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Welcome  » March 28, 2024 5:16 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Hospital, Inpatient
03/28/2024  

Claims : Submission

Topic #17797

1500 Health Insurance Claim Form Completion Instructions

These instructions are for the completion of the 1500 Health Insurance Claim Form for ForwardHealth. Refer to the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC and available on their website, to view instructions for all item numbers not listed below.

Use the following claim form completion instructions, in conjunction with the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC, to avoid denial or inaccurate claim payment. Be advised that every code used is required to be a valid code, even if it is entered in a non-required field. Do not include attachments unless instructed to do so.

Members enrolled in BadgerCare Plus or Medicaid receive a ForwardHealth member identification card. Always verify a member's enrollment before providing nonemergency services to determine if there are any limitations to covered services and to obtain the correct spelling of the member's name.

When submitting a claim with multiple pages, providers are required to indicate page numbers using the format "Page X of X" in the upper right corner of the claim form.

Other health insurance sources must be billed prior to submitting claims to ForwardHealth, unless the service does not require commercial health insurance billing as determined by ForwardHealth. When submitting paper claims, if the member has any other health insurance sources, providers are required to complete and submit an Explanation of Medical Benefits form, along with the completed paper claim.

Submit completed paper claims and the completed Explanation of Medical Benefits form, as applicable, to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

Item Number 6 — Patient Relationship to Insured
Enter "X" in the "Self" box to indicate the member's relationship to insured when Item Number 4 is completed. Only one box can be marked.

Item Number 9 — Other Insured's Name (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 9a — Other Insured's Policy or Group Number (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 9d — Insurance Plan Name or Program Name (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 10d — Claim Codes (Designated by NUCC)
When applicable, enter the Condition Code. The Condition Codes approved for use on the 1500 Health Insurance Claim Form are available on the NUCC website under Code Sets.

Item Number 11 — Insured's Policy Group or FECA Number (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Item Number 11d — Is There Another Health Benefit Plan?
This field is not used for processing by ForwardHealth.

Item Number 19 — Additional Claim Information (Designated by NUCC)
When applicable, enter provider identifiers or taxonomy codes. A list of applicable qualifiers are defined by the NUCC and can be found in the NUCC 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by the NUCC.

If a provider bills an unlisted (or not otherwise classified) procedure code, a description of the procedure must be indicated in this field. If a more specific code is not available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered.

Item Number 22 — Resubmission Code and/or Original Reference Number
This field is not used for processing by ForwardHealth.

Section 24
The six service lines in section 24 have been divided horizontally. Enter service information in the bottom, unshaded area of the six service lines. The horizontal division of each service line is not intended to allow the billing of 12 lines of service.

For physician-administered drugs: NDCs must be indicated in the shaded area of Item Numbers 24A-24G. Each NDC must be accompanied by an NDC qualifier, unit qualifier, and units. To indicate an NDC, providers should do the following:

  • Indicate the NDC qualifier N4, followed by the 11-digit NDC, with no space in between
  • Indicate one space between the NDC and the unit qualifier
  • Indicate one unit qualifier (F2 [International unit], GR [Gram], ME [Milligram], ML [Milliliter], or UN [Unit]), followed by the NDC units, with no space in between

For additional information about submitting a 1500 Health Insurance Claim Form with supplemental NDC information, refer to the completion instructions located under "Section 24" in the Field Specific Instructions section of the NUCC's 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12.

Item Number 24C — EMG
Enter a "Y" in the unshaded area for each procedure performed as an emergency. If the procedure was not an emergency, leave this field blank.

Item Number 29 — Amount Paid (not required)
This field is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer as an attachment(s) to their completed paper claim.

Topic #10677

Advanced Imaging Services

Claims for advanced imaging services should be submitted to ForwardHealth using normal procedures and claim completion instructions. When PA is required, providers should always wait two full business days from the date on which eviCore healthcare approved the PA request before submitting a claim for an advanced imaging service that requires PA. This will ensure that ForwardHealth has the PA on file when the claim is received.

Submitting Claims for Situations Exempt From the Prior Authorization Requirement

In the following situations, PA is not required for advanced imaging services:

  • The service is provided during a member's inpatient hospital stay.
  • The service is provided when a member is in observation status at a hospital.
  • The service is provided as part of an emergency room visit.
  • The service is provided as an emergency service.
  • The ordering provider is exempt from the PA requirement.

Service Provided During an Inpatient Stay

Advanced imaging services provided during a member's inpatient hospital stay are exempt from PA requirements.

Institutional claims for advanced imaging services provided during a member's inpatient hospital stay are automatically exempt from PA requirements. Providers submitting a professional claim for advanced imaging services provided during a member's inpatient hospital stay should indicate POS code 21 (Inpatient Hospital) on the claim.

Service Provided for Observation Status

Advanced imaging services provided when a member is in observation status at a hospital are exempt from PA requirements when completed during a covered observation stay.

Providers using a paper institutional claim form should include modifier UA in Form Locator 44 (HCPCS/Rate/HIPPS Code) with the procedure code for the advanced imaging service. To indicate a modifier on an institutional claim, enter the appropriate five-digit procedure code in Form Locator 44, followed by the two-digit modifier. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should indicate modifier UA with the advanced imaging procedure code.

Service Provided as Part of Emergency Room Visit

Advanced imaging services provided as part of an emergency room visit are exempt from the PA requirements.

Providers using an institutional claim form should include modifier UA in Form Locator 44 with the procedure code for the advanced imaging service. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should indicate POS code 23 (Emergency Room — Hospital) on the claim.

Service Provided as Emergency Service

Advanced imaging services provided as emergency services are exempt from the PA requirements.

Providers using an institutional claim form should include modifier UA in Form Locator 44 with the procedure code for the advanced imaging service. Providers submitting claims electronically using the 837I should refer to the appropriate companion guide for instructions on including a modifier.

Providers using a professional claim form should submit a claim with an emergency indicator.

Ordering Provider Is Exempt from Prior Authorization Requirement

Health systems, groups, and individual providers (requesting providers) that order CT, MR, and MRE imaging services and have implemented advanced imaging decision support tools may request an exemption from PA requirements for these services from ForwardHealth. Upon approval, ForwardHealth will recognize the requesting provider's advanced imaging decision support tool (e.g., ACR Select, Medicalis) as an alternative to current PA requirements for CT, MR, and MRE imaging services. Requesting providers with an approved tool will not be required to obtain PA through eviCore healthcare for these services when ordered for Medicaid and BadgerCare Plus fee-for-service members.

Providers rendering advanced imaging services for an ordering provider who is exempt from PA requirements are required to include modifier Q4 (Service for ordering/referring physician qualifies as a service exemption) on the claim detail for the CT, MR, or MRE imaging service. This modifier, which may be used in addition to the TC (Technical component) or 26 (Professional component) modifiers on advanced imaging claims, indicates to ForwardHealth that the referring provider is exempt from PA requirements for these services.

