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Billing Tips to Help Providers Avoid Common Billing Problems - Overview Proper Forms and the Fields Causing The Proper Forms and the Fields Causing The

Most ProblemsMost Problems Provider Number UsageProvider Number Usage Top 5 Reasons a Bill Is ReturnedTop 5 Reasons a Bill Is Returned Common Bill Denial Reasons & What To Common Bill Denial Reasons & What To

Do About ThemDo About Them How To Request an AdjustmentHow To Request an Adjustment

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HCFA 1500 Also called OWCP–1500 and CMS - 1500Also called OWCP–1500 and CMS - 1500 Submitted by:Submitted by:

PhysiciansPhysiciansDME VendorsDME VendorsTherapistsTherapistsRural Health ClinicsRural Health ClinicsChiropractorsChiropractorsOther specialized medical providers, Other specialized medical providers,

excluding dentistsexcluding dentists

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HCFA 1500

Fields that cause the most problems are highlighted.

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HCFA 1500 Problematic Fields

Box 1a or 11 – Claimant Case NumberBox 1a or 11 – Claimant Case Number Boxes 12 & 13 – “Signature on File”Boxes 12 & 13 – “Signature on File” Box 21 – ICD-9 Diagnosis CodesBox 21 – ICD-9 Diagnosis Codes Box 24A – Dates of ServiceBox 24A – Dates of Service Box 24D – CPT/HCPCS Procedure Codes Box 24D – CPT/HCPCS Procedure Codes

and modifiers if applicableand modifiers if applicable

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HCFA 1500 Problematic Fields

Box 24E – Diagnosis pointersBox 24E – Diagnosis pointers Box 24F – Line ChargesBox 24F – Line Charges Box 24G – UnitsBox 24G – Units Box 25 – Provider Federal Tax ID #Box 25 – Provider Federal Tax ID # Box 28 – Total ChargeBox 28 – Total Charge Box 31 – Signature of physician and bill Box 31 – Signature of physician and bill

date date

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BOX 31 – Treating Provider Appropriate signatureAppropriate signature Bill date must be after last date of service Bill date must be after last date of service

BOX 32 – Service AddressBOX 32 – Service Address Address where service was rendered Address where service was rendered Include Zip CodeInclude Zip Code

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BOX 33 – Billing Address

Address where payment is sent Address where payment is sent Provider number (generated by enrollment)Provider number (generated by enrollment)

From a provider perspective this is the most important field on a HCFA. This information is vital to pay the correct provider.

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UB-92

Submitted by:Submitted by:-General Hospitals-General Hospitals-Nursing Homes-Nursing Homes-Hospices-Hospices-Skilled Nursing Facilities-Skilled Nursing Facilities

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UB-92

Fields that cause the most problems are highlighted.

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UB-92 Problematic Fields Box 1 – Billing AddressBox 1 – Billing Address Box 4 – Type of billBox 4 – Type of bill Box 5 – Provider Federal Tax ID #Box 5 – Provider Federal Tax ID # Box 6 – Statement covers periodBox 6 – Statement covers period Box 17 to 20 – Admission Box 17 to 20 – Admission

(date/hour/type/source)(date/hour/type/source) Box 21 & 22 – Discharge hour and Box 21 & 22 – Discharge hour and

Discharge statusDischarge status

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UB-92 Problematic Fields Box 42 to 47 – Detail line items (Provide Box 42 to 47 – Detail line items (Provide

HCPCS for required RCC’s)HCPCS for required RCC’s) Box 51 – Provider number and Medicare Box 51 – Provider number and Medicare

numbernumber Box 60 – Claimant’s case numberBox 60 – Claimant’s case number Box 67 to 75 – ICD-9 Diagnosis codesBox 67 to 75 – ICD-9 Diagnosis codes Box 80 to 81 – Appropriate procedure codesBox 80 to 81 – Appropriate procedure codes

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Provider Number/ID Usage

Identifies proper provider for authorizations and Identifies proper provider for authorizations and paymentpayment

Use it when you billUse it when you bill Use it on the web portalUse it on the web portal Use it when you call in to get information from Use it when you call in to get information from

our call centerour call center

Please Learn it and Use it!Please Learn it and Use it!

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Top 5 Reasons A Bill is Returned

1.1. No signature on file in box 12 and 13 on No signature on file in box 12 and 13 on HCFA-1500HCFA-1500

2.2. Claimant ID missing Claimant ID missing 3.3. Tax ID missingTax ID missing4.4. Doctors billing for prescriptions dispensed in Doctors billing for prescriptions dispensed in

office MUST to use J8499 and the NDC codeoffice MUST to use J8499 and the NDC code5.5. Revenue codes missing on UB-92Revenue codes missing on UB-92

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Return letter contains specific information about why the bill was returned.

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Resubmit Returned Bills for Processing Correct items noted in letterCorrect items noted in letter Resubmit the bill for processingResubmit the bill for processing

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Common Bill Denial Reasons & What to Do About Them Claimant is ineligibleClaimant is ineligible Disagreements with accepted conditionDisagreements with accepted condition Treatment SuiteTreatment Suite No authorizationNo authorization Improper CPT codesImproper CPT codes

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Claimant Eligibility Each claimant must be eligible on date of Each claimant must be eligible on date of

service service Claimant case status is determined by DOLClaimant case status is determined by DOL Claimants areClaimants are responsible for contacting responsible for contacting

the district office if there are questions the district office if there are questions regarding case status regarding case status

Resubmit bills for processing once claim is Resubmit bills for processing once claim is approved or reopenedapproved or reopened

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Disagreement With Accepted Conditions Claimants are responsible for providing Claimants are responsible for providing

their treating physicians with the accepted their treating physicians with the accepted condition(s) on the claimcondition(s) on the claim

Providers need to acquire this information Providers need to acquire this information from the claimantfrom the claimant

OWCP pays only for services related to the OWCP pays only for services related to the accepted conditions on the claimaccepted conditions on the claim

Bill with the accepted conditionsBill with the accepted conditions

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Treatment Suite

Services that greatly differ from expected Services that greatly differ from expected services to treat an injury will denyservices to treat an injury will deny Billing for a hand x-ray when the Billing for a hand x-ray when the

claimant has a cut lip will trigger this claimant has a cut lip will trigger this denial codedenial code

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No Authorization Certain procedures require prior authorizationCertain procedures require prior authorization Submitting a request does not guarantee approval. Submitting a request does not guarantee approval. If an authorization was not previously requested, a retro-If an authorization was not previously requested, a retro-

authorization may be requested for services already authorization may be requested for services already providedprovided Follow same guidelines as for requesting an Follow same guidelines as for requesting an

authorization prior to serviceauthorization prior to service Dates MUST be specific for retro-authorizationsDates MUST be specific for retro-authorizations

Once the authorization is approved, resubmit the billOnce the authorization is approved, resubmit the bill

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Authorization EOB Codes EOB code 529 - Case is deniedEOB code 529 - Case is denied EOB code 530 - No authorization on fileEOB code 530 - No authorization on file EOB Code 531 - Authorization for claimant, not EOB Code 531 - Authorization for claimant, not

for providerfor provider EOB Code 532 - Authorization for claimant and EOB Code 532 - Authorization for claimant and

provider, not for dates of serviceprovider, not for dates of service EOB Code 533 - Authorization for claimant, EOB Code 533 - Authorization for claimant,

provider, and dates of service; not for procedure provider, and dates of service; not for procedure

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How to Request an Adjustment – Two Options1.1. Resubmit a corrected bill - At the top of the Resubmit a corrected bill - At the top of the

form write “Corrected Bill” or “Adjustment”. form write “Corrected Bill” or “Adjustment”. OROR

2.2. Submit your RVSubmit your RVa.a. Block out all information not pertaining to Block out all information not pertaining to

your adjustment.your adjustment.b.b. Write what you need adjusted.Write what you need adjusted.