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Claims Submission Policies and Procedures
ncreasingly, local, state and federal governments have sought clinical and cost data to more
carefully monitor the use of public health care funds. In order to comply with governmental
mandates for information, managed care organizations such as CBH have had to request more
detailed and complex claims data from providers.
I
We recognize that this often poses an ardous task. Nevertheless, submission of accurate claims
information in a timely manner is an essential part of the provider's role in delivering care, tracking clinical activity and maintaining fiscal stability.
For this reason, CBH is committed to working with providers to help the process go as smoothly
and efficiently as possible. We welcome your comments and suggestions on how to further improve the process. In this chapter, we provide general and specific policy and procedural statements pertaining to the submission of claims to CBH. If we can assist you with any additional
information, please contact the Claims Department at (215) 413-7125.
Submitting Claims to CBH
Provider shall bill CBH for Covered Services rendered to Enrollees, in the manner specified in this
section. Provider shall submit "Clean Claims" no more than 90 days following the date of service
for Covered Services. In the event Provider is pursuing Coordination of Benefits, provider must
obtain a final determination from the primary payor dated no more than 180 days following the
date of service and submit a clean claim to CBH within 90 days after receipt of a determination
from the primary payor. "Unclean Rejected Claims" must be resubmitted as clean claims within
the time requirements stated herein. CBH reserves the right to make no payments for claims
received beyond the time requirements stated herein.
Definitions:
clean claim: A clean claim shall mean a claim that can be processed without requiring additional information from the provider of the service or from a third party. A clean claim does not
include: claims pended or rejected because they require additional information either from a provider or from internal sources (i.e., claims pended for a determination of third-party liability, etc.);
a claim under review for medical necessity; or a claim submitted by a provider reported as being
under investigation by a governmental agency, the City of Philadelphia or DBH/CBH for fraud or
abuse. However, if under investigation by the City or DBH/CBH, the Department of Public
Welfare (DPW) must have prior notice of the investigation.
unclean rejected claim: An unclean rejected claim shall mean a claim that is returned to
the provider or third party for additional information.
clean rejected claim: A clean rejected claim shall mean a claim that is returned to the provider or third party due to ineligible recipient or service.
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4.2
Verification of Eligibility:
In order to receive payment for services rendered, providers must check the member’s eligibility.
Providers can access the DPW’s daily eligibility file by phone by calling (800) 766-5387. Providers may also use the various methods described on DPW’s website: Go to http://www.dpw.state.
pa.us/Partners Providers/PROMISe/003675036.htm and click on the "Eligibility Verification Information" link.
Authorized Services:
The authorization process and the claims process are closely related. (See Authorization section
for details on the authorization process.) For all services requiring an authorization, the provider
will need to obtain an authorization number prior to submitting a claim. A claim form without a
required authorization number will be rejected. (If filed manually, the claim will be returned.)
Non-Authorized Services:
All laboratory services (600-level services) and most outpatient services do not require an authorization. When completing the claim forms, these non-authorized services must have a Blanket
Authorization Number (BAN) placed in the authorization number field. Please refer to Schedule
A of the Provider Agreement to identify the non-authorized services and the corresponding BAN.
There are sample claim forms at the end of this chapter available for reference.
Pricing and Information Modifiers:
Certain services (both authorized and non-authorized) require pricing and/or information modifiers. Please refer to Schedule A to identify the services which require modifiers. When completing
the claim form, place the pricing modifier in the first modifier field and the information modifier
in the second modifier field. There are sample claim forms at the end of this chapter available for
reference.
Entering the Correct Year Format:
When completing the UB-04 or CMS-1500 (08-05) claim forms, the provider must use the complete
four-digit year. For example, enter the full year as “2011” rather that ’11. Any manual claims submitted without the full year date format will be returned.
Billing for Consecutive Days - "Span Billing":
When billing for per diem services that were provided on consecutive days, the provider does not
need to enter each individual date of service on the claim form, but may “span bill” the entire period of service. “Span billing” means that the provider notes on the claim the dates that treatment
began and ended and the number of units of service provided.
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Both the "service begin" date and the "service end" date must be within the
authorized period. The day of discharge from inpatient treatment does not
count for units of service.
Billing for Non-Consecutive Days:
When billing for non-consecutive days within a particular authorization period, the provider must
note each date of service individually.
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Do not span date for non-consecutive days of service or non-per diem
services. Such claims will be rejected.
Requirements for Provider Signature:
The provider rendering the service must sign all invoices for claims, whether they are submitted
manually or electronically. The signature certifies that the service has been rendered according to
Medical Assistance (MA) regulations.
Methods of signing claims: The following are acceptable methods of signing claims:
For Paper Claims:

An actual handwritten authorization signature of the provider directly on the signature
line of the invoice. The provider’s initials or printed name are not acceptable signatures.

A signature stamp of the provider placed directly over the signature line of the invoice is
acceptable, if the provider authorizes its use and assumes responsibility for the
information in the invoice.

An actual handwritten authorization signature of the provider directly on the MA-307
Invoice Transmittal Form, a form used to certify that treatment services have been
delivered by the provider.
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4.4
For Claims submitted via modem:

