Bureau of TennCare

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Medicare/Medicaid
Crossover Claims

Would having your paper claim processed
in a timely manner make life easier?

UB 04’s

Helpful hints to avoid errors that cause delays when paper claims are submitted for processing...

When submitting paper claim, submit original claim form for processing

UB-04 NOTICE: The submitter of this form understands that misrepresentation of falsification of essential information as requested by this form may serve as the basis for civil monetary penalties and assessments and may upon conviction include fines and/or imprisonment under Federal and/or State Laws. Sample Form

Claims must be submitted on a CMS approved claim form. Refer to CMS Manual System, Transmittal 1104, dated November 3, 2006 for the UB-04 Printing Standards. Compliance with these standards is required to facilitate the use of image processing technology. The attached claims are being returned as they do not meet these standards and/or do not have the ATTESTATION printed on the back of the form.

No copies submitted for processing (see example)

Black and white copies cause data entry errors and alignment issues

Supply all data in a legible manner on the claim form in accordance with billing guidelines...

HCFA CMS -1500 (08-05’s)

Helpful reminders to avoid errors and delays when submitting a paper claim...
(see instruction manual)

Include a copy of your Medicare EOMB and TPL EOB if applicable.
Form locator 17 b - NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN numbers.
Form locator 24 J - NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN numbers.
Form Locator 32 - Service Facility Location

32 a - Enter the NPI #.
32 b - Enter the two digit qualifier identifying the non-NPI number followed by the ID number.

Form Locator 33 - Billing provider Info and phone number

33 a - Enter NPI of the billing provider.
33 b – Enter the two digit qualifier identifying the non – NPI number followed by the ID #.

NOTICE: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal and State laws. Sample Form

If things go wrong as they sometimes do, then follow the instructions on the second page/back of the Adjustment Form

Adjustment Form for Medicare/Medicaid claims

UB 04 CHEAT SHEET

Form Locator	Field	Information
1	Provider Name, Address and Telephone Number	Required. Enter the provider’s Name, Address (including Zip code) and telephone number
2	Pay-to Name and Address	Self explanatory
3a	Patient Control Number	Assigned by provider or facility
3b	Medical/Health Record Number	Assigned by patient’s medical/health record
4	Type of Bill	4 digits. First digit as zero. (Swing bed is 0111). Pages 16 to 19.
5	Federal Tax Number	The number assigned to the provider by the federal government for tax reporting purposes. Also known as a tax identification number (TIN) or employer identification number (EIN).
6	Statement Covers Period	Span dates
8a	Patient Name/Identifier	Enter patient’s social security number or ID
8b	Patient Name/Identifier	Enter patient’s name: last (suffix if applicable), first, middle initial
9	Patient Address	(a.) Street/mailing address, (b.) City, (c.) State, (d.) Zip code (e.) Country Code (if other than USA)
10	Patient Birth date	MMDDYYYY (example 12311921)
11	Patient Sex	M = Male, F = Female, or U = Unknown
12	Admission/Start of Care Date	Date of admission MMDDYY
13	Admission Hour	2 digit code to identify hour. Page 29
14	Priority (Type) of Visit	Provider will select 1 digit. Page 30
15	Source of Referral for Admission or Visit	Source code Page 32 - 34
16	Discharge Hour	2 digit code to identify hour. Page 35
17	Patient Discharge Status	Indicates the patient status upon discharge. (EXAMPLE: Deceased enter Status Code 20 and Date of Death) Page 37 - 39
18-28	Condition Codes	Enter "81" for Outpatient or "82" for Inpatient
29	Accident State	N/A
31-34	Occurrence Codes and Dates	Enter "53" and the Medicare Paid date. Pages 65 - 70
38	Responsible Party Name and Address	Enter: Tennessee Medicaid , PO Box 480, Nashville, TN. 37202-0480 For Crossover Billing
39-40	Value Codes and Amounts	Enter Value Code A1 for Deductible (07 is not valid) + $ amount Enter Value Code 06 for blood deductible + $ amount Enter Value Code 08 for Lifetime Reserve Days + $ amount Enter Value Code 09 or A2 for Part B Co-insurance + $ amount (FOR THE FOLLOWING Enter; value code and the number of days) Enter Value Code 80 for Covered Days Enter Value Code 81 for Non-Covered Days Enter Value Code 82 for Co-insurance Days Enter Value Code 83 for Lifetime Reserve Days(Pages 77 - 91)
42	Revenue Code	4 digits, 0001= total line for all charges
43	Revenue Description	Self explanatory
44	HCPCS/Rates/HIPPS Rate Codes	digits must correspond w/rev. code in fl.42-44
45	Service Date	MMDDYY
46	Service Units	Must be more than zero. Total number of units per line. (one days is one unit for accommodation claims)
47	Total Charges	Self explanatory
48	Non-covered Charges	Self explanatory
50	Payer Name	A = Primary Payer; (Medicare or HMO) B = Secondary Payer; (Medicaid or TPL, if TPL exist) C = Tertiary Payer; (Medicaid if TPL exist)
51	Health Plan Identification Number	A = Primary Payer (Medicare or HMO)-State Medicare whether the primary payer is Traditional Medicare or a Medicare Advantage B = Secondary Payer (Medicaid or TPL, if TPL exist B = Secondary Payer (Medicaid or TPL, if TPL exist) C = Tertiary Payer (Medicaid if TPL exist)
52	Release of Information Certification Indicator	Indicates if a Consent statement signed was by provider
53	Assignment of Benefits Certification Indicator	"N" = No, "Y" = Yes & "W" = N/A
54	Prior Payments - Payer	Medicare payment amount on Medicare line (do not add contractual adjustment) (If there is a TPL the amount they paid should be on the TPL's line.)
55	Estimated Amount Due - Payer	Total due from Medicaid (on Medicaid line)
56	National Provider Identifier - Billing Provider	10 digit NPI number
57	Other Provider Identifier	Provider ID number assigned by Health Plan
58	Insured's Name	(Medicaid Line) -Patient name as it appears in our system ( no titles or prefixes)
59	Patient's Relationship to the Insured	2 digit code. Page 169
60	Insured's Unique Identification	(Medicaid Line) -Patient Medicaid ID or SS#
61a	Group Name	Payer Name
62	Insurance Group Number	N/A
63	Treatment Authorization Code	(Prior Authorization # - N/A for Crossovers)
64	Document Control Number
66	Diagnosis and Procedure Qualifier	9 for ICD -09 Codes
67	Principal Diagnosis Code And Present on Admission (POA) Indicator	1- 7 digit for ICD code. ICD -09 Code. No decimal necessary 8th digit Provider must enter "Y" for yes, "N" for no, "W" Clinically Undetermined, and "U" for No information in the record
67A-Q	Other Diagnoses Codes	ICD -09 Code. No decimal necessary
69	Admitting Diagnosis	ICD -09 Code. No decimal necessary
70a-c	Patient's Reason for Visit	For Outpatient claims only. ICD -09 Code. No decimal necessary
71	Prospective Payment System (PPS) Code	Not Required for Crossover Claims
72a-c	External Cause of Injury (ECI) Code	External Cause of Injury ICD -09 Code. No decimal necessary
74	Principal Procedure Code and Date	ICD -09 Code. No decimal necessary. Enter date as MMDDYY
74a-e	Other Procedure Codes and Dates	ICD -09 Code. No decimal necessary. Enter date as MMDDYY
76	Attending Provider Name and Identifiers	NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers
77	Operating Physician Name and Identifiers	NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers
78-79	Other Provider Name and Identifiers	NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers