Kansas Medical Assistance Program Provider Manual
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KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Hospital PART II HOSPITAL PROVIDER MANUAL Introduction Section BILLING INSTRUCTIONS Page 7000 UB-04 Billing Instructions .... ......... ......... ......... ......... ........ 7-1 Submission of Claim . ......... ......... ......... ......... ........ 7-8 7010 MS-2126 Billing Instructions . ......... ......... ......... ......... ........ 7-9 7020 Hospital Specific Billing Information . ......... ......... ......... ........ 7-13 7030 State Institution for Mental Health Billing Instructions .... ......... ......... ......... ......... ........ 7-21 BENEFITS AND LIMITATIONS 8100 Copayment ............ ......... ......... ......... ......... ......... ........ 8-1 8200 Medical Assessment ........... ......... ......... ......... ......... ........ 8-2 8300 Benefit Plans .......... ......... ......... ......... ......... ......... ........ 8-15 8400 Medicaid ............... ......... ......... ......... ......... ......... ........ 8-16 8410 Medicaid-Inpatient Only ................ ......... ......... ......... ........ 8-27 8420 Medicaid-Outpatient Only .............. ......... ......... ......... ........ 8-32 8430 Family Planning/Sterilization .......... ......... ......... ......... ........ 8-37 HCPCS Procedure Codes and Nomenclature .. ......... ......... ........ Appendix I Ambulatory Surgery/Outpatient Surgery - Procedure Codes and Nomenclature ... ......... ......... ........ Appendix II Hospital Cost Report .. ......... ......... ......... ......... ......... ........ Appendix IV FORMS SECTION DRG WEIGHTS AND RATES PART II HOSPITAL PROVIDER MANUAL This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to hospital providers. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendices. The Billing Instructions subsection gives examples of the billing forms applicable to hospital services. The forms are followed by directions for completing and submitting them. The Benefits and Limitations subsection defines specific aspects of the scope of hospital services allowed within the Kansas Medical Assistance Program (KMAP). The Appendix subsection contains information concerning procedure codes, emergency diagnosis codes and swing bed nursing facility supplies. The appendices were developed to make finding and using codes easier for the biller. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A. 21-3853 and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations. 7000. HOSPITAL BILLING INSTRUCTIONS Updated 12/08 Introduction to the UB-04 Claim Form Hospital providers must use the UB-04 red claim form when requesting payment for medical services and supplies provided under the KMAP. Any UB-04 claim not submitted on the red claim from will be returned to the provider. An example of the UB-04 claim form is in the Forms section at the end of this manual. Instructions for completing this claim form are included in the following pages. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the UB-04 claim form to providers. Refer to Section 1100. The following numbered form locators (FL) are to be completed when required or if applicable. Completing the UB-04 claim form: FL 1 Billing Provider Name, Address and Telephone Number – Required. Enter the name and address of the billing provider. FL 3A Patient Control No. Enter a patient account number if desired. (This number will be referenced on the Remittance Advice [RA].) FL 3B Medical Record No.-Desired. Enter the patient’s medical record number. (This number will appear on the provider’s RA.) FL 4 Type of Bill - Required. Enter the 3-digit number specific to the type of claim. 1st digit indicates facility. 2nd digit indicates location within facility. 