An electronic certification is incorporated into the submission process.
non-compliance: All claims received that do not meet the provider signature requirements
will not be processed. These claims will be returned to the provider for correction.
Third Party Liability (TPL) Billing:
Third Party Liability (TPL) refers to specific entities, such as Medicare, Blue Cross and parties
other than CBH that may be liable for all or part of a client’s health care expenses. When thirdparty resources are available to cover behavioral services provided to Medicaid recipients, CBH is
the “payor of last resort.”
For all services requiring prior authorization, the provider should obtain an authorization number
from a DBH/CBH Care Manager prior to submitting a claim. This applies regardless of whether
CBH is the primary payor or if it is Medicare or any other insurance carrier. Please also note that
providers should obtain authorization numbers at the time clients are admitted to a facility.
Once it is determined that a client has other insurance, the bill should be sent first to the primary
insurance carrier(s) for payment consideration. CBH will consider for payment all balances for
behavioral health services that are unpaid by the other insurance carriers.
Before CBH can consider a TPL claim for payment, the provider must submit the completed claim
form, the Explanation of Benefits (EOB), or the denial letter(s) sent to the provider by any and all
other carriers.
The claim must be fully considered and resolved with the primary carrier before it is billed to
CBH. If the services are rejected by the primary carrier due to missing, incomplete, or incorrect information, the service must be re-billed to the primary carrier before CBH will consider payment.
The EOB, or the denial letter(s) must be the final determination. If the primary carrier rejects the
claim, the primary carrier’s internal appeals process must be exhausted before CBH will consider
the claim for payment.
It is important that the provider’s bill matches the EOB information. This applies to the billed
amount, beginning and ending dates, Medicare approved amount, and other insurance paid
amount, Medicare deductible and the Medicare co-insurance amount. If the EOB form is larger
than letter size, please reduce the EOB to 8-1/2” by 11” in size. Please include a copy of the EOB
with each claim. Do not attach several claims to one EOB.
TPL Medicare Inpatient Claims:
When submitting Medicare and other insurance carriers’ third-party liability claims for one inpatient stay, CBH requires separate claim forms for each authorization number issued for the various levels of care during the stay. Be sure to use the appropriate authorization number on each
claim.
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Once you receive your Medicare or other insurance EOB, complete the UB-04 Claim Form for each
authorized period. The billed charges must be for the authorized period. Attach a copy of the EOB
to each claim prior to submitting to CBH. It is essential to submit these claims together to ensure
proper processing.
Exhausted Medicare Inpatient Lifetime Psychiatric Days:
If the member’s lifetime psychiatric days have been exhausted, manually submit both the Medicare Part A and Part B EOBs with the claim form.
The Medicare Part A EOB must show the Medicare Lifetime Exhaustion rejection code. If you do
not have the Medicare Part A EOB, you must submit the HIQA Inquiry Form from the Medicare
system. However, the Medicare HIQA Inquiry Form will only be accepted if the inquiry date is the
admission date or the date on which the benefits exhausted during the stay, or should be covered
in the Date of Earliest Billing (DOEBA) or Date of Last Billing (DOLBA) time period.
For Medicare Part B, you must use the appropriate value code in Field 39 on the UB-04 Claim
Form to indicate the Medicare Part B payment. The Part B value amount on each claim must
reflect only the portion that applies to the dates of services on each claim.
Medicare Remittance Advices/ Other Insurance Carrier Remittance Advices
For CBH to process Medicare claims correctly, the following information is needed on the remittance advices:
1.
2.
3.
4.
5.
6.
7.
8.
From and Thru Date
Total Days (Cost Days)
Covered Days
Non-Covered Days
Total Charges
Covered Charges
Non-Covered Charges
Remark Codes and description of remark codes
For CBH to process commercial insurance carriers and Medicare Advantage Plans claims, the following information is needed on the remittance advices:
1.
2.
3.
4.
5.
From and Thru Date
Total Days
Covered Days
Non-Covered Days
Remark Codes and description of remark codes
If you or your vendor is unable to include this data on your remittance advices, please add the
information to your explanation of benefits. This will help to assure that your claims are processed and paid correctly. Otherwise, we may have to reject your claim to allow you to correct
and resubmit the claims with all of the necessary requirements.
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4.6
ACT 62 Pennsylvania Mandate for Autism
As of 7/1/09, DPW requires that private insurers pay for the first $36,000 of the cost of covered
behavioral services for children age 21 and under with Autism Spectrum Disorders. Each
month when the employer group renews, the children become a part of the program. All of the
benefits must be coordinated with the primary carrier until the first $36,000 is paid out for covered services for the contract year. After the primary carrier pays $36,000 for the contract year,
CBH will pay as the primary for those services for the rest of that contract year. The $36,000
benefit starts again each year when the employer group renews the contract with the primary
carrier.
It is the responsibility of the provider to contact the parents and the primary carrier of each client with an Autism Spectrum disorder to determine whether or not they have the Pennsylvania
Mandate for Autism, ACT 62. If the client has the ACT 62 mandate, the benefits must be coordinated with the primary carrier for all levels of care, except the ones noted below that CBH will
continue to pay as the primary. Once the EOB and/or final determination letter is obtained, the
claims must be submitted manually along with a copy of an EOB/final determination letter attached to each claim.
If a client is being seen, and CBH does not have a record of the ACT 62 benefit, and later finds
out retro back that the client has the ACT 62 benefits, all the claims will be identified for which
CBH should not have paid as the primary carrier, and the claims will be backed out.
Please note that in order for us to consider these claims for payment, the benefits must be coordinated with the primary carrier. There must be a final determination submitted with each
claim. Two denial reasons have been set up to be used when the final determination has not
been submitted, or is not correct. The rejection reasons are “Act 62 Coordinate Benefits” or
“ACT 62 Determination not acceptable”. If the primary carrier denies the services as a non-covered benefit, CBH will pay as the primary. Also, if the services are being denied because they
are provided in the school, currently, CBH is paying as the primary carrier.
If the client is receiving the same level of care (service) on the same day in two different place of
service, and the primary only covered some of the units of service, you must bill all of the units
together. It must be noted on the EOB and/or final determination letter how many units were
covered, and how many units were not covered. If the claims are submitted separately, one will
pay and the other one will reject as being previously paid.
CBH will continue to pay as the primary for the following levels of care:
a.
450
b.
550
c.
700
d.
800
e.
900
All of the other levels of care must be coordinated with the primary carrier, before they can be
considered for payment by CBH.
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Post-Payment Recoveries
According to the City of Philadelphia’s contract with the Commonwealth of Pennsylvania DPW,
CBH is required to take all reasonable measures to ensure that CBH is the payor of last resort
when other third-party resources are available to cover the cost of medical services.
When CBH becomes aware of payments made on behalf of CBH clients who have valid thirdparty resources, post-payment recoveries will be pursued. If a provider is identified as having
received an inappropriate payment, a post-payment recovery letter will be sent to the provider.
Providers who receive such letters are required to bill the primary carrier(s) and resubmit the
claim along with a copy of the recovery letter and the final determination for CBH review and
processing. These should not be submitted as regular adjustments. They should be sent to the
attention of the CBH staff that is handling the recovery. If CBH does not receive a response within
60 days from the date of the letter on the status of the recovery, CBH will automatically backout
the claims. The provider has 90 days from the date the payment has been retracted to submit the
claims and EOB and/or final determination letter to CBH for processing.
The Commonwealth of Pennsylvania (DPW) will pursue all cases that CBH is unable to recover.
Member Co-Payment Prohibition
Federal law prohibits treatment providers from requesting co-payments from MA recipients in
the Commonwealth of Pennsylvania. Billing CBH members for co-payments for services is also in
violation of the CBH Provider Agreement.
Where to Mail Claims
All manual claims must be sent via the U.S. Postal System or delivery service to: CBH, Claims Department, 801 Market Street, 7th Floor, Philadelphia, PA 19107. Hand-deliveries will not be
accepted.
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4.8
Filing Electronic Claims
Filing claims electronically helps providers minimize data entry errors after submission, ensure
information is legible, and expedite the processing of their claims. In order to submit claims electronically, the provider must have the appropriate software.
Please refer to the CBH website, www.dbhids.org for the necessary information regarding the
submission of electronic claims. On the website under “HIPAA Resources,” you will find the
following key information:
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Browser Interface Manual
CBH Companion Guide 837 Professional
CBH Companion Guide 837 Institutional
CBH Companion Guide 835RA
Prior to any initial electronic claims submission to CBH, contact Provider Relations at (215) 4137660 for specific information needed to create an electronic file and to coordinate the submission of
the test file.
A sample of the electronic file submission, adjudication and payment cycle can be found on page
4.34.
Filing Manual Claims
Providers filing manual claims must use one of two printed claim forms designated for that purpose. Please refer to Schedule A of your CBH Provider Agreement for all contractual services and
the appropriate CPT codes, pricing and information modifiers, and BANs. This section provides
specific information about which forms are to be submitted for the specific types of treatment. It
also provides examples of each form.
inpatient claims, UB-04 claim form: All inpatient hospital or RTF-Accredited claims
must be submitted using the UB-04 Claim Form.
outpatient claims, cms-1500 (08-05) claim form: All other claims must be submitted
using the CMS-1500 (08-05) Claim Form.
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Claims Form Guidelines
The succeeding section provides specific details on the use of the UB-04 and CMS-1500 (08-05)
Claims Forms. Following is an index:
UB-04 Inpatient Billing Provider Information, Compensable Service and Patient Information........................................4.8
UB-04 Inpatient Billing Third Party Liability (TPL) Billing.....................................................................................................4.9
CMS-1500 (08-05) Outpatient Information, Provider Name and Compensable Medical Services..................................4.11
CMS-1500 (08-05) For Outpatient TPL Billing Information, Provider Name and Compensable Medical Services......4.12
Common Causes for Claim Rejections and Remedies for Providers.........................................................................4.18 - 4.20
Specific Claims Submission Information
Completion of the UB-04 Claim Form
The UB-04 Claim Form is used when an inpatient (hospital inpatient or RTF Accredited) stay has
occured. Revenue Codes are used exclusively on the UB-04 claim form. (See sample UB-04
Claim Forms later in this section.)
Listed below are the specific fields that must be completed on the UB-04 Claim Form before submitting it to CBH for processing. Remember that all services require an authorization number
for billing and only one authorization number per claim form is allowed. When an item is "not
applicable," do not use zero. Leave it blank. See the PROMISe Desk Reference for assistance
in the completion of the UB-04 Claim Form on pages 4.23 and 4.24.
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4.10
UB-04 PATIENT INFORMATION, PROVIDER NAME, AND COMPENSABLE BEHAVIORAL HEALTH SERVICES
Form
Locator
Field Name
Form
Locator
1
Billing Provider Name, Address, and
Telephone Number
3a
Patient Control Number
46
Units of Service
4
Type of Bill (See UB-04) Desk
Reference for Hospitals
47
Total Charges
6
Statement Covers Period
47 (23)
Total Charges
8a
Patient Name
50
Payor Name (Enter the name of each
payor organization from which the
provider might expect some payment for
the bill)
Patient Address
56
NPI # (Enter the 10-digit National
Provider Identifiier)
10
Patient Birth Date
58
Patient Name
12
Admission Date
60
Patient Number (Enter the 10-digit MA
Number)
13
Admission Hour
63
Treatment Authorization Number (CBH
Authorization Number)
14
Admission Type (See UB-04 Desk
Reference for Hospitals)
67
Principal Diagnosis Code
16
Discharge Hour
69
Admitting Diagnosis Code
17
Patient Status (See UB-04 Desk
Reference for Hospitals)
76
Attending Physician NPI# (Enter the 10digit National Provider Identifier) OR
QUAL (Enter Attending Physician License
Number)
Value Codes and Amount (Value Codes
must be entered in numeric sequence,
starting in From Locators 39a thru 41a,
39b thru 41b, 39c thru 41c, and lastly
39d thru 41d. (See UB-04 Desk
Reference for Hospitals)
80
CBH Provider Number
9a-d
39a-41d
42
Revenue Code (See CBH Schedule A)
43
Revenue Code Description
45 (23)
Field Name
Creation Date (Enter the claim creation
date)
Each batch of claims submitted MUST be accompanied by 1 (one) properly completed Signature
Transmittal Form (MA307)
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UB-04 INPATIENT THIRD PARTY LIABILITY (TPL) BILLING
When using the UB-04 Claim Form for inpatient TPL billing, the fields in the chart below must be
completed. The standard fields must also be completed. See Explanation of the Completion of
the UB-04 on page 4.26; sample UB-04 – Inpatient Third Party Liability (TPL) Claim Form on page
4.26, and Explanation of Benefits (EOB) for Inpatient UB-04 Third Party Liability (TPL) on page
4.27.
UB-04 Inpatient Third Party Liability (TPL) Billing
Form
Locator
39-41
50
Field Name
Form
Locator
Field Name
Value Codes and Amounts (Deductible
and coinsurance values, if applicable)
51
Health Plan ID
Payer’s name (Enter the name of each
payer organization from which the
provider might expect some payment for
the bill)
54
Prior Payment (Enter the covered
charges amount on the EOB (for
Medicare, or the other insurance
carrier’s payment amount)
55
Estimated Amount Due (Enter the
estimated amount you expect to be paid
by CBH)
!
When using the UB-04 Claim Form to bill for inpatient services,
the following information must be retrieved from the EOB and
indicated on the form:
Information To Be Retrieved From EOB
Field No. On UB-04 Claim Form
Service From/Thru
6
Covered Days
39-41
Deductibles
39-41
Covered Charges for billed period for
Medicare and the other insurance payment
amount for other insurance carriers.
54
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4.12
Completion of the CMS-1500 (08-05) Claim Form
The CMS-1500 (08-05) Claim Form is primarily used for outpatient services.
WHEN TO USE THE CMS-1500 (08-05) CLAIM FORM
The CMS-1500 (08-05) Claim Form may be used when filing a claim for the following behavioral
health services:
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Outpatient psychiatric treatment
Non-hospital services (3a, 3b, 3c)
Outpatient drug and alcohol (D&A) treatment services
Residential treatment facilities (non-accredited)
Psychiatric partial hospital programs (acute and maintenance)
Behavioral health rehabilitation services for children
Intensive outpatient programs (IOP)
Consultations
Methadone maintenance
Laboratory services
The chart on the following page lists the specific fields that must be completed on the CMS-1500
(08-05) Claim Form before submitting it to CBH for processing. Never use zeros in fields for items
that are not applicable. Leave spaces blank.
E
PLEAS
NOTE
The CMS-1500 (08-05) Paper Claim Form has room for 6 lines of service, but
CBH's claims system can only accept 4 lines of service per claim. Use no
more than 4 lines of service on the CMS-1500 (08-05) Claim Form.
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CMS-1500 (08-05) Outpatient Information, Provider Name, and Compensable Behavioral Health Services
Form
Locator
Field Name
Form
Locator
Field Name
1
Type of Claim (Place an X in the Medicaid
box)
23
Prior Authorization Number (CBH
Authorization Number or BAN
Number)
1a
Patient Number
24a
Date of Service (note begin and end date)
2
Patient Name
24b
Place of Service (see OMHSAS Desk
Reference)
3
Patient Birth Date
24d
Procedure Code (In the first section of the block,
enter the procedure code that describes the service provided. In the second section of this block,
enter the pricing modifier, when applicable. In
the third to fifth sections of this block, enter up
to three information modifiers, when applicable.
Failure to use the appropriate modifier (s) in the
appropriate blocks will result in claim denial.)
5
Patient Address
24e
Diagnosis Pointer
12
Patient's or Authorized
Person's Signature and Date
24f
Usual Charges
17
Name of Referring or Prescribing Practitioner
24g
Units of Service
17a
Referring or Prescribing Practitioner
License Number (enter the first portion of
this block, enter two-digit qualifier that
indicates the type of ID:)
OB = license number
ID = 13 digit Provider ID Number in the
second portion enter the license number
or the 13 digit Provider ID Number of
the referring or prescribing practitioner
named in Block 17.
28
Total charges (enter total sum of 24f, 1 thru 4 in
dollars and cents)
17b
Referring or Prescribing Practitioner NPI
# (enter the 10 digit National Provider
Identifier number)
31
Signature of physician, date claim was submitted
or Signature Transmittal Form MA-307
21
Diagnosis (enter the most specific 3, 4, or
5 digit ICD-9-CM code that describes the
diagnosis)
33
Billing Provider Name and Address
33a
NPI # (enter the 10 digit NPI number of billing
provider)
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4.14
CMS-1500 (08-05) Third Party Liability (TPL) Billing When completing the CMS-1500
Claim Form for TPL billing, the following must be completed. The standard fields must also be
completed as described on the previous page under Explanation of Completion of the CMS-1500
Claim Form on page 4.11. See sample CMS-1500 (08-05) - Outpatient Third Party Liability (TPL)
on page 4.32.
CMS-1500 (08-05) For Patient TPL Billing Information, Provider Name, and Compensable Medical Services
Field #
Field Name
Field #
9
Other Insured's Name (Another
health insurance secondary to
insurance in block 11)
11b
Employer's Name or School
Name (if applicable)
9a
Other Insured's Policy or
Group Number (if applicable)
(other than MA)
11c
Insurance Plan Name or Program Name (other than MA)
9b
Other's Insured's Date of Birth
(if applicable)
24f
Usual Charges (The amounts
must agree with the other
plan's EOB)
9c
Employer's Name or School
Name (if applicable)
28
Total Charges (Enter total sum
of lines 24f, lines 1 thru 4 in
dollars and cents)
11
Primary Insurance (other than
MA) policy number (if applicable)
11a
Insured's Date of Birth
(if applicable)
REMINDER
Field Name
When billing for payment of Medicare deductibles and/or coinsurances
for services covered by MA, the provider must use the appropriate MA
Procedure Code.
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Processing Payments
When a provider submits a claim to CBH, it goes through several stages of review and processing,
as described below:
Claims Processing Cycle
Adjudication process: CBH will adjudicate 100% of clean claims within 45 days and adjudicate 100% of all claims within 90 days. Adjudicate means to pay or reject a claim.
payment of claims: Payment will be mailed in the form of a check to the address designated
by the provider in the provider information form. Changes in address must be reported in writing
under the signature of the Chief Executive Officer to CBH's Chief Executive Officer, 801 Market
Street, 7th Floor, Philadelphia, PA 19107.
claims reports: Whether a claim is accepted, rejected or pended, claims reports will be made
available to the provider explaining the reasons for the action taken on the claim. (Learn more and
see samples in the following section under Claims Reports.)
Claims Adjustments
On occasion, after a payment has been issued, either CBH Claims staff or the provider may detect
an error in the processing of the claim that was paid. The adjustment process deals with the correction of those claims that have been through the adjudication cycle and been paid. If a claim has
been rejected and not yet paid, it is not subject to an “adjustment.” Only those claims that have
already been paid can be adjusted. Claims adjustments generally occur for the following reasons:








