Provider Manual
ƒ Billing and Payment
Billing and
Payment
This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente’s billing and payment policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If, at any time, you have a question or concern about the information in this Manual, you can reach our Provider Inquiry Department by calling 503‐813‐2700 or 1‐800‐813‐2700. 5
KAISER PERMANENTE
Table of Contents
INTRODUCTION....................................................................................................................... 6
SECTION 5: BILLING AND PAYMENT ............................................................................... 6
5.1. WHOM TO CONTACT WITH QUESTIONS .................................................................................... 6
5.2 METHODS OF CLAIMS FILING ..................................................................................................... 8
5.3 PAPER CLAIM FORMS .................................................................................................................. 8
5.4 RECORD AUTHORIZATION NUMBER ........................................................................................... 8
5.5 ONE MEMBER/ PROVIDER PER CLAIM FORM ............................................................................... 8
5.6 NO FAULT/ WORKERS’ COMPENSATION/OTHER ACCIDENT ................................................... 8 5.7 ENTERING DATES......................................................................................................................... 8
5.8 MULTIPLE DATES OF SERVICES AND PLACE OF SERVICES ....................................................... 10
5.9 SURGICAL AND/OR OBSTETRICAL PROCEDURES ...................................................................... 10
5.10 BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS ................................................ 10
5.11 SUPPORTING DOCUMENTATION FOR PAPER CLAIMS (REQUIRED) ....................................... 10
5.12 WHERE TO MAIL/FAX PAPER CLAIMS .................................................................................... 11
5.13 ELECTRONIC DATA INTERCHANGE (EDI).............................................................................. 11
5.14 ELECTRONIC CLAIMS FORMS .................................................................................................... 12
5.15 SUPPORTING DOCUMENTATION FOR EDI CLAIMS (REQUIRED) ........................................... 12
5.16 TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS .................................................................. 12
5.17 ELECTRONIC SUBMISSION PROCESS ....................................................................................... 14
5.18 KP Contracted Clearinghouses…………………………………………………….
5.19 HIPAA REQUIREMENTS........................................................................................................... 16
5.20 CLEAN CLAIMS ........................................................................................................................ 16
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5.21 CLAIMS SUBMISSION TIMEFRAMES (REQUIRED) .................................................................... 17
5.22 CLAIMS PROCESSING TURN‐AROUND TIME (REQUIRED)...................................................... 17
5.23 Appeal of Timely Claims Submission……………………………………………… 5.24 PROOF OF TIMELY CLAIMS SUBMISSION (REQUIRED)........................................................... 18
5.25 Claim Adjustments/Corrections…………………………………………………….
5.26 Incorrect Claims Payments (Required) ................................................................................. 20 5.27 REJECTED CLAIMS DUE TO EDI CLAIMS ERROR (REQUIRED)............................................... 22
5.28 FEDERAL TAX ID NUMBER (REQUIRED) ................................................................................. 22
5.29 CHANGES IN FEDERAL TAX ID NUMBER (REQUIRED)........................................................... 23
5.30 NATIONAL PROVIDER IDENTIFICATION (NPI) (REQUIRED).................................................. 23
5.31 Member Cost Share………………………………………………………………….
5.32 Member Claims Inquiries ............................................................................................................... 24
5.33 Visiting Members (Required) ....................................................................................................... 24
5.34 Coding for Claims (Required) ....................................................................................................... 24
5.35 Coding Standards ........................................................................................................................ 24
5.36 Modifiers in CPT and HCPCS (Required)...................................................................................... 25
5.37 Modifier Review ........................................................................................................................... 29
5.38 CODING & BILLING VALIDATION (REQUIRED) ...................................................................... 29
5.39 Coding Edit Rules (Required) ....................................................................................................... 29
5.40 Medical Claims Review (Required)................................................................................................ 30
Major Categories of Claim Coding Errors/Inconsistencies ....................................................... 30
Incidental Procedures......................................................................................................................31
Mutually Exclusive Procedures........................................................................................................31
Age and Gender (Sex) Conflicts ......................................................................................................32
Obsolete/Deleted Codes .................................................................................................................32
Multiple/ Duplicate Component Billing .............................................................................................33
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5.41 Other Party Liability (OPL) ............................................................................................................ 34
5.42 Workers’ Compensation................................................................................................................ 34
5.43 PROVIDER CLAIMS APPEALS (REQUIRED).............................................................................. 34
5.44 CMS‐1500 (08/05) FIELD DESCRIPTIONS ......................................................................... 36
5.45 CMS‐1450 (UB‐04) FIELD DESCRIPTIONS........................................................................ 45
5.46 BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ................................. 51
5.46.1 Evaluation Management (E/M) Services.......................................................................... 51
5.46.2 Emergency Rooms................................................................................................................ 52
5.46.3 Durable Medical Equipment………………………………………………………
5.46.4 Injection/ Immunizations .................................................................................................... 53
5.46.5 Newborn Services................................................................................................................. 53
5.46.6 Expanded Care…………………………………………………………………… 5.47 Anesthesia ...................................................................................................................................