Topic #542

Attached Documentation

Providers should not submit additional documentation with a claim unless specifically requested.

Topic #17017

Claim Submission for Genetic Counseling

Genetic counselors cannot currently enroll independently with Wisconsin Medicaid and, therefore, cannot submit separate professional claims or be reimbursed for services provided in non-institutional settings. When genetic counseling services are provided by a trained genetic counselor, revenue code 510 (Clinic, General) and CPT procedure code 96040 (Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family) should be reported on the institutional claim form. Claim submission instructions for inpatient hospital services and outpatient hospital services are available.

Topic #6957

Copy Claims on the ForwardHealth Portal

Providers can copy institutional, professional, and dental paid claims on the ForwardHealth Portal. Providers can open any paid claim, click the "Copy" button, and all of the information on the claim will be copied over to a new claim form. Providers can then make any desired changes to the claim form and click "Submit" to submit as a new claim. After submission, ForwardHealth will issue a response with a new ICN along with the claim status.

Topic #5017

Correct Errors on Claims and Resubmit to ForwardHealth on the Portal

Providers can view EOB codes and descriptions for any claim submitted to ForwardHealth on the ForwardHealth Portal. The EOBs help providers determine why a claim did not process successfully, so providers may correct the error online and resubmit the claim. The EOB appears on the bottom of the screen and references the applicable claim header or detail.

Topic #17557

Dates on Inpatient Claims

Providers are required to indicate correct dates on inpatient claims as outlined by NUBC guidelines. Claims submitted with incorrect or inaccurate information are subject to audit by the Wisconsin DHS and may result in recoupment. When determining the dates to indicate on inpatient claims, providers should refer to the following definitions, which are based on NUBC guidelines:

  • The "from" DOS is the date on which the member initially receives care (e.g., care received in the ER prior to admission to the hospital).
  • The "admission" date is the date on which the member is admitted to the hospital as an inpatient and is subsequently first counted in the midnight census.
  • The "to" DOS is the date on which the member is discharged from the hospital.

Based on the above definitions, if a member enters the ER on January 1 and receives care, is admitted to the hospital on January 2, and is discharged from the hospital on January 3, providers would be required to indicate the following on the inpatient claim that they submit to ForwardHealth:

  • January 1 as the "from" DOS
  • January 2 as the "admission" date
  • January 3 as the "to" DOS

Providers should not indicate the same "from" DOS and "admission" date unless the member received their initial care on the same day that they were admitted to the hospital.

Topic #1353

Dilation and Curettage

When submitting claims for dilation and curettage surgical procedures, hospitals are required to attach a copy of the preoperative history and physical exam document and an operative and pathology report with the UB-04 Claim Form.

Topic #4997

Direct Data Entry of Professional and Institutional Claims on the Portal

Providers can submit the following claims to ForwardHealth via DDE on the ForwardHealth Portal:

  • Professional claims
  • Institutional claims
  • Dental claims
  • Compound drug claims
  • Noncompound drug claims

DDE is an online application that allows providers to submit claims directly to ForwardHealth.

When submitting claims via DDE, required fields are indicated with an asterisk next to the field. If a required field is left blank, the claim will not be submitted and a message will appear prompting the provider to complete the specific required field(s). Portal help is available for each online application screen. In addition, search functions accompany certain fields so providers do not need to look up the following information in secondary resources.

On professional claim forms, providers may search for and select the following:

  • Procedure codes
  • Modifiers
  • Diagnosis codes
  • Place of service codes

On institutional claim forms, providers may search for and select the following:

  • Type of bill
  • Patient status
  • Visit point of origin
  • Visit priority
  • Diagnosis codes
  • Revenue codes
  • Procedure codes
  • HIPPS codes
  • Modifiers

On dental claims, providers may search for and select the following:

  • Procedure codes
  • Rendering providers
  • Area of the oral cavity
  • Place of service codes

On compound and noncompound drug claims, providers may search for and select the following:

  • Diagnosis codes
  • NDCs
  • Place of service codes
  • Professional service codes
  • Reason for service codes
  • Result of service codes

Using DDE, providers may submit claims for compound drugs and single-entity drugs. Any provider, including a provider of DME or of DMS who submits noncompound drug claims, may submit these claims via DDE. All claims, including POS claims, are viewable via DDE.

Topic #15957

Documenting and Billing the Appropriate National Drug Code

Providers are required to use the NDC of the administered drug and not the NDC of another manufacturer's product, even if the chemical name is the same. Providers should not preprogram their billing systems to automatically default to NDCs that do not accurately reflect the product that was administered to the member.

Per Wis. Admin. Code §§ DHS 106.03(3) and 107.10, submitting a claim with an NDC other than the NDC on the package from which the drug was dispensed is considered an unacceptable practice.

Upon retrospective review, ForwardHealth can seek recoupment for the payment of a claim from the provider if the NDC(s) submitted does not accurately reflect the product that was administered to the member.

Topic #344

Electronic Claim Submission

Providers are encouraged to submit claims electronically. Electronic claim submission does the following:

  • Adapts to existing systems
  • Allows flexible submission methods
  • Improves cash flow
  • Offers efficient and timely payments
  • Reduces billing and processing errors
  • Reduces clerical effort

Topic #1433

Electronic Claim Submission for Inpatient Hospital Services

Electronic claims for inpatient hospital services must be submitted using the 837I transaction. Claims for inpatient hospital services submitted using any transaction other than the 837I will be denied.

Providers should use the companion guide for the 837I transaction when submitting these claims.

Provider Electronic Solutions Software

The DMS offers electronic billing software at no cost to providers. The PES software allows providers to submit electronic claims using an 837 transaction. To obtain PES software, providers may download it from the ForwardHealth Portal. For assistance installing and using PES software, providers may call the EDI Helpdesk.

Topic #16937

Electronic Claims and Claim Adjustments With Other Commercial Health Insurance Information

Effective for claims and claim adjustments submitted electronically via the Portal or PES software on and after June 16, 2014, other insurance information must be submitted at the detail level on professional, institutional, and dental claims and adjustments if it was processed at the detail level by the primary insurance. Except for a few instances, Wisconsin Medicaid or BadgerCare Plus is the payer of last resort for any covered services; therefore, providers are required to make a reasonable effort to exhaust all existing other health insurance sources before submitting claims to ForwardHealth or to a state-contracted MCO.

Other insurance information that is submitted at the detail level via the Portal or PES software will be processed at the detail level by ForwardHealth.

Under HIPAA, claims and adjustments submitted using an 837 transaction must include detail-level information for other insurance if they were processed at the detail level by the primary insurance.