Claim was submitted and paid twice.
Claim was paid at a wrong rate.
Claim was paid for the wrong date(s) of service.
Claim was paid at a wrong level of care.
Claim was submitted with excessive units of service within time period.
Services were span billed with overlapping days on more than one claim.
A Compliance audit was conducted.
Post Payment recoveries
Adjustments must be received within the claims submission timeframes noted on page 4.1
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4.16
Submitting Adjustments Manually
Complete and submit the following:
 A Claims Adjustment Request Form - Note the invoice number(s) and the invoice
line(s) in the space that is provided or attach a copy of the payment detail clearly
indicating the line requiring an adjustment
 Corrected Claim(s) Form
 The EOB for TPL Claims
•
Submitting Adjustments Electronically (Where No TPL is Involved)
Complete and submit the following:
 Back-outs only: For claims back-outs of more than 10 invoice lines, a CD must be
submitted using Excel, and must only contain the invoice numbers (first column)
and line(s) (second column). One adjustment form must be submitted with each CD.
 Back-out and Reprocess:
For claims back-outs of more than 10 invoice lines, a CD must
be submitted using Excel, and must contain the invoice numbers (first column) and
line(s) (second column). For the related claims reprocessing, submit new claims via
FTP once you have confirmation of the original claim reversal. One adjustment form
must be submitted with each CD.
The top two copies of the Claims Adjustment Request Form must be mailed with the appropriate
support documents to: CBH, Claims Department, Attention: Adjustments, 801 Market Street, 7th
Floor, Philadelphia, PA 19107.
Pended Claims
Pended claims are those claims that are put on temporary hold to assure that CBH is the payor of
last resort for members that have other primary coverage in addition to MA. It also determines if
the services are covered by a third party payor. TPL Claims will pend when:

The provider indicates on the claims form that the member has another coverage.