5.48 COORDINATION OF BENEFITS (COB) ..................................................................................... 58
5.48.1 How to Determine the Primary Payor ............................................................................ 58
5.48.2 Description of COB Payment Methodologies ................................................................ 59
5.48.3 COB Claims Submission Requirements and Procedures ............................................. 59
5.48.4 Members Enrolled in Two Kaiser Permanente Plans.................................................... 60
5.48.5 COB Claims Submission Timeframes.............................................................................. 60
5.48.6 COB FIELDS ON THE UB‐92 and UB‐04 CLAIM FORM ............................................ 60
5.48.7 COB FIELDS ON THE CMS‐1500 (HCFA‐1500) CLAIM FORM................................. 62
5.49 EXPLANATION OF PAYMENT (EOP) (REQUIRED) .................................................................. 64
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Introduction
At the heart of Kaiser Permanente‘s claim processing operation is the set of policies and
procedures followed in determining the appropriate handling and reimbursement of claims
received.
Kaiser Permanente uses code editing software from third party vendors to assist in
determining the appropriate handling and reimbursement of claims. Currently, Kaiser
Permanente has selected IntelliClaim, which in turn uses software from McKesson and Claims
Edit System (CES) Knowledgebase. From time to time, Kaiser Permanente may change this
coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser
Permanente’s goal is to help ensure the accuracy of claims payments.
IntelliClaim is a code editor software application designed to evaluate professional
claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is
a rule-based application; some of these rules have been chosen to meet Kaiser Permanente’s
goals of increased accuracy in claims payment.
IntelliClaim assists Kaiser Permanente in identifying various categories of claims coding and
possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Medical
Claim Review staff for manual review. Each claim is validated against Kaiser Permanente’s
payment criteria, and then is subsequently released for processing. This process has a goal of
improving the accuracy of coding and consistency in claims payment procedures.
In order to help illustrate how this process works, examples have been provided where
appropriate. If you have questions about the application of these rules, please contact our
Claims Inquiry Unit.