Adjustments to Claims Submitted Prior to June 16, 2014

Providers who submit professional, institutional, or dental claim adjustments electronically on and after June 16, 2014, for claims originally submitted prior to June 16, 2014, are required to submit other insurance information at the detail level on the adjustment if it was processed at the detail level by the primary insurance.

Topic #365

Extraordinary Claims

Extraordinary claims are claims that have been denied by a BadgerCare Plus HMO or SSI HMO and should be submitted to fee-for-service.

Topic #4837

HIPAA-Compliant Data Requirements

Procedure Codes

All fields submitted on paper and electronic claims are edited to ensure HIPAA compliance before being processed. Compliant code sets include CPT and HCPCS procedure codes entered into all fields, including those fields that are "Not Required" or "Optional."

If the information in all fields is not valid and recognized by ForwardHealth, the claim will be denied.

Provider Numbers

For health care providers, NPIs are required in all provider number fields on paper claims and 837 transactions, including rendering, billing, referring, prescribing, attending, and "Other" provider fields.

Non-healthcare providers, including personal care providers, SMV providers, blood banks, and CCOs should enter valid provider numbers into fields that require a provider number.

Topic #1432

Leaves of Absence

Member leaves of absence from an inpatient hospital are not covered. Use revenue code 180 for all days the member was not present at the midnight census. Indicate the total leave days in Form Locator 46 (units) of the UB-04 Claim Form.

Topic #562

Managed Care Organizations

Claims for services that are covered in a member's state-contracted MCO should be submitted to that MCO.

Topic #1431

Multiple Page Claims

Multiple page claims are accepted for inpatient hospital stays. Providers should refer to the UB-04 (CMS 1450) Claim Form Instructions for Inpatient Hospital Services for more information on submitting multiple page claims.

Topic #1430

Noncovered Days and Noncovered Charges

For hospital admissions, the entire length of stay is required to be shown in the "Statement Covers Period" even if the member is not enrolled during the entire stay, or if part of the stay is not covered. Wisconsin Medicaid does not reimburse the date of discharge; while the date of discharge is indicated in Form Locator 6 of the UB-04 Claim Form, it should not be counted in Form Locator 7.

Topic #10837

Note Field for Most Claims Submitted Electronically

In some instances, ForwardHealth requires providers to include a description of a service identified by an unlisted, or NOC, procedure code. Providers submitting claims electronically should include a description of an NOC procedure code in a "Notes" field, if required. The Notes field allows providers to enter up to 80 characters. In some cases, the Notes field allows providers to submit NOC procedure code information on a claim electronically instead of on a paper claim or with a paper attachment to an electronic claim.

The Notes field should only be used for NOC procedure codes that do not require PA.

Claims Submitted via the ForwardHealth Portal Direct Data Entry or Provider Electronic Solutions

A notes field is available on the ForwardHealth Portal DDE and PES software when providers submit the following types of claims:

  • Professional
  • Institutional
  • Dental

On the professional form, the Notes field is available on each detail. On the institutional and dental forms, the Notes field is only available on the header.

Claims Submitted via 837 Health Care Claim Transactions

ForwardHealth accepts and utilizes information submitted by providers about NOC procedure codes in certain loops/segments on the 837 transactions. Refer to the companion guides for more information.

Topic #18017

Observation

Indicating Dates of Service

For institutional claims for both outpatient and inpatient hospital services, the "from" DOS is the date on which the member first received care. If observation was the first service provided, then the date observation began must be indicated as the "from" DOS. Additionally, the "to" DOS is the last date on which the member received care. This may be the date that the member was released without being admitted to the hospital or the date that the member, who was admitted as an inpatient, was discharged from the hospital.

Indicating Observation Information

For institutional claims for both outpatient and inpatient hospital services, the following must be indicated on the claim detail specifying observation:

  • Revenue code 0762 (Specialty services — Observation hours)
  • Number of hours that the member was under observation as the number of units

Note: Revenue code 0762 is exempt from the requirement to indicate a corresponding HCPCS or CPT procedure code on the claim detail; however, providers submitting institutional claims for outpatient hospital services are encouraged to indicate the corresponding HCPCS or CPT procedure code in order to be reimbursed appropriately under the EAPG system. Claim details that indicate revenue code 0762 without a corresponding HCPCS or CPT procedure code will receive a 999 (Unassigned) EAPG and will be reimbursed $0.

Claims indicating observation hours above what ForwardHealth allows under the observation policy will be denied. If the member is kept in observation for more hours than ForwardHealth allows and is subsequently admitted as an inpatient or dismissed, the number of hours billed with revenue code 0762 should be prorated, and the provider should indicate a non-covered span for the remaining observation period. Providers can use occurrence span code 74 to indicate a non-covered level of care on the UB-04 claim form. The "from" and "to" DOS, indicated in Form Locator 6 (Statement Covers Period), should reflect the entire period in which care was provided, in keeping with the ForwardHealth continuous stay policy, but services rendered during the non-covered span should not be billed on the claim.

Examples of Indicating Observation Information

Example 1: The member presents at 1:00 AM on January 5 and is placed in observation for 24 hours, then admitted for a three-day inpatient stay.

  • Statement covers period: January 5 through January 9
  • Admission date: January 6
  • Bill 24 units with revenue code 0762
  • Entire span is covered

Example 2: The member presents at 1:00 AM on January 5 and is placed in observation for 60 hours, then admitted for a three-day inpatient stay. Requirements for allowing greater than 48 hours of observation are not satisfied.

  • Statement covers period: January 5 through January 10
  • Admission date: January 7
  • Bill 48 units with revenue code 0762
  • Indicate a non-covered span starting and ending on January 7

Example 3: The member presents at 1:00 AM on January 5 and is placed in observation for 84 hours, then admitted for a three-day inpatient stay. Requirements for allowing greater than 48 hours of observation are not satisfied.

  • Statement covers period: January 5 through January 11
  • Admission date: January 8
  • Bill 48 units with revenue code 0762
  • Indicate a non-covered span starting on January 7 and ending January 8

Example 4: The member presents at 1:00 AM on January 5 and is placed in observation for 84 hours, then dismissed. Requirements for allowing greater than 48 hours of observation are not satisfied.

  • Statement covers period: January 5 through January 8
  • Admission date: not applicable
  • Bill 48 units with revenue code 0762
  • Indicate a non-covered span starting on January 7 and ending January 8

Example 5: The member presents at 1:00 AM on January 5 and is placed in observation for 72 hours, then dismissed. Requirements for allowing greater than 48 hours of observation are satisfied.

  • Statement covers period: January 5 through January 8
  • Admission date: not applicable
  • Bill 72 units with revenue code 0762
  • Do not indicate a non-covered span
Topic #561

Paper Claim Form Preparation and Data Alignment Requirements

Optical Character Recognition

Paper claims submitted to ForwardHealth on the 1500 Health Insurance Claim Form and UB-04 Claim Form are processed using OCR software that recognizes printed, alphanumeric text. OCR software increases efficiency by alleviating the need for keying in data from paper claims.