The provider submits an EOB along with the claim.

During the processing of the claim, CBH's eligibility file, as transmitted by the
Pennsylvania DPW, indicates that the client is covered by another insurance.
DBH/CBH PROVIDER MANUAL REV.2011
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The provider will receive a Rejection Report listing those claims that have pended after the adjudication process.
To avoid disruptions to treatment of children, BHRS claims will first pend, but will be released for
payment by CBH within two weeks.
Rejected/Denied Claims
CBH may reject or deny a claim for a variety of reasons. In some cases, crucial claims information,
such as dates, authorization numbers or client information, may be missing or incorrect. In addition, the provider may not have submitted the claim to the primary payor.
When rejecting a claim, CBH will provide a Rejected/Denied Claims Report listing those claims
that have been rejected/denied after the adjudication process.
Providers are encouraged to carefully review the original claims, the Rejected/Denied Claims
Reports, and to make any necessary corrections or revisions, and when appropriate, resubmit the
claims for payment.
!
One of the most common causes for claims rejection is entering date
information incorrectly. When entering inpatient treatment days, please
enter the date of admission as the "begin date" and the day of discharge
as the "service end" date, but count the length of the stay according to
the number of "nights" of stay. The day of discharge is not counted as a
day of treatment.
Claims Appeals Process
There are three categories of claims rejections that providers may appeal. The processes for each
category are described separately.
APPEALING REJECTED CLAIMS FOR THIRD PARTY LIABILITY (TPL) CAUSED BY DISCREPANCIES BETWEEN THE ELIGIBILITY VERIFICATION SYSTEM (EVS) AND THE CBH
CLAIMS SYSTEM
If the provider accesses the EVS information and it indicates that the client does not have TPL coverage, but during processing of the claim, the CBH system detects such coverage and consequently
rejects the claim, within 90 days from the date of the rejection the provider must do the following:
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4.18

Note the invoice number(s) and the invoice line(s) with the specific TPL rejection
reason or send a copy of the rejection report with the TPL rejection reason.

Make a copy of the eligibility information that notes the client does not have TPL
coverage.

Make a copy of all outstanding claims along with any other evidence of non-coverage
by a third party.

Mail the above to the CBH Claims Department, 801 Market Street, 7th Floor,
Philadelphia, PA 19107. Clearly write on the envelope "TPL Discrepancy."
CBH will then perform a manual review of the client's coverage. If it is determined that the client
has no TPL coverage. CBH will reprocess the claim and make the necessary system adjustments. If
it is found that the client does have TPL coverage CBH will return the claim to the provider along
with the name of the primary carrier and policy number. The provider must obtain a final determination from the primary payor dated no more then 180 days following the date of the TPL Discrepancy continuation letter issued by CBH to the provider. The provider must submit a clean claim to
CBH within 90 days after receipt of the final determination from the primary payor.
APPEALING REJECTED CLAIMS FOR "recipient not eligible" caused by discrepancies between the evs and the cbh claims system
If the provider accesses the eligibility information and it indicates that the client is eligible for treatment on a particular date, but during the processing of the claim CBH does not show the individual to be eligible and rejects the claim, within 90 days from the date of rejection the provider must
do the following:

Make a copy of the rejection report that notes the eligibility rejection.

Make a copy of the eligibility information that notes the client was CBH eligible to
receive service on the date(s) indicated on the claim.

Prepare a new clean claim for the service(s) performed.

Mail the above to the CBH Claims Department, 801 Market Street, 7th Floor,
Philadelphia, PA 19107. Clearly write on the envelope "Eligibility Rejection Appeal."
The claims will be handled by CBH in one of the following ways:

If the claim was rejected within the last month, it will be overridden and appear on the
next Payment Detail.
DBH/CBH PROVIDER MANUAL REV.2011
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
If the claim rejection is older than one month, we will re-enter the newly submitted
claim(s) after the eligibility information is updated in our system. The re-submitted
claim(s) will go through our normal adjudication process.
E
PLEAS
NOTE
The override for eligiblity applies only to claims that were submitted and
rejected for "Recipient Not Eligible." It does not apply to authorization
requests that were denied because of ineligibility.
APPEALING claims for late submission beyond the timely submission
requirements
If CBH receives a claim or Adjustment Request Form beyond the timely submission requirements
noted on page 4.1, the claim or adjustment form will reject or be returned to the provider due to late
submission. Claims or adjustments rejected or returned for late submission may be appealed only
due to processing errors made by CBH. The following requirements are necessary in order to be
eligible for appeal:

Provider had submitted a clean claim within the required timeframes.

CBH had improperly processed the clean claim causing an incorrect payment or a
rejection only resulting from CBH's processing error.

Provider resubmits the clean claim (along with an Adjustment Request Form for
incorrect payments) within 90 days from the date of the incorrect payment or rejection.
for tpl claims only

A letter addressed to the Claims Appeals Specialist indicating the specific cause of
the rejection or incorrect payment due to CBH's error.

A copy of the rejection report that notes the rejection reason caused by CBH's error or
a copy of the payment detail that notes the incorrect payment made due to CBH's
error, and

A copy of the claim and EOB for TPL claims.
If the appeal is due to untimely final EOB, documentation is needed. Documentation must be
submitted to explain or show why the final determination could not be obtained timely.
Mail all claims appeals to the attention of CBH Claims Appeals Specialist, 801 Market Street, 7th
Floor, Philadelphia, PA 19107. Clearly write on the envelope "Claims Appeal."
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4.20
The following chart lists the most frequent causes for claims to be rejected and the remedies for providers.
common causes for claim rejectionS and remedies for providers
rejection description
cause
remedy
1. If exact same date(s) of service(s)
for same person was previously paid,
claim will reject.
Check to ensure no data entry error was
made.
2. When a provider submits two
claims for separate units of service
within the same billing period, the
second claim will reject if the first
claim form has referenced the entire
billing period. (For example, a provider has authorization for 30 units
from 1/1/08 to 1/31/08. Claim #1 is
submitted for 15 units used on 1/1
to 1/15, but references 1/1 to 1/31 on
the claim form. If a second claim is
submitted for the remaining 15 units
with service dates 1/16 to 1/31, the
second claim will be rejected because
it is covering a period that was already paid, and therefore appears to
the system to be an overlapping bill.)
Submit a Claims Adjustment Request
Form for the initial claim indicating that
only a portion of the entire billing period
and units of service were used. Also
resubmit a corrected claim reflecting the
entire billing period.
1. This may occur when all authorized units were paid, and the
provider submitted a claim for additional units.
2. If the initial authorization was zeroed out or cancelled, the claim will
be rejected for this reason.
Check to see if additional date(s) of
service for additional units are under
another authorization number. If so,
resubmit the claim using the corrected
authorization. If additional units are
needed for the same individual, the CBH
Care Manager must approve extending authorization. Then provider can
resubmit a claim for the added units.
Or, a new authorization may be issued
and the provider can re-submit the claim
with the correct authorization for payment.
Invalid or unknown recipient ID
number.
If a claim was submitted with the
wrong recipient number or no number, the claim will reject.
Check to ensure no data entry error was
made. Re-submit with the correct CIS
number.
Recipient was not eligible for
service on a specified date.
These claims have been rejected
because according to CBH records,
the client was not eligible for service
on that date.
Re-submit with proof of eligibility. Attach eligibility information for that date
of service for correct processing. Send
claims to the attention of the Claims
Department "Eligibility Rejections."
Billed dates of service do not
match authorized dates of
service.
If a claim is submitted for service
dates outside the authorization
period, this error will appear. (For
example, if the authorization period
is for 1/1/08 to 2/1/08 and the claim
submitted is for 2/5/08, the claim will
be rejected.)
Check the authorization report for the
correct authorization number for this
date of service. Re-submit the claim for
the correct period or obtain a corrected
authorization.
Claim line was
previously paid.
No units of service left for this
authorization
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rejection description
cause
remedy
Invalid primary ICD-9 Behavioral
Diagnosis Code
Diagnosis code is not considered valid
by CBH, was not correctly entered, or
was missing on the claim.
Use the correct ICD-9 code number,
for proper payment. Contact Provider
Relations at (215) 413-7660 if you need
assistance.
Invalid or unknown
authorization number
The claim was submitted either with
no authorization number, an incorrect
authorization number, or no BAN or
an incorrect BAN.
Check to ensure no data entry error
was made. Re-submit with correct
authorization number or BAN.
Client is not the same as client
referenced in authorization
This rejection will typically appear
Refer to authorization report to check
when the client number in the claim
for accuracy of client number or
form is not the same as the client num- authorization number.
ber on the authorization. This rejection
will also appear with the "Invalid or
unknown recipient number," and with
"Invalid or unknown authorization
number."
Provider is not the same as provid- Provider number billed is not the same Re-submit the correct provider number
as the one referenced in the authoriza- that was authorized, or request that
er of authorization referenced
tion.
the authorization be changed.
Service is not the same as service
of authorization referenced.
Service is not the same as the service
referenced in the authorization. Claim
report will indicate wrong service
was used. (The claim was submitted
with the incorrect authorization or the
incorrect CPT or revenue code.) This
rejection will also appear with "Invalid
or unknown authorization number."
Re-submit with the correct authorization or the correct CPT or revenue
code.
Claim is no longer eligible for payment: late submission
Claim is submitted beyond the timely
submission requirements.
Refer to Claims Appeals Process section of the manual.
Unknown or invalid case number
Case is not opened.
Reference Case Open Process in
Authorization section of this manual.
Cannot match provider to service
for specific date
Discrepancy in the Contract Schedule
A for that level of care
Verify the billing combination matches
your Schedule A. Contact Provider
Relations at (215) 413-7660 if you need
assistance.
No-known cross-reference for NPI
to provider ID
Provider submitted claims with NPI
number which is not connected to
CBH number
Re-submit with the correct NPI number that is connected to CBH number.
Blanket Authorization
Numbers 1000 are being replaced
Claims submitted with the old blanket
authorization number
Re-submit with the correct 9-digit
blanket authorization number
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4.22
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rejection description
cause
remedy
No known cross-reference of NPI
to authorized provider identification number.
Provider submitted wrong authorization numbers for billed NPI numbers
Re-submit with correct NPI number
that is connected to CBH number issued to the authorization
Non-Electronic claim with Invalid/
Unknown provider NPI
Provider submitted incorrect NPI
number not listed on their Contract
Schedule A
Re-submit with correct NPI number
Electronic claim with Invalid/Unknown provider NPI
Provider submitted incorrect NPI
number not listed on their Contract
Schedule A
Re-submit with correct NPI number
Claim without NPI provider ID
Claim submitted without NPI number
Re-submit with the correct NPI number
Claims Reports
Below are brief descriptions of the available claims reports via download from the CBH EDI
Browser:

The Payment Detail Report lists all paid services.

The Rejected/Denied/Pended Claims Report refers to all claims that will not be paid
by CBH as submitted. It lists pended claims, warnings, and the reasons for denials
and rejections along with their corresponding amounts.
OTE
EN
PLEAS
For help in understanding your rejected claims report, see Common Causes
for Claims Rejection and Remedies for Providers.
DBH/CBH PROVIDER MANUAL REV.2011
4.23
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Sample Forms
The succeeding section provides reference materials as well as samples of claims forms and reports:
Claims Adjustment Request Form..............................................................................................................................................4.22
PROMISe UB-04 Desk Reference for Hospitals..............................................................................................................4.23 - 4.24
UB-04 Inpatient Claim Form.......................................................................................................................................................4.25
UB-04 Inpatient Third Party Liability (TPL) Claim Form.......................................................................................................4.26
Explanation of Benefits (EOB) for Inpatient UB-04 Third Party Liability (TPL).................................................................4.27
Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) Desk Reference
OMHSAS Desk Reference - Provider Types.............................................................................................................4.28 - 4.29
OMHSAS Desk Reference - Modifiers.................................................................................................................................4.29
OMHSAS Desk Reference - HIPAA Place of Service Codes.............................................................................................4.30
assistance in completion of the outpatient and cms-1500 (08-05)
CMS-1500 (08-05) - Outpatient Claim Form........................................................................................................................4.31
CMS-1500 (08-05) - Outpatient Third Party Liability (TPL) Claim Form........................................................................4.32
Explanation of Benefits (EOB) for CMS-1500 (08-05) Outpatient Third Party Liability (TPL) ....................................4.33
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DBH/CBH PROVIDER MANUAL REV.2011
4.24
4.25
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PA PROMISe™
Provider Handbook
837 Institutional/UB-04 Claim Form
UB-04 Desk Reference for Hospitals
These values are valid for paper claim submission on the UB-04 Claim Form only.
Condition Codes (continued)
X3 Hysterectomy Acknowledgment Form (MA 30)
X4 Medicare Denial on File
X5 Third Party Payment on File
X6 Restricted Recipient Referral Form
X7 Medical Documentation for Hysterectomy
Y0 Newborn Eligibility
Y3 Copay Not Collected
Y6 Third Party Denial on File
Type of Bill Codes
(Form Locator 4)
INPATIENT ONLY:
First Digit
1 Type of Facility – Hospital
Second Digit
1 Bill Classification – Inpatient
Third Digit
0 Non Payment/Zero Claim
1 Admit through Discharge Claim
2 Interim – First Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim
OUTPATIENT ONLY:
First Digit
1 Type of Facility – Hospital
Second Digit
3 Bill Classification – Outpatient
4 Bill Classification – Hospital Special Treatment
Room
Third Digit
0 Nonpayment/Zero Claim
1 Admit through Discharge Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim
Patient Status Codes
(Form Locator 17)
01 Discharge to home or self-care – Routine
Discharge
02 Discharged/transferred to another hospital for
inpatient care
03 Discharged/transferred to a skilled nursing facility
04 Discharged/transferred to an intermediate care
facility
05 Discharged/transferred to another type of
institution for inpatient care
07 Left against medical advice or discontinued care
20 Expired
30 Still a patient
Admission Type
(Form Locator 14)
1 Emergency Admission
2 Urgent Admission
3 Elective Admission
4 Newborn Admission
5 Trauma Admission (Emergency Admission)
Occurrence Codes
(Form Locators 31–34)
01 Auto Accident
02 No Fault Accident
03 Accident/Tort Liability
04 Accident/Employment Related
05 Other Accident
06 Crime Victim
24 Date Insurance Denied
25 Date Benefits Terminated By Primary Payer
A3 Benefits Exhausted
B3 Benefits Exhausted
C3 Benefits Exhausted
DR Disaster Related
Condition Codes
(Form Locators 18–28)
02 Condition is Employment Related
03 Patient is Covered by Insurance Not Reflected
Here
05 Lien Has Been Filed
60 Day Outlier
77 Provider accepts or is obligated/required to a
contractual agreement or law to accept payment by
primary payer as payment in full
A1 EPSDT
A4 Family Planning Outpatient
AA Abortion Consent (MA 3) – Rape
AB Abortion Consent (MA 3) – Incest
AD Abortion Consent (MA 3) – Danger to Life
AI Sterilization Patient Consent Form (MA 31)
B3 Pregnancy
X2 Medicare EOMB on File
Provider Handbook UB-04
Occurrence Span Codes
(Form Locator 35–36)
71 Prior Stay Dates
74 Non-covered Level of Care/Leave of Absence
(JCAHO RTF only)
MR Disaster Related
1
January 14, 2008
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PA PROMISe™
Provider Handbook
837 Institutional/UB-04 Claim Form
Value Codes
(Form Locators 39–41)
06 Medicare Blood Deductible
14 No Fault, Including Auto/Other
15 Worker’s Compensation
16 PHS or Other Federal Agency
38 Medicare Blood Deductible Pints Furnished
39 Medicare Blood Deductible Pints Replaced
47 Any Liability Insurance
66 Patient Pay
80 Covered Days
81 Non-Covered Days
82 Co-insurance Days
83 Lifetime Reserve Days, Inpatient Only
A1 Deductible Payer A
A2 Coinsurance and Lifetime Reserve Payer A
A7 Copayment, Payer A
B1 Deductible Payer B
B2 Coinsurance and Lifetime Reserve Payer B
B7 Copayment, Payer B
X0 Medicare Part B
Present on Admission (POA) Indicator Codes
(Form Locators 67, 67 A-Q)
INPATIENT ONLY:
Y Yes, present at the time of inpatient admission
N No, not present at the time of inpatient
admission
U Unknown, documentation is insufficient to
determine if condition was present at time of
inpatient admission
W Clinically undetermined, provider is unable to
clinically determine whether condition was
present at time of inpatient admission or not
1 Exempt from POA reporting
Claims Adjustment Reason Codes
(Form Locator 80)
8001 Changing the Patient Control Number
8002 Changing the Covered Dates
8003 Changing the Covered/Non covered Days
8004 Changing the Admission Dates/Time
8005 Changing the Discharge Times
8006 Changing the Status
8007 Changing the Medical Record Number
8008 Changing the Condition Codes (sometimes to
make claim an “outlier” claim)
8009 Change the Occurrence Codes
8010 Changing the Value Codes
8011 Change the Revenue Codes
8012 Change the Units Billed
8013 Change the Amount Billed
8014 Change the Payer Codes
8015 Change the Prior Payments
8016 Change the Prior Authorization Number
8017 Change the Diagnosis Codes
8018 Change the ICDN Codes and Dates
8019 Change the Phys. ID Numbers
8020 Changed the Billed Date
Patient’s Relationship to Insured Codes
(Form Locator 59)
01 Spouse
04 Grandparent
05 Grandchild
07 Niece/Nephew
10 Foster Child
15 Ward of the Court
17 Step Child
18 Patient is Insured
19 Natural Child/Insured Financial Responsibility
20 Employee
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Minor Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Natural Child/Insured does not have Financial
Responsibility
53 Life Partner
G8 Other Relationship
Please note that the Patient’s Relationship to Insured
Codes are the same codes used electronically in the
837I.
Provider Handbook UB-04
DBH/CBH PROVIDER MANUAL REV.2011
2
January 14, 2008
4.26
4.27
cl aims department
1
2
3a
Pat.
Cntl #
Provider Name
Type
of Bill
b
Med.
Rec. #
Address
Telephone Number
5
111
6
Fed. Tax No.
Patient
Name
a
9
Doe, Jane
b
Patient Address
b
11
Birthdate
Admission
Sex
12
Date
13
Hr
10-10-47
3-01-07
Occurrence
Code
Date
Occurrence
Code
Date
31
32
11
14
2
15
Type
16
Src
33
DHR
18
17
34
Occurrence
Code
Date
a
3-10-07
1234 Maple Lane
c
Philadelphia
Stat
d
PA
e
19121
19
20
01
21
22
23
24
25
26
35
Occurrence
Code
Date
27
30
29
Condition Codes
18
7
Statement Covers Period
From
Through
3-1-07
8
10
4
90876543
28
ACDT
state
36
Occurrence Span
Code
From
Through
37
Occurrence Span
Code
From
Through
a
b
39
40
Value Codes
Code
