avaiable Missing Diagnosis Codes InvalidDiagnosis Codes2300HI01-1 ABF or BFHI01-2 Other DiagnosisHI01-9 Y, N, U , W23004 of 6

Clean Claim Edits – UB04DescriptionNot usedAdmitting diagnosis6869Not UsedSituationalNot UsedSituationalAction ifMissingPassPass/RejectPatient Reason Diagnosis70SituationalSituationalPassPPS Code (DRG)71SituationalSituationalPass/RejectExternal Cause of Injury (ECI code)72 a-cSituationalSituationalPassNot usedProcedure Codes7374Not UsedSituationalNot UsedSituationalPassPass/RejectNot usedAttending physician ID7576Not UsedSituationalNot UsedSituationalPassPassOperating physician IDField ject Reason DescriptionLoopRequired for Types of Bill:230011X, 12X, 21X, and 22Xwhere X is any number,reject if invalidThe patient reason visit Add comments UB Comments from UB 2300code is required forEditorsclaims for TOB 013X and085XNot required, but if one is2300provided, reject if invalidNot required, but if one isprovided, reject if invalidPassSegmentHI01-1 ABJ or BJHI01-2 Admitting diagnosis codeHI01-1 APR or PRHI01-2 Patient's Reason to visitHI01-1 DR (Diagnosis Releted Group)HI01-2 MS- DRG2300HI01-1 ABN or BNHI01-2 External cause of injury code2300HI01-1 BBR or BR or CAH (ABC codes)HI01-2 Principal procedure codeHI01-3 D8HI01-4 Date2310ANM101 71 Attending ProviderNM102 1 (Person)NM103 Attending Provider Last NameNM104 Atttending Provider First NameNM105 AttendingProvider Middle NameNM107 Attending SuffixNM108 XX National Provider IdentifierNM109 Provider Primary ID2310AREF01 Qualifer OB, 1G, G2, LUREF02 Operating provider secondaryidentifierNM101 72 Operating ProviderNM102 1 (Person)NM103 Operating Provider Last NameNM104 Operating Provider First NameNM105 Operating Provider Middle NameNM107 Operating SuffixNM108 XX National Provider IdentifierNM109 Provider Primary IDPRV01 AT Attending ProviderPRV02- PXC Taxonomy codePRV03 Provider Taxonomy codeREF01 Attending provider secondary idqualifierREF02 Attending provider secondary04/25/195 of 6