The data alignment requirements do not apply to the Compound Drug Claim form and the Noncompound Drug Claim form.

Speed and Accuracy of Claims Processing

OCR software processes claim forms by reading text within fields on claim forms. After a paper claim form is received by ForwardHealth, the claim form is scanned so that an image can be displayed electronically. The OCR software reads the electronic image on file and populates the information into the ForwardHealth interChange system. This technology increases accuracy by removing the possibility of errors being made during manual keying.

OCR software speeds paper claim processing, but only if providers prepare their claim forms correctly. In order for OCR software to read the claim form accurately, the quality of copy and the alignment of text within individual fields on the claim form need to be precise. If data are misaligned, the claim could be processed incorrectly. If data cannot be read by the OCR software, the process will stop and the electronic image of the claim form will need to be reviewed and keyed manually. This will cause an increase in processing time.

Handwritten Claims

Submitting handwritten claims should be avoided whenever possible. ForwardHealth accepts handwritten claims; however, it is very difficult for OCR software to read a handwritten claim. If a handwritten claim cannot be read by the OCR software, it will need to be keyed manually from the electronic image of the claim form. Providers should avoid submitting claims with handwritten corrections as this can also cause OCR software processing delays.

Use Original Claim Forms

Only original 1500 Health Insurance Claim Forms and UB-04 Claim Forms should be submitted. Original claim forms are printed in red ink and may be obtained from a federal forms supplier. ForwardHealth does not provide these claim forms. Claims that are submitted as photocopies cannot be read by OCR software and will need to be keyed manually from an electronic image of the claim form. This could result in processing delays.

Use Laser or Ink Jet Printers

It is recommended that claims are printed using laser or ink jet printers rather than printers that use DOT matrix. DOT matrix printers have breaks in the letters and numbers, which may cause the OCR software to misread the claim form. Use of old or worn ink cartridges should also be avoided. If the claim form is read incorrectly by the OCR software, the claim may be denied or reimbursed incorrectly. The process may also be stopped if it is unable to read the claim form, which will cause a delay while it is manually reviewed.

Alignment

Alignment within each field on the claim form needs to be accurate. If text within a field is aligned incorrectly, the OCR software may not recognize that data are present within the field or may not read the data correctly. For example, if a reimbursement amount of $300.00 is entered into a field on the claim form, but the last "0" is not aligned within the field, the OCR software may read the number as $30.00, and the claim will be reimbursed incorrectly.

To get the best alignment on the claim form, providers should center information vertically within each field, and align all information on the same horizontal plane. Avoid squeezing two lines of text into one of the six line items on the 1500 Health Insurance Claim Form.

The following sample claim forms demonstrate correct and incorrect alignment:

Clarity

Clarity is very important. If information on the claim form is not clear enough to be read by the OCR software, the process may stop, prompting manual review.

The following guidelines will produce the clearest image and optimize processing time:

  • Use 10-point or 12-point Times New Roman or Courier New font.
  • Type all claim data in uppercase letters.
  • Use only black ink to complete the claim form.
  • Avoid using italics, bold, or script.
  • Make sure characters do not touch.
  • Make sure there are no lines from the printer cartridge anywhere on the claim form.
  • Avoid using special characters such as dollar signs, decimals, dashes, asterisks, or backslashes, unless it is specified that these characters should be used.
  • Use Xs in check boxes. Avoid using letters such as "Y" for "Yes," "N" for "No," "M" for "Male," or "F" for "Female."
  • Do not highlight any information on the claim form. Highlighted information blackens when it is imaged, and the OCR software will be unable to read it.

Note: The above guidelines will also produce the clearest image for claims that need to be keyed manually from an electronic image.

Staples, Correction Liquid, and Correction Tape

The use of staples, correction liquid, correction tape, labels, or stickers on claim forms should be avoided. Staples need to be removed from claim forms before they can be imaged, which can damage the claim and cause a delay in processing time. Correction liquid, correction tape, labels, and stickers can cause data to be read incorrectly or cause the OCR process to stop, prompting manual review. If the form cannot be read by the OCR software, it will need to be keyed manually from an electronic image.

Additional Diagnosis Codes

ForwardHealth will accept up to 12 diagnosis codes in Item Number 21 of the 1500 Health Insurance Claim Form.

 
Correctly Aligned Sample 1500 Health Insurance Form
 
Incorrectly Aligned Sample 1500 Health Insurance Form
 
Correctly Aligned Sample UB-04 Claim Form
 
Incorrectly Aligned Sample UB-04 Claim Form
Topic #1429

Paper Claim Submission

Paper claims for inpatient hospital services must be submitted using the UB-04 Claim Form. Claims for inpatient hospital services submitted on any other claim form are denied.

Providers should use the appropriate claim form instructions for inpatient hospital services when submitting these claims.

Obtaining the Claim Forms

ForwardHealth does not provide the UB-04 Claim Form. The form may be obtained from any federal forms supplier.

Topic #1428

Patient Status Codes

The following patient status codes are accepted on claims submitted by inpatient hospital providers in most instances.

Patient Status Code Description
02 Discharged/transferred to a short-term general hospital for inpatient care.
05 Discharged/transferred to another type of institution not defined elsewhere in this code list.
21 Discharged/transferred to court/law enforcement.
43 Discharged/transferred to a federal health care facility.
61 Discharged/transferred to hospital-based Medicare approved swing bed.
62 Discharged/transferred to an IRF including rehabilitation distinct part units of a hospital.
63 Discharged/transferred to a Medicare LTCH.
64 Discharged/transferred to a nursing facility enrolled in Medicaid but not enrolled in Medicare.
65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital.
66 Discharged/transferred to critical access hospital.
82 Discharged/transferred to a short-term general hospital for inpatient care with a planned acute care hospital inpatient readmission.
85 Discharged/transferred to a designated cancer center or children's hospital with a planned acute care hospital inpatient readmission.
93 Discharged/transferred to a psychiatric hospital/distinct part unit of a hospital with a planned acute care hospital inpatient readmission.
94 Discharged/transferred to a CAH with a planned acute care hospital inpatient readmission.

Refer to the National UB-04 Uniform Billing Manual for a complete list of all nationally defined patient status codes.

All Patient Status Codes Valid for Inpatient Hospital Claims

For inpatient hospitals, all of the patient status codes listed in the chart are valid for both Medicare crossover claims and claims submitted only to ForwardHealth.

ForwardHealth Does Not Accept Patient Status Codes Reserved for National Assignment

ForwardHealth does not accept the following patient status codes that were redefined as "reserved for national assignment" by the National Uniform Billing Committee: 10–19, 22–29, 31–39, 44–49, 52–60, 67–81, 83–84, 86–92, and 95–99.

Topic #22797

Payment Integrity Review Supporting Documentation

Providers are notified that an individual claim is subject to PIR through a message on the Portal when submitting claims. When this occurs, providers have seven calendar days to submit the supporting documentation that must be retained in the member's record for the specific service billed. This documentation must be attached to the claim. The following are examples of documentation providers may attach to the claim; however, this list is not exhaustive, and providers may submit any documentation available to substantiate payment:

  • Case management or consultation notes
  • Durable medical equipment or supply delivery receipts or proof of delivery and itemized invoices or bills
  • Face-to-face encounter documentation
  • Individualized plans of care and updates
  • Initial or program assessments and questionnaires to indicate the start DOS
  • Office visit documentation
  • Operative reports
  • Prescriptions or test orders
  • Session or service notice for each DOS
  • Testing and lab results
  • Transportation logs
  • Treatment notes

Providers must attach this documentation to the claim at the time of, or up to seven days following, submission of the claim. A claim may be denied if the supporting documentation is not submitted. If a claim is denied, providers may submit a new claim with the required documentation for reconsideration. To reduce provider impact, claims reviewed by the OIG will be processed as quickly as possible, with an expected average adjudication of 30 days.

Topic #1427

Point of Origin for Admission or Visit

Providers may refer to the National UB-04 Uniform Billing Manual for a complete list of all nationally defined Patient Status and Point of Origin for Admission or Visit codes.

Topic #8257

Present on Admission Indicator

All inpatient hospital providers are required to include POA indicator information for all primary and secondary diagnoses.

The DRA of 2005 requires a quality adjustment in DRG payments for certain HACs. Wisconsin Medicaid and BadgerCare Plus have adopted the HACs established by the federal CMS and reflected in the DRG payments. Reimbursement may be affected by this information. The CMS website contains the list of HACs that may affect reimbursement.

Present on Admission Indicator Options and Definitions

The following are POA indicator options and corresponding definitions:

  • Y: This indicates that the diagnosis was present at the time of inpatient admission.
  • N: This indicates that the diagnosis was not present at the time of inpatient admission.
  • U: This indicates that the documentation is insufficient to determine if the condition was present at the time of inpatient admission.
  • W: This indicates that the provider is unable to clinically determine whether the condition was present at the time of inpatient admission.
Topic #10177

Prior Authorization Numbers on Claims

Providers are not required to indicate a PA number on claims. ForwardHealth interChange matches the claim with the appropriate approved PA request. ForwardHealth's RA and the 835 report to the provider the PA number used to process a claim. If a PA number is indicated on a claim, it will not be used and it will have no effect on processing the claim.

When a PA requirement is added to the list of drugs requiring PA and the effective date of a PA falls in the middle of a billing period, two separate claims that coincide with the presence of PA for the drug must be submitted to ForwardHealth.

Topic #13337

Professional Services

When provided in an inpatient hospital setting, professional and other services must be submitted on a professional claim by a separately certified provider when the following professionals are providing them or the services themselves are:

  • Air, water, and land hospital-based ambulance
  • Anesthesia assistants
  • Audiologists
  • CRNAs
  • Chiropractors
  • Dentists
  • DME and supplies for non-hospital use
  • Hearing aid dealers
  • Independent nurse practitioners
  • Nurse midwives
  • Optometrists
  • Pharmacy, for take home drugs on the date of discharge
  • Physician assistants
  • Physicians
  • Podiatrists
  • Psychiatrists
  • Psychologists
  • SMV transportation

These services are ineligible for reimbursement under the DRG payment system for inpatient hospital services.

When provided in an outpatient hospital setting, the following professional and other services must be submitted on a professional claim by a separately certified provider:

These services are ineligible for reimbursement under the EAPG payment system for outpatient hospital services.

Topic #23039

Qualifying Clinical Trials

ForwardHealth requires the following on all claims submitted for routine services associated with participation in a clinical trial:

  • The National Clinical Trial number
  • HCPCS modifier Q1
  • An ICD-10-CM diagnosis code to indicate the services are associated with a clinical trial, such as Z00.6
Topic #10637

Reimbursement Reduction for Most Paper Claims

As a result of the Medicaid Rate Reform project, ForwardHealth will reduce reimbursement on most claims submitted to ForwardHealth on paper. Most paper claims will be subject up to a $1.10 reimbursement reduction per claim.

For each claim that a reimbursement reduction was applied, providers will receive an EOB to notify them of the payment reduction. For claims with reimbursement reductions, the EOB will state the following, "This claim is eligible for electronic submission. Up to a $1.10 reduction has been applied to this claim payment."

If a paid claim's total reimbursement amount is less than $1.10, ForwardHealth will reduce the payment up to a $1.10. The claim will show on the RA as paid but with a $0 paid amount.

The reimbursement reduction applies to the following paper claims:

Exceptions to Paper Claim Reimbursement Reduction

The reimbursement reduction will not affect the following providers or claims:

  • In-state emergency providers
  • Out-of-state providers
  • Medicare crossover claims
  • Any claims that ForwardHealth requires additional supporting information to be submitted on paper, such as:
Topic #21197

Select High Cost, Orphan, and Accelerated Approval Drugs

For the interim, select high cost, orphan, and accelerated approval drugs will be covered and reimbursed under the pharmacy benefit. When a noncompound drug is covered under the pharmacy benefit, providers may submit claims for the cost of the drug to ForwardHealth through one of the following methods:

  • Real-time POS system using the NCPDP Telecommunication Standard
  • ForwardHealth Portal
  • PES software
  • Noncompound Drug Claim form

Related physician and clinical services associated with the administration of the drug will be reimbursed separately based on existing coverage and reimbursement policy.

The Services Requiring Prior Authorization chapter of the Prior Authorization section of the Pharmacy service area of the Online Handbook contains clinical criteria for select high cost, orphan, and accelerated approval drugs that are identified in the Select High Cost, Orphan, and Accelerated Approval Drugs data table.

Pharmacy Direct Billing for Select High Cost, Orphan, and Accelerated Approval Drugs

To clarify, if a provider or facility obtains a drug that is specifically addressed in the Select High Cost, Orphan, and Accelerated Approval Drugs data table from a pharmacy provider, then the administering provider or facility may not bill for the cost of that drug because the pharmacy provider will bill for the cost of the drug.

It is the responsibility of the pharmacy provider to use appropriate management and packaging practices to ensure drug stability and integrity are maintained during drug shipment and delivery. Once the drug is in possession of the administering provider or facility, it is the responsibility of the administering provider or facility to use appropriate management and storage practices to ensure drug stability and integrity are maintained. If a drug is damaged prior to administration or is delivered but not administered to a member, ForwardHealth will not reimburse for the cost of the drug; it is the responsibility of the administering provider or facility to alert the pharmacy provider and the responsibility of the pharmacy provider to reverse their claim to ForwardHealth and work with the pharmaceutical company or administering provider or facility regarding payment for the damaged or wasted drug.