Section 5: Billing and Payment It is your responsibility to submit itemized claims for services provided to Members in a
complete and timely manner in accordance with your Agreement, this Manual and applicable
law. The Member’s Payor is responsible for payment of claims in accordance with your
Agreement
5.1 Whom to Contact with Questions
If you have any questions relating to the submission of claims to Kaiser Permanente for
processing, please refer to the table below for the correct department/number to call:
PLEASE CALL:
CLAIMS
ADMINISTRATION
IF YOU HAVE QUESTIONS ABOUT:
• Coordination of Benefits (COB
• Third Party Liability (TPL)
TELEPHONE NUMBER(S):
COB Local Telephone #: (503) 813-4332
COB Toll-Free Telephone #: (888) 454-4332
TPL Local Telephone #: (503) 813-2703
TPL Toll-Free Telephone #: (866) 374-0929
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PLEASE CALL:
IF YOU HAVE QUESTIONS ABOUT:
TELEPHONE NUMBER(S):
Fax #: (503) 813-2710
Address: Kaiser Permanente
Claims Administration Department
500 NE Multnomah Street, Suite 100
Portland, OR 97232-2099
CLAIMS INQUIRY
•
•
•
•
•
•
•
•
Benefits/Co-Pay Information
Claim Payment Inquiries *
Claim Status *
Claim Submission
Explanation of Payment (EOP)
Medical Policy Questions
Member Eligibility
Referral Questions
For Questions regarding Refunds and Refund
Requests
Local Telephone #: (503) 735-2727
Toll-Free Telephone #: (866) 441-1221
Address: Kaiser Permanente
Claims Inquiry Unit
500 NE Multnomah Street, Suite 100
Portland, OR 97232-2099
Local Telephone #: (503) 813-1900
Toll-Free Telephone #: (800) 756-2777
Address: Kaiser Permanente
Claims Inquiry Unit
500 NE Multnomah Street, Suite 100
Portland, OR 97232-2099
PROVIDER
CONTRACTING &
RELATIONS
•
•
•
•
•
•
•
•
•
Contracts
Credentialing
Fee Schedule
Participation Request
Participation Status
Practice Demographic Updates
Provider Appeals
Referral Policy
Orientation
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Local Telephone #: (503) 813-3376
Fax #: (503) 813-2017
Address: Kaiser Permanente
Provider Contracting & Relations
500 NE Multnomah Street, Suite 100
Portland, OR 97232-2099
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Topic
Instructions
5.2 Methods of Kaiser Permanente of the Northwest accepts all claims submitted by mail or
electronically.
Claims Filing
5.3 Paper
Claim Forms
•
•
•
CMS-1500 (8/05) must be used for all professional services and
suppliers.
UB-04 (CMS-1450) must be used by all facilities (e.g.,
hospitals).
Any professional services (for example, services rendered by
radiologists, ER physicians, etc.) should be billed on CMS-1500
claim forms, unless you are contracted under a GLOBAL rate,
in which case “professional services” should not be billed
separately.
Please use standard claim forms formatted with RED ink to ensure
maximum compatibility with Kaiser Permanente’s optical scanning
equipment. Claim forms formatted with black or blue lines will not
scan as efficiently as those formatted with RED.
5.4 Record
Authorization
Number
Services that require prior authorization must have an authorization number
reflected on the claim form.
5.5 One
Member/
Provider per
Claim Form
One Member per Claim Form/One Provider per claim
• Do not bill for different Members on the same claim form
• Do not bill for different Providers on the same claim form.
• Separate claim forms must be completed for each Member and for
each Provider
5.6 No Fault/
Workers’
Compensation/
Other Accident
Be sure to indicate on the CMS-1500 (HCFA-1500) Claim Form in the “Is
Patient’s Condition Related To” fields (Fields 10a -10c), whenever No Fault,
Workers’ Compensation, or Other Accident situations apply.
5.7 Entering
Dates
All dates (dates of birth, dates of service, etc.) must be reported in the
following format: month, day, and FOUR DIGITS for the year
(MM/DD/YYYY).
CMS 1500(8/05) Form
If applicable, enter the Authorization Number (Field 23) and the Name of
the Referring Provider (Field 17) on the claim form, to ensure efficient
claims processing and handling.
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Instructions
Example: 01/05/2008
CONSECUTIVE DATES OF SERVICE
•
Consecutive dates of service can be billed on one claim line as long
as the units entered in Field 24g equal the total number of days
billed.
Example:
Correct Way to Bill Æ
CPT/HCPCS DATE OF SERVICE
97110
01/05/2008-01/07/2008
97110
01/09/2008-01/13/2008
UNITS
3
5
Incorrect Way to Bill Æ
CPT/HCPCS
97110
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DATE OF SERVICE
01/05/2008-01/13/2008
UNITS
5
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Topic
5.8 Multiple
Dates of
Services and
Place of
Services
Instructions
•
DIFFERENT PLACES OF SERVICE
When services are rendered in DIFFERENT places of service
(locations), a separate claim form must be submitted for EACH
different place of service.
•
SAME PLACES OF SERVICE
Whenever services are provided in the SAME place of service, on
DIFFERENT dates, these services may be reported and listed as
separate lines on ONE claim form, along with the corresponding
date, diagnosis code(s), procedure code(s), and charges.