Amount
38
a
b
80
41
Value Codes
Code
Amount
Value Codes
Code
Amount
9
c
d
42
43
Rev cod
114
44
Description
Inpatient
45
HCPCS/Rate/HIPPS code
46
Serv.
9
Serv. units
47
Total Charges
9750 00
48
Non-covered charges
49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
PAGE ____ OF _____
50
51
Payer Name
CBH
58
6-1-07
CREATION DATE
52
Health Plan ID
53
Rel Info
Asg. Ben.
54
9750
TOTALS
55
Prior Payments
56
Est. Amt Due
57
NPI
Other
Prv ID
59
Insured’s Name
P. Rel
60
61
Insured’s Unique ID
1023456789
62
Group Name
00
23
9876543210
A
1234567890002
B
C
Insurance Group No.
A
B
63
64
Treatment Authorization Codes
7000000
66
69
DX
65
Document Control Number
68
290.3
Admit
DX
290.3
74
Principal Procedure
Code
Date
c
Other Procedure
Code
Date
70
71
Patient
Reason DX
b
a
Other Procedure
Code
Date
Other Procedure
Code
Date
d
e
Other Procedure
Code
Date
Other Procedure
Code
Date
72
PPS
Code
654321
81CC
a
b
c
d
A
B
C
73
ECI
75
76
Attending
NPI
Last
77
Operating
78
Other
79
Qual
MD123456
Qual
First
NPI
Last
Other
Last
1123456789
First
NPI
Last
Remarks
C
Employer Name
Qual
First
NPI
Qual
First
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1
2
3a
Pat.
Cntl #
Provider Name
Telephone Number
b
10
a
Patient Name
11
Birthdate
Type
of Bill
b
Med.
Rec. #
Address
8
4
908771132
5
9
Doe, John
b
Admission
Sex
12
Date
13
Hr
2-5-59
5-22-07
Occurrence
Code
Date
Occurrence
Code
Date
31
09
32
14
2
15
Type
16
Src
33
DHR
13
17
34
Occurrence
Code
Date
Fed. Tax No.
20 First Street
c
Philadelphia
01
5-30-07
d
PA
e
19111
18
19
20
X2
21
22
23
24
25
26
35
Occurrence
Code
Date
27
30
29
Condition Codes
Stat
7
Statement Covers Period
From
Through
5-22-07
a
Patient Address
111
6
28
ACDT
state
36
Occurrence Span
Code
From
Through
37
Occurrence Span
Code
From
Through
a
b
40
39
Value Codes
Code
Amount
38
a
b
A1
41
Value Codes
Code
Amount
992
00
80
Value Codes
Code
Amount
8
c
d
42
43
Rev cod
124
44
Description
Inpatient
45
HCPCS/Rate/HIPPS code
46
Serv.
8
Serv. units
47
Total Charges
8000 00
48
Non-covered charges
49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
PAGE ____ OF _____
50
51
Payer Name
Medicare
CBH
58
Health Plan ID
123456
59
Insured’s Name
6-1-07
CREATION DATE
52
P. Rel
60
53
Rel Info
Asg. Ben.
54
55
Prior Payments
1996
61
Insured’s Unique ID
111456789
8000
TOTALS
00
56
Est. Amt Due
992
57
NPI
Other
Prv ID
00
62
Group Name
00
23
9876543210
A
1234567890002
B
C
Insurance Group No.
A
B
63
64
Treatment Authorization Codes
8000000
66
69
DX
Employer Name
68
296.34
Admit
DX
296.34
74
Principal Procedure
Code
Date
c
Other Procedure
Code
Date
80
65
Document Control Number
C
70
71
Patient
Reason DX
b
a
Other Procedure
Code
Date
Other Procedure
Code
Date
d
e
Other Procedure
Code
Date
Other Procedure
Code
Date
72
PPS
Code
75
76
Attending
NPI
Last
77
Operating
765341
81CC
a
b
c
d
DBH/CBH PROVIDER MANUAL REV.2011
78
Other
Other
Last
Qual
Qual
First
NPI
Last
79
1123460889
First
NPI
Last
Remarks
73
ECI
Qual
First
NPI
Qual
First
MD654321
A
B
C
cl aims department
4.29
EXPLANATION OF BENEFITS (EOB) FOR INPATIENT UB-04 THIRD PARTY LIABILITY (TPL) (Sample)
Patient Control Number
RC
RC
REM
REM
PROF COMP
OUTCO CAPCD DRG CAP AMT
DRG#
MSP PAYMT
NCOVD CHGS
COVD CHGS
COINSURANCE
INTEREST
ESRD NET ADJ
PAT REFUND
HCPCS AMOUNT
PER DIEM RATE
CONTRACT ADJ
FIFTH AVENUE PLACE, PITTSBURGH, PA 15222 TEL# 412-255-7000
PART A
PAID DATE: 6/18/08
REMITN: 147
PAGE 1
Patient Name
ICN Number
REM
VERITUS MEDICARE SERVICES
FEEL GOOD HOSPITAL
HIC Number
RC
.00
8000.00
.00
345.00
4442.05
DRG OUT AMT
FROM DT THRU DT NACHG HICHG TOB
DENIED CHGS
.00
NET REIMB
DEDUCTIBLES
B3
.00
992.00
.00
.00
.00
992.00
.00
.00
.00
.00
8000.00
.00
.00
.00
. 00
4442.05
1996.00
.00
. 00
4442.05
Covered charges
.00
.00
8000.00
.00
. 00
.00
.00
.00
1996.00
1996.00
.00
.00
.00
Deductible
.00
992.00
Net Reimbursement
Co-insurance
DRG OPR AMT
01
HA02
REM
111
COVDY NCOVDY
N
8
8
A2
RC
COST
1575179
CLM STATUS
Doe, John
19815609540204
QC
8
8
Covered days
8
Service from/thru
123456789A
05/22/2007
05/30/2007
1
Subtotal Fiscal Year 2007
Subtotal Part A
8
.00
WWW.DBHIDS.ORG
cl aims department
4.30
omhsas desk reference - provider types
Provider
Type
Provider Type Description
Provider
Type
01
Inpatient Facility
010
011
013
018
019
022
027
183
07
24a
08
Capitation
Clinic
09
CRNP
093
548
549
559
11
Mental Health/Substance Abuse
110
111
112
113
114
115
116
117
118
119
123
127
128
129
131
132
133
134
184
548
549
559
16
Nurse
162
17
Therapist
174
175
19
Psychologist
190
548
549
559
DBH/CBH PROVIDER MANUAL REV.2011
080
081
082
084
110
184
548
549
559
Provider Speciality Description
Acute Care Hospital
Private Psychiatric Hospital
RTF (Accredited) Hospital
Extended Acute Psychiatric Inpatient Unit
D&A Rehabilitation Hospital/Unit
Private Psychiatric Unit
RTF (Accredited) Unit
Hospital-Based Medical Clinic
Managed Care Organization-Behavioral Health
Federally Qualified Health Center
Rural Health Clinic
Independent Medical/Surgical Clinic
Methadone Maintenance
Psychiatric Outpatient
D&A Outpatient
Therapeutic Staff Support
Mobile Therapy
Behavioral Specialist Consultant
CRNP
Therapeutic Staff Support
Mobile Therapy
Behavioral Specialist Consultant
Psychiatric Outpatient
Community Mental Health
Outpatient Practitioner - Mental Health
Partial Psychatric Hospital - Children
Partial Psychiatric Hospital - Adult
Family Based Mental Health
Licensed Clinical Social Worker
Licensed Social Worker
Mental Health Crisis Intervention
Mental Health - OMHSAS
Psychiatric Rehabilitation
D&A Outpatient
D&A Intensive Outpatient
D&A Partial Outpatient
D&A Medically Monitored Halfway House
D&A Medically Monitored Detox
D&A Medically Monitored Resid., Short Term
D&A Medically Monitored Resid., Long Term
Outpatient D&A
Therapeutic Staff Support
Mobile Therapy
Behavioral Specialist Consultant
Psychiatric Nurse
Art Therapist
Music Therapist
General Psychologist
Therapeutic Staff Support
Mobile Therapy
Behavioral Specialist Consultant
4.31
cl aims department
Provider
Type
Provider Type Description
Provider
Type
Provider Speciality Description
21
Case Manager
138
212
221
222
D&A Targeted Case Manager
MA Case Management
Mental Health TCM - Resource Coordination
Mental Health TCM - Intensive
28
Laboratory
Physician
280
Program Exception
Community Residential Rehabilitation
340
52
56
Residential Treatment Facility
560
Independent Laboratory
Psychiatry & Neurology
Therapeutic Staff Support
Mobile Therapy
Behavioral Specialist Consultant
Program Exception
Child Residential Service - 3800 (Group Home)
Community Residential Rehabilition - Mental
Health (Host Home)
Residential Treatment Facility (Non-Accredited)
31
34
339
548
549
559
520
523
omhsas desk reference - modifiers
Modifiers
Modifier Descriptions
Modifiers
Modifier Descriptions
AH
Clinical Psychologist
TF
Intermediate Level of Care
EP
TG
Complex/High-Tech Level of Care
TJ
HE
Services Provided as Part of Medicaid
EPSDT Program
Child/Adolescent Program
Adult Program, Non-Geriatric
Mental Health Program
HF
Substance Abuse Program
UA
Program Group, Child and/or Adolescent
Follow-up Service
Individualized Service Provided to More than
One Patient in Same Setting
Licensed Children's Program
HG
Opiod Addiction Treatment Program
UB
Behavioral Health Pricing Modifier
HK
UC
Pilot Program
HO
Specialized Mental Health Program for
High-Risk Populations
Master's Degree Level
UK
Someone Other than the Client (Collateral)
HP
Doctoral Level
U1
Psychiatric
HQ
Group Setting
U2
Medicare/TPL Contractual Disallowance
HT
Multi-Disciplinary Team
U7
Pricing Modifier
HW
Funded by State Mental Health Agency
U8
Pricing Modifier
SC
Medically Necessary Service or Supply
HA
HB
TS
TT
WWW.DBHIDS.ORG
cl aims department
4.32
omhsas desk reference - hipaa place of service codes
Use only the HIPAA Place of Service (POS) Codes listed below when submitting claims to DBH/CBH.
These are the codes expected by DPW for DBH/CBH services. Do not use any other codes listed in
the 837 Professional Billing Guide from the Commonwealth of Pennsylvania.
POS
Place of Service Description
POS
Place of Service Description
11
Office
50
Federally Qualified Health Center
12
52
22
Home
Mobile Unit
Inpatient Hospital
Outpatient Hospital
23
Emergency Room - Hospital
65
Psychiatric Facility - Partial Hospital
ICF/MR
Psychiatric Residential Treatment Facility
Non-Residential Substance Abuse Treatment
Facility
End-Stage Renal Disease Treatment Facility
24
Ambulatory Surgical Center
72
Rural Health Clinic
31
Skilled Nursing Facility
81
Independent Laboratory
32
Nursing Facility