For the interim, select high cost, orphan, and accelerated approval drugs will be covered under the pharmacy benefit, but it is the responsibility of the health care provider to determine the medically appropriate setting for administration. Providers are required to comply with all relevant safety protocols when administering these drugs to ForwardHealth members.

For specific questions about institutional billing or coverage of high cost, orphan, and accelerated approval drugs listed in the Select High Cost, Orphan, and Accelerated Approval Drugs data table, providers may contact Provider Services or email DHSOrphanDrugs@dhs.wisconsin.gov.

Note: Select high cost, orphan, and accelerated approval drugs covered under the pharmacy benefit will not be covered as physician-administered drugs. When a high cost, orphan, or accelerated approval drug is covered under the pharmacy benefit, it will be reimbursed fee-for-service and MCOs will not be responsible for the cost of the drug, but MCOs are still responsible for the physician and clinical services associated with the high cost, orphan, or accelerated approval drug.

Topic #15977

Submitting Multiple National Drug Codes per Procedure Code

If two or more NDCs are submitted for a single procedure code, the procedure code is required to be repeated on separate details for each unique NDC. Whether billing a compound or noncompound drug, the procedures for billing multiple components (NDCs) with a single HCPCS code are the same.

Claim Submission Instructions for Claims With Two or Three National Drug Codes

When two NDCs are submitted on a claim, a KP modifier (first drug of a multiple drug unit dose formulation) is required on the first detail and a KQ modifier (second or subsequent drug of a multiple drug unit dose formulation) is required on the second detail.

For example, if a provider administers 150 mg of Synagis, and a 100 mg vial and a 50 mg vial were used, then the NDC from each vial must be submitted on the claim. Although the vials have different NDCs, the drug has one procedure code, 90378 (Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each). In this example, the same procedure code would be reported on two details of the claim and paired with different NDCs.

Procedure Code NDC NDC Description
90378 60574-4111-01 Synagis— 100 mg
90378 60574-4112-01 Synagis— 50 mg

Example Claim Form for 2 National Drug Codes

When three NDCs are submitted on a claim, a KP modifier is required on the first detail, a KQ modifier on the second detail, and the modifier should be left blank on the third detail.

For example, if a provider administers a mixture of 1 mg of hydromorphone HCl powder, 125 mg of bupivacaine HCl powder, and 50 ml of sodium chloride 0.9 percent solution, each NDC is required on a separate detail. However, this compound drug formulation is required to be billed under one procedure code, J3490 (Unclassified drugs), and the same procedure code must be reported on three separate details on the claim and paired with different NDCs.

Procedure Code NDC NDC Description
J3490 00406-3245-57 Hydromorphone HCl Powder — 1 mg
J3490 38779-0524-03 Bupivacaine HCl Powder — 125 mg
J3490 00409-7984-13 Sodium Chloride 0.9% Solution — 50 ml

Example Claim Form for 3 National Drug Codes

Claims for physician-administered drugs with two or three NDCs may be submitted to ForwardHealth via the following methods:

  • The 837P transaction
  • PES software
  • DDE on the ForwardHealth Portal
  • A 1500 Health Insurance Claim Form

Claim Submission Instructions for Claims with Four or More National Drug Codes

When four or more components are reported, each component is required to be listed separately in a statement of ingredients on an attachment that must be appended to a paper 1500 Health Insurance Claim Form.

Note: The reimbursement reduction for paper claims will not affect claims submitted on paper with four or more NDCs, as described above.

Topic #1352

Submitting Newborn Claims

When a woman gives birth, the hospital provider is required to submit separate claims for the hospital stay of the woman and the hospital stay of her newborn. In addition, the newborn's birth weight must only be recorded on the newborn's claim, using Value Code 54.

Hospital claims for births may be submitted using any of the following submission methods:

Topic #4817

Submitting Paper Attachments With Electronic Claims

Providers may submit paper attachments to accompany electronic claims and electronic claim adjustments. Providers should refer to their companion guides for directions on indicating that a paper attachment will be submitted by mail.

Paper attachments that go with electronic claim transactions must be submitted with the Claim Form Attachment Cover Page. Providers are required to indicate an ACN for paper attachment(s) submitted with electronic claims. (The ACN is an alphanumeric entry between 2 and 80 digits assigned by the provider to identify the attachment.) The ACN must be indicated on the cover page so that ForwardHealth can match the paper attachment(s) to the correct electronic claim.

ForwardHealth will hold an electronic claim transaction or a paper attachment(s) for up to seven calendar days to find a match. If a match cannot be made within seven days, the claim will be processed without the attachment and will be denied if an attachment is required. When such a claim is denied, both the paper attachment(s) and the electronic claim will need to be resubmitted.

Providers are required to send paper attachments relating to electronic claim transactions to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

This does not apply to compound and noncompound claims.

Topic #1403

Transfers Between Institutions for Mental Disease Hospitals and Acute Care General Hospitals

An inpatient at an IMD may transfer to an acute care general hospital, then return to the IMD and eventually be discharged from the IMD. If the patient's absence from the IMD and simultaneous stay at the acute care general hospital is three or fewer consecutive days, Wisconsin Medicaid reimburses the IMD for one DRG discharge payment. The member's payment covers the period before and the period after the stay at the acute care general hospital.

If the patient does not return to the IMD after the acute care general hospital stay, Wisconsin Medicaid reimburses the IMD one DRG payment for the patient's stay prior to their transfer to the acute care general hospital.

Three or fewer consecutive days means the patient is absent or on leave from the IMD for three or fewer consecutive IMD midnight census counts.

If the patient's stay at the acute care general hospital is more than three consecutive days, Wisconsin Medicaid reimburses the IMD with one DRG discharge payment for the patient's stay at the IMD prior to going to the acute care general hospital. If the patient returns to the IMD, Wisconsin Medicaid reimburses the IMD a second DRG discharge payment for the period after the acute care general hospital stay. In this situation, the IMD must separately bill for the two periods so that the IMD may receive two DRG discharge payments.

Wisconsin Medicaid reimburses the acute care hospital to which the patient was transferred for the medically necessary stay without regard to the patient's length of stay. The acute care hospital is paid a DRG discharge payment without regard to which condition described above applies to the IMD.

Any payment to the IMD for a patient's stay is subject to the person's coverage for their stay at the IMD.

Topic #1426

Transfers Between Units Within a Hospital

Patients who are transferred from one hospital unit to another within the same hospital are not considered discharged until the entire hospital stay has ended. A discharge occurs when the patient leaves the hospital for any reason other than a "leave of absence." Wisconsin Medicaid pays hospitals one DRG per stay and does not recognize specialty rehabilitation or psychiatric units for separate reimbursement purposes.