3rd digit indicates the frequency of the claim billed. Medicaid allowed codes: 1st digit: 1 Hospital (IP/OP) 8 Outpatient – Critical Access 2nd digit: 1 Inpatient 3 Outpatient 5 Critical Access Hospital 8 Swing bed NF 3rd digit: 0 Nonpayment/zero claim 1 Admit through discharge claim 2 Interim - first claim 3 Interim - continuing claim 4 Interim - last claim (thru date is discharge date) KANSAS MEDICAL ASSISTANCE PROGRAM HOSPITAL PROVIDER MANUAL BILLING INSTRUCTIONS 7-1 7000. Updated 12/08 FL 5 Federal Tax Number – Required. FL 6 Statement Covers Period – From/Through – Required. Enter inpatient dates of admission and discharge or outpatient from and through dates in MM/DD/YY format. FL 7 Reserved for assignment by NUBC. Covered Days - Required - Inpatient Only. Enter the number of days for which you are billing. Note: Count date of admission, but not date of discharge. FL 8 Patient Name/Identifier – Required. Enter patient's last name, first name and middle initial exactly as it appears on the ID card. If patient is a newborn, enter "newborn", "baby boy", or "baby girl" in the first name field and enter the last name. FL 9 Patient Address – Required. FL 10 Birthdate – Required. Enter patient's date of birth in MM/DD/YYYY format. If newborn, enter baby's date of birth (not mother's). FL 11 Sex – Required. Enter "M" for male or "F" for female. If newborn services, enter "M" or "F" for the baby. FL 12 Admission/Start of Care Date – Required. Enter date patient was admitted as inpatient or date of outpatient care in MM/DD/YY format. FL 13 Admission Hour – Required – Inpatient Only. Enter treatment hour using the continental time system (i.e., 6:00 p.m. equals 1800 hours). FL 14 Priority Type of Visit Admission Type–Required – Inpatient Only. Enter a one-digit code to indicate type of admission. 1 – Emergency 3 – Elective 5 – Trauma 2 – Urgent, etc. 4 – Newborn FL 15 Point of Origin for Admission or Visit Admission Source– Required. Enter a one-digit code to indicate admission source. 1 – Nonhealth care facility point of origin 2 – Clinic 3 – Reserved for assignment by NUBC 4 – Transfer from hospital 5 – Transfer from skilled nursing facility Nursing Home 6 – Transfer from another healthcare facility 7 – Emergency room 8 – Court/law enforcement 9 – Information not available KANSAS MEDICAL ASSISTANCE PROGRAM HOSPITAL PROVIDER MANUAL BILLING INSTRUCTIONS 7-2 7000. Updated 12/08 A – Reserved for assignment by NUBC B – Transfer from another home health facility C – Readmission to same home health agency D – Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in separate claim to the payer E – Transfer from ambulatory surgery center F – Transfer from hospice and is under a hospice plan of care or enrolled in a hospice program G-Z – Reserved for assignment by NUBC Code structure for newborn 1-4 – Reserved 5 – Born inside this hospital 6 – Born outside of this hospital 7-9 – Reserved FL 16 Discharge Hour – Required on inpatient claims with a frequency code of 1 or 4 except Type of Bill 021X. FL 17 Patient Status - Required - Inpatient Only. Enter a two-digit code to indicate status of patient: 01 Discharged to home or self care (routine discharge). 02 Discharged/transferred to another short-term general hospital for inpatient care. 03 Discharged/transferred to skilled nursing facility (SNF) with Medicare certification. 04 Discharged/transferred to an Intermediate Care Facility (ICF). 05 Discharge/transfer to a designated cancer center or children’s hospital. 06 Discharged/transferred to a home under care of organized home health service organization. 07 Left against medical advice or discontinued care. 08 Discharged/transferred to home under care of a home IV drug therapy provider. This is not a certified Medicare provider. 09 Admitted as an inpatient to this hospital (for use on Medicare Outpatient Hospital claims only). 20 Expired (or did not recover - Christian Science Patient). 30 Still patient. 40 Expired at home. (Hospice claims only.) 41 Expired in a medical facility, such as a hospital, SNF, ICF, or freestanding hospice. (Hospice claims only.) 42 Expired - place unknown. (Hospice claims only.) 43 Discharge/transferred to a Federal Health Care Facility. 50 Discharge to hospice – home. 51 Discharge to hospice - medical facility. 61 Discharged/transferred within this institution to a hospital-based, Medicare-approved, swing bed. KANSAS MEDICAL ASSISTANCE PROGRAM HOSPITAL PROVIDER