99
Other POS
49
Independent Clinic
15
21
DBH/CBH PROVIDER MANUAL REV.2011
54
56
57
4.33
cl aims department
CARRIER
1500
(Sample CBH)
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
MEDICARE
(Medicare #)
MEDICAID
X
TRICARE
CHAMPUS
(Sponsor’s SSN)
(Medicaid #)
GROUP
HEALTH PLAN
(SSN or ID)
CHAMPVA
(Member ID#)
OTHER 1a. INSURED’S I.D. NUMBER
FECA
BLK LUNG
(SSN)
3. PATIENT’S BIRTH DATE
MM
DD
YY
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
Brown, Lily
625 Daisy Street
Self
CITY
STATE
Philadelphia
PA
M
F
Child
Spouse
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX
28 1935
03
19122
7. INSURED’S ADDRESS (No., Street)
Other
8. PATIENT STATUS
STATE
CITY
Single
Married
Other
Employed
Full-Time
Student
Part-Time
Student
TELEPHONE (Include Area Code)
ZIP CODE
0123456789
(ID)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
(For Program in Item 1)
ZIP CODE
( 215 ) 222-0000
TELEPHONE (Include Area Code)
(
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
MM
DD
YY
NO
YES
b. OTHER INSURED’S DATE OF BIRTH
MM
DD
YY
b. AUTO ACCIDENT?
SEX
PLACE (State)
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
NO
YES
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
10d. RESERVED FOR LOCAL USE
YES
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
SIGNED
DATE
14. DATE OF CURRENT:
MM
DD
YY
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
17a. OB
John, M. M. D.
17b. NPI
19. RESERVED FOR LOCAL USE
05/24/2007
SIGNED
MD123456X
O123456789
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
FROM
TO
20. OUTSIDE LAB?
YES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
1.
If yes, return to and complete item 9 a-d.
NO
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
DD
YY
MM
DD
YY
MM
DD
YY
GIVE FIRST DATE MM
FROM
TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
304
F
b. EMPLOYER’S NAME OR SCHOOL NAME
NO
YES
F
M
SEX
M
PATIENT AND INSURED INFORMATION
1.
03
$ CHARGES
NO
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
3.
23. PRIOR AUTHORIZATION NUMBER
MM
1 05
DATE(S) OF SERVICE
From
To
DD
YY
MM
DD
24
07 05
YY
B.
C.
PLACE OF
SERVICE EMG
24 07
4.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
HF
H0018
11
10101010
E.
DIAGNOSIS
POINTER
F.
160
1
H.
G.
00
I.
J.
RENDERING
PROVIDER ID. #
EPSDT
ID.
Family
Plan QUAL.
DAYS
OR
UNITS
$ CHARGES
2
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
(For
govt. claims, see back)
YES
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
06/01/2007
DATE
32. SERVICE FACILITY LOCATION INFORMATION
NO
28. TOTAL CHARGE
$
160
00
29. AMOUNT PAID
Name & Address
a.
NUCC Instruction Manual available at: www.nucc.org
NPI
b.
NPI
1123457789
a.
30. BALANCE DUE
$
33. BILLING PROVIDER INFO & PH #
PHYSICIAN OR SUPPLIER INFORMATION
2.
24. A.
$
(
)
b.
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)
WWW.DBHIDS.ORG
4.34
cl aims department
CARRIER
TPL
1500
(Sample CBH)
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
MEDICARE
(Medicare #)
MEDICAID
X
TRICARE
CHAMPUS
(Sponsor’s SSN)
(Medicaid #)
GROUP
HEALTH PLAN
(SSN or ID)
CHAMPVA
(Member ID#)
OTHER 1a. INSURED’S I.D. NUMBER
FECA
BLK LUNG
(SSN)
3. PATIENT’S BIRTH DATE
MM
DD
YY
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
Brown, Lily
03
625 Daisy Street
Self
CITY
STATE
Philadelphia
PA
M
F
Child
Spouse
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX
28 1935
19122
7. INSURED’S ADDRESS (No., Street)
Other
8. PATIENT STATUS
STATE
CITY
Single
Married
Other
Employed
Full-Time
Student
Part-Time
Student
TELEPHONE (Include Area Code)
ZIP CODE
0123456789
(ID)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
(For Program in Item 1)
ZIP CODE
( 215 ) 222-0000
TELEPHONE (Include Area Code)
(
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
MM
DD
YY
123456789A
b. OTHER INSURED’S DATE OF BIRTH
MM
DD
YY
b. AUTO ACCIDENT?
SEX
Medicare
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
10d. RESERVED FOR LOCAL USE
YES
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
DATE
14. DATE OF CURRENT:
MM
DD
YY
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
17a. OB
John, M. M. D.
05/24/2007
SIGNED
17b. NPI
MD123456X
O123456789
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
YES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
304
If yes, return to and complete item 9 a-d.
NO
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
DD
YY
MM
DD
YY
MM
DD
YY
GIVE FIRST DATE MM
FROM
TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
1.
F
c. INSURANCE PLAN NAME OR PROGRAM NAME
NO
YES
SIGNED
1935
NO
c. OTHER ACCIDENT?
d. INSURANCE PLAN NAME OR PROGRAM NAME
28
SEX
M
PLACE (State) b. EMPLOYER’S NAME OR SCHOOL NAME
YES
F
M
c. EMPLOYER’S NAME OR SCHOOL NAME
03
NO
YES
PATIENT AND INSURED INFORMATION
1.
03
$ CHARGES
NO
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
3.
23. PRIOR AUTHORIZATION NUMBER
MM
1 12
DATE(S) OF SERVICE
From
To
DD
YY
MM DD
27
06 12
YY
B.
C.
PLACE OF
SERVICE EMG
4.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
F.
90
H.
G.
I.
00 1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
90
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
(For
govt. claims, see back)
YES
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
01/01/07
DATE
32. SERVICE FACILITY LOCATION INFORMATION
$
90
NPI
00
29. AMOUNT PAID
$
33. BILLING PROVIDER INFO & PH #
Name & Address
a.
NUCC Instruction Manual available at: www.nucc.org
DBH/CBH PROVIDER MANUAL REV.2011
NO
00
28. TOTAL CHARGE
NPI
b.
NPI
0123457789
a.
J.
RENDERING
PROVIDER ID. #
EPSDT
ID.
Family
Plan QUAL.
DAYS
OR
UNITS
$ CHARGES
1
99242
27 06 11
101010100
E.
DIAGNOSIS
POINTER
(
PHYSICIAN OR SUPPLIER INFORMATION
2.
24. A.
30. BALANCE DUE
27 18
$
)
b.
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)
cl aims department
4.35
From
2
Yr.
5
Amount
Applied To
3
Amount
Amount
Codes
Service
EXPLANATION OF MEDICARE BENEFITS
To
Deductible
0.00
Approved
54.36
6
Co-
ins.
6.80
8
Paid
7
50% of this
Provider
Medicare
Amount
27.18
Medicare Pays
54.36
Medicare
Provider
Paid
50% of this
Medicare Pays
90.00
Billed
51/1
Co-ins
Page: 1
27.18
Check Number: 034432427
54.36
Date Paid: 1/24/08
PLC/TYP
4
EXPLANATION OF BENEFITS (EOB) FOR CMS 1500 OUTPATIENT THIRD PARTY LIABILITY (TPL) (Sample)
No.
XACT Medicare Services
Proced.
1
Health Insurance Claim
When
Patient
Mo./Day
7
Amount Applied
12/27
Amount
12/27
Mo./Day
Svcs.
1
Code
90862
Number/Control No.
Acct. #493848
Amount
* Claim Totals
Number of
To Deductible
Amt.
6.80
Week Ending: 1/24/08
0.00
Apprv’d
54.36
Provider Number: 111111
90.00
Billed
1
Claims
36736321446-00
123456789A
Name
B. Lee
Total
SUMMARY
XXY Mental Health 1234
N. 100th Street
Philadelphia, PA 19121
WWW.DBHIDS.ORG
•
•
Sunday 7
File Submission. Adjudication and Payment Example
Tuesday 9
Provider receives
Response Files TA1,
997 for Filename1.txt.
These response files
are available on CBH’s
FTP Browser
Application by 10:00
AM. Filename1.txt
moves into
Adjudication
Provider Submits
Filename2.txt
Provider submits
Filename3.txt.
Saturday 6
Provider’s
Filename2.txt
moves into
Adjudication
Saturday 13
Friday 5
Electronic
Payment detail
and rejection
reports available
by 10:00 AM.
Friday 12
Saturday 20
Thursday 4
Provider receives
Response Files TA1,
997 for
Filename2.txt.
These response files
are available on
CBH’s FTP Browser
Application by 10:00
AM.
Thursday 11
Friday 19
Wednesday 17
Check sent to
Provider will include
payments for
Filename1.txt
Posting of approved
adjudicated claims
normally occurs.
Wednesday 10
Thursday 18
Wednesday 3
November
Provider submits
Filename1.txt
Files normally
submitted by 11:30 PM
will be adjudicated the
next day.
Rejection results from
Filename3.txt are
available by 10:00
AM.
Tuesday 2
Filename3.txt moves
into adjudication
Tuesday 16
Monday 8
Monday 15
Monday 1
A provider submits three text files: filename1.txt (blue), filename2.txt (yellow), and filename3.txt (purple) in two weeks.
Adjudication takes place on Mondays, Tuesdays and Fridays, and checks are issued 8 to 12 days later. *
Provider receives
Response Files TA1, 997
for Filename3.txt.
These response files are
available on CBH’s FTP
Browser Application.
Rejection reports for
Filename2.txt are
available by 10:00 AM.
Sunday 14
Check sent to
Provider will include
Payments for
Filename2.txt
And payments for
Filename3.txt
* As noted this is a “Normal Schedule”. CBH will post notifications on the CBH EDI Browser when deviations to this schedule occur.
CBH’s contractual obligation is to pay clean claims within 45 days.
DBH/CBH PROVIDER MANUAL REV.2011
4.36
cl aims department