Topic #3448

UB-04 (CMS 1450) Claim Form Instructions for Inpatient Hospital Services

These instructions are for the completion of the UB-04 claim for ForwardHealth. For complete billing instructions, refer to the National UB-04 Uniform Billing Manual prepared by the NUBC. The National UB-04 Uniform Billing Manual contains important coding information not available in these instructions. Providers may purchase the National UB-04 Uniform Billing Manual by calling 312-422-3390 or by accessing the NUBC website.

Members enrolled in BadgerCare Plus or Medicaid receive a ForwardHealth identification card. Always verify a member's enrollment before providing nonemergency services to determine if there are any limitations on covered services and to obtain the correct spelling of the member's name.

Note: Every code used on this claim form, even if the code is entered in a non-required form locator, is required to be a valid code. In addition, each provider is solely responsible for the truthfulness, accuracy, timeliness, and completeness of claims relating to reimbursement for services submitted to ForwardHealth.

When submitting paper claims, if the member has any other health insurance sources, providers are required to complete and submit an Explanation of Medical Benefits form, along with the completed paper claim.

Submit completed paper claims and the completed Explanation of Medical Benefits form, as applicable, to the following address:

ForwardHealth
Claims and Adjustments
313 Blettner Blvd
Madison WI 53784

Form Locator 1 — Provider Name, Address, and Telephone Number
Enter the name of the hospital submitting the claim and the hospital's complete practice location address. The minimum requirement is the hospital's name, city, state, and ZIP+4 code. Do not enter a Post Office Box or a ZIP+4 code associated with a PO Box. The name in Form Locator 1 must correspond with the NPI in Form Locator 56.

Form Locator 2 — Pay-to Name, Address, and ID (not required)

Form Locator 3a — Pat. Cntl # (optional)
Providers may enter up to 20 characters of the patient's internal office account number. This number will appear on the RA and/or the 835 transaction.

Form Locator 3b — Med. Rec. #
Enter the number assigned to the patient's medical/health record by the provider. This number will appear on the RA and/or the 835 transaction.

Form Locator 4 — Type of Bill
Exclude the leading zero and enter the three-digit type of bill code. The type of bill codes for inpatient hospital services include the following:

  • 111 = Hospital, inpatient, admit through discharge claim.
  • 851 = Special facility, critical access hospital, admit through discharge claim.

Form Locator 5 — Fed. Tax No.
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator. If computer software does not automatically complete this form locator, enter information such as the provider's federal tax identification number.

Form Locator 6 — Statement Covers Period (From - Through)
Enter both dates in MMDDYY format (for example, November 3, 2008, would be 110308). Include the date of discharge or death.

Form Locator 7 — Unlabeled Field (not required)

Form Locator 8 a-b — Patient Name
Enter the member's last name and first name, separated by a space or comma, in Form Locator 8b. Use Wisconsin's EVS to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth card and the EVS do not match, use the spelling from the EVS.

Form Locator 9 a-e — Patient Address
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator (for example, "On file"). If computer software does not automatically complete this form locator, enter information such as the member's complete address in field 9a.

Form Locator 10 — Birthdate
Enter the member's birth date in MMDDCCYY format (for example, September 25, 1975, would be 09251975).

Form Locator 11 — Sex (not required)

Form Locator 12 — Admission/Start of Care Date
Enter the admission date in MMDDYY format (for example, November 3, 2008, would be 110308).

Form Locator 13 — Admission Hr (not required)

Form Locator 14 — Priority (Type) of Admission or Visit
Enter the appropriate admission type for the services rendered. Refer to the UB-04 Billing Manual for more information.

Form Locator 15 — Point of Origin for Admission or Visit
Enter the code indicating the source of this admission. Refer to the UB-04 Billing Manual for more information.

Form Locator 16 — DHR (not required)

Form Locator 17 — Patient Discharge Status
Enter the code indicating disposition or discharge status of the member at the end service for the period covered on this claim. Refer to the UB-04 Billing Manual for more information.

Form Locators 18-28 — Condition Codes (required, if applicable)
Enter the code(s) identifying a condition related to this claim, if appropriate. Refer to the UB-04 Billing Manual for more information.

Form Locator 29 — ACDT State (not required)

Form Locator 30 — Unlabeled Field (not required)

Form Locators 31-34 — Occurrence Code and Date (required, if applicable)
If appropriate, enter the code and associated date defining a significant event relating to this claim that may affect payer processing. To indicate that Medicare Part A or Part B benefits were exhausted mid-stay, enter occurrence code "C3" and the date that Medicare benefits were exhausted. All dates must be printed in the MMDDYY format. Refer to the UB-04 Billing Manual for more information.

Form Locators 35-36 — Occurrence Span Code (From - Through) (not required)

Form Locator 37 — Unlabeled Field (not required)

Form Locator 38 — Responsible Party Name and Address (not required)

Form Locators 39-41 a-d — Value Code and Amount
Enter the applicable value code and associated amount. Enter covered days using value code "80" and enter the number of covered days in the corresponding amount field using two decimal places. (For example, to indicate one day, providers would enter "1.00;" to indicate 12 days, providers would enter "12.00.") Enter noncovered days using value code "81" and enter the number of noncovered days in the amount field using two decimal places. Do not count the day of discharge for covered days. For noncovered days, enter the total noncovered days by the primary payer. The sum of covered days and noncovered days must equal the number of days in the "From-Through" period in Form Locator 6.

To indicate that Medicare Part A or Part B benefits were exhausted mid-stay, enter value code "AB" and the amount that Medicare allowed. Refer to the UB-04 Billing Manual for more information.

To record birth weight for newborns, enter value code "54" and enter the newborn's birth weight in grams in the corresponding amount field.

Form Locator 42 — Rev. Cd.
Enter the appropriate four-digit revenue code as defined by the NUBC that identifies a specific accommodation or ancillary service. Refer to hospital publications or the UB-04 Billing Manual for information and codes.

Form Locator 43 — Description (not required)

Form Locator 44 — HCPCS/Rate/HIPPS Code (not required)

Form Locator 45 — Serv. Date (not required)

Form Locator 46 — Serv. Units
Enter the number of covered accommodation days or ancillary units of service for each line item. Do not count or include the day of discharge or death for accommodation codes.

Form Locator 47 — Total Charges (by Accommodation/Ancillary Code Category)
Enter the usual and customary charges pertaining to the related revenue code for the current billing period as entered in Form Locator 6.

Form Locator 48 — Non-covered Charges (not required)

Form Locator 49 — Unlabeled Field
Enter the "to" DOS in DD format only if the detail line includes a range of consecutive dates. The revenue code, procedure code and modifiers (if applicable), service units, and the charge must be identical for each date within the range.

Detail Line 23

PAGE ___ OF ___
Enter the current page number in the first blank and the total number of pages in the second blank. This information must be included for both single- and multiple-page claims.

CREATION DATE (not required)

TOTALS
Enter the sum of all charges for the claim in this field. If submitting a multiple-page claim, enter the total charge for the claim (i.e., the sum of all details from all pages of the claim) only on the last page of the claim.

Form Locator 50 A-C — Payer Name
Enter all health insurance payers here. Enter "T19" for Medicaid and the name of the commercial health insurance, if applicable. If submitting a multiple-page claim, enter health insurance payers only on the first page of the claim.

Form Locator 51 A-C — Health Plan ID (not required)

Form Locator 52 A-C — Rel. Info (not required)

Form Locator 53 A-C — Asg. Ben. (not required)

Form Locator 54 A-C — Prior Payments (not required)
This information is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer listed in Form Locator 50 A-C as an attachment(s) to their completed claim.

Form Locator 55 A-C — Est. Amount Due (not required)

Form Locator 56 — NPI
Enter the provider's NPI. The NPI in Form Locator 56 should correspond with the name in Form Locator 1.

Form Locator 57 — Other Provider ID (not required)

Form Locator 58 A-C — Insured's Name
Data are required in this form locator for OCR processing. Any information populated by a provider's computer software is acceptable data for this form locator (for example, "Same"). If computer software does not automatically complete this form locator, enter information such as the member's last name, first name, and middle initial.

Form Locator 59 A-C — P. Rel (not required)

Form Locator 60 A-C — Insured's Unique ID
Enter the member identification number. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to obtain the correct member ID.

Form Locator 61 A-C — Group Name (not required)

Form Locator 62 A-C — Insurance Group No. (not required)

Form Locator 63 A-C — Treatment Authorization Codes (not required)

Form Locator 64 A-C — Document Control Number (not required)

Form Locator 65 A-C — Employer Name (not required)

Form Locator 66 — Dx (not required)

Form Locator 67 —Principal Diagnosis Code and Present on Admission Indicator
Enter the valid, most specific ICD code describing the principal diagnosis (for example, the condition established after study to be chiefly responsible for causing the admission or other health care episode). The principal diagnosis code selected must be the reason for admission. It should relate to one or more conditions or symptoms identified in the admission notes and/or admission work-up. Do not enter manifestation codes as the principal diagnosis; code the underlying disease first. The principal diagnosis may not include External Cause of Morbidity codes. The POA indicator is required for the primary diagnosis and must be included in the eighth digit of this field and be right justified. The diagnosis code must be left justified.

Form Locators 67A-Q — Other Diagnosis Codes and Present on Admission Indicator
Enter valid, most specific ICD diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Diagnoses that relate to an earlier episode and have no bearing on this episode are to be excluded. Providers should prioritize diagnosis codes as relevant to this claim. The POA indicator is required for secondary diagnoses and must be included in the eighth digit of this field and be right justified. The diagnosis code must be left justified.

Form Locator 68 — Unlabeled Field (not required)

Form Locator 69 — Admit Dx
Enter a valid, most specific ICD diagnosis code provided at the time of admission as stated by the physician.

Form Locator 70 — Patient Reason Dx (not required)

Form Locator 71 — PPS Code (not required)

Form Locator 72 — ECI (not required)

Form Locator 73 — Unlabeled Field (not required)

Form Locator 74 — Principal Procedure Code and Date (required, if applicable)
Enter the valid ICD procedure code that identifies the principal procedure performed during the period covered by this claim and the date on which the principal procedure described on the claim was performed.

Note: Most often, the principal procedure will be that procedure which is most closely related to the principal discharge diagnosis.

Form Locator 74a-e — Other Procedure Code and Date (required, if applicable)
If more than six procedures are performed, report those that are most important for the episode using the same guidelines for determining principal procedure (Form Locator 74).

Form Locator 75 — Unlabeled Field (not required)

Form Locator 76 — Attending
Enter the attending provider's NPI.

Form Locator 77 — Operating (not required)

Form Locators 78 and 79 — Other Provider Name and Identifiers (not required)

Form Locator 80 — Remarks (not required)

Commercial Health Insurance Billing Information

This information is not required on the claim.

Note: When submitting paper claims to ForwardHealth, if the member has any other health insurance sources (for example, commercial health insurance, Medicare, Medicare Advantage Plans), providers are required to complete and submit a separate Explanation of Medical Benefits form for each other payer listed in Form Locator 50 A-C as an attachment(s) to their completed claim.

Form Locator 81 a-d — CC
If the billing provider's NPI was indicated in Form Locator 56, enter the qualifier "B3" in the first field to the right of the form locator, followed by the appropriate 10-digit provider taxonomy code on file with ForwardHealth in the second field.

Note: Providers should use qualifier "PXC" when submitting an electronic claim using the 837I transaction. For further instructions, refer to the companion guide for the 837I transaction.

Topic #11677

Uploading Claim Attachments Via the Portal

Providers are able to upload attachments for most claims via the secure Provider area of the ForwardHealth Portal. This allows providers to submit all components for claims electronically.

Providers are able to upload attachments via the Portal when a claim is suspended and an attachment was indicated but not yet received. Providers are able to upload attachments for any suspended claim that was submitted electronically. Providers should note that all attachments for a suspended claim must be submitted within the same business day.

Claim Types

Providers will be able to upload attachments to claims via the Portal for the following claim types:

  • Professional.
  • Institutional.
  • Dental.

The submission policy for compound and noncompound drug claims does not allow attachments.

Document Formats

Providers are able to upload documents in the following formats:

  • JPEG (.jpg or .jpeg).
  • PDF (.pdf).
  • Rich Text Format (.rtf).
  • Text File (.txt).

JPEG files must be stored with a ".jpg" or ".jpeg" extension; text files must be stored with a ".txt" extension; rich text format files must be stored with a ".rtf" extension; and PDF files must be stored with a ".pdf" extension.

Microsoft Word files (.doc) cannot be uploaded but can be saved and uploaded in Rich Text Format or Text File formats.

Uploading Claim Attachments

Claims Submitted by Direct Data Entry

When a provider submits a DDE claim and indicates an attachment will also be included, a feature button will appear and link to the DDE claim screen where attachments can be uploaded.

Providers are still required to indicate on the DDE claim that the claim will include an attachment via the "Attachments" panel.

Claims will suspend for seven days before denying for not receiving the attachment.

Claims Submitted by Provider Electronic Software and 837 Health Care Claim Transactions

Providers submitting claims via 837 transactions are required to indicate attachments via the PWK segment. Providers submitting claims via PES software will be required to indicate attachments via the attachment control field. Once the claim has been submitted, providers will be able to search for the claim on the Portal and upload the attachment via the Portal. Refer to the Implementation Guides for how to use the PWK segment in 837 transactions and the PES Manual for how to use the attachment control field.

Claims will suspend for seven days before denying for not receiving the attachment.

 
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