5.9 Surgical
and/or
Obstetrical
procedures
If any surgical and/or obstetrical procedures were performed, record the
ICD-9-CM principal procedure and date in Field 80 (Principal Procedure
Code and Date) and enter any additional ICD-9-CM procedure codes and
corresponding dates in Field 81A-E (Other Procedure Codes and Dates).
When submitting the UB-04, use Field 74a-e (Principal Procedure Code
and Date)
5.10 Billing
Inpatient
Claims That
Span Different
Years
When an inpatient claim spans different years (for example, the patient was
admitted in December and was discharged in January of the following
year), it is NOT necessary to submit two claims for these services. Bill all
services for this inpatient stay on one claim form (if possible), reflecting the
correct date of admission and the correct date of discharge. Kaiser
Permanente will apply the appropriate/applicable payment methodologies
when processing these claims.
5.11
Supporting
Documentation
for Paper
Claims
To expedite claims processing and adjudication, a Practitioner/Provider
should submit supporting written documentation (for example, copies of
pertinent medical records) with certain types of claims.
Supporting Documentation Submitted WITH a Claim:
•
When supporting documentation is submitted WITH the
corresponding paper claim form, attach/secure the documentation to
the paper claim with a paper clip (do not staple) and mail to Kaiser
Permanente’s mailing address.
Supporting Documentation Submitted SEPARATELY From a Claim:
•
When sending supporting documentation SEPARATELY from the
claim (for example, when sending in requested medical information
for a pended claim)
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Topic
Instructions
5.12 Where to
Mail Paper
Claims
Kaiser Permanente
Claims Administration
500 NE Multnomah Street, Suite 100
Portland, OR 97232-2099
Note: Faxed Claims are not acceptable
5.13
Electronic Data
Interchange
(EDI)
Electronic Claim Submissions: Kaiser Permanente encourages electronic
submission of claims.
EDI is an electronic exchange of information in a standardized format that
adheres to all Health Insurance Portability and Accountability Act (HIPAA)
requirements. EDI transactions replace the submission of paper claims.
Required data elements (for example, claims data elements) are entered
into the computer only ONCE - typically at the Provider’s office, or at
another location where services were rendered.
Benefits of EDI Submission
1 Reduced Overhead Expenses: Administrative overhead expenses
are reduced, because the need for handling paper claims is
eliminated.
2 Improved Data Accuracy: Because the claims data submitted by the
Provider is sent electronically to Kaiser Permanente via the
Clearinghouse, data accuracy is improved, as there is no need for
re-keying or re-entry of data.
3 Low Error Rate: Additionally, “up-front” edits applied to the claims
data while information is being entered at the Provider’s office, and
additional payer-specific edits applied to the data by the
Clearinghouse before the data is transmitted to the appropriate
payer for processing, increase the percentage of clean claim
submissions.
4 Bypass US Mail Delivery: The usage of envelopes and stamps is
eliminated. Providers save time by bypassing the U.S. mail delivery
system.
5 Standardized Transaction Formats: Industry-accepted standardized
medical claim formats may reduce the number of “exceptions”
currently required by multiple payers.
NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under
a capitated arrangement, periodic interim payments (PIP), or other
reimbursement methodology, you are still required to submit Member
Encounter Data to Kaiser Permanente electronically (preferred) or via
standard claim forms (CMS-1500/08/05 or UB-04), and to follow all claims
completion instructions set forth in this Manual.
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Topic
Instructions
5.14 Electronic
Claims Forms
5.15
Supporting
Documentation
for EDI Claims
Currently, Kaiser Permanente receives and sends the following
electronically via the current 4010A1 version through our contracted
Clearinghouses
•
837P must be used for all professional services and suppliers.
•
837I must be used by all facilities (e.g., hospitals).below
To expedite claims processing and adjudication, a Practitioner/Provider
should submit supporting written documentation (for example, copies of
pertinent medical records) with certain types of claims.
Supporting Documentation Submitted SEPARATELY From a Claim:
•
When sending supporting documentation SEPARATELY from the
claim (for example, when sending in requested medical information
for a pended claim)
1) Complete a Supporting Documentation Cover Sheet for
each Member for whom you are submitting paper
documentation.
2) Attach the cover sheet to each Member’s paper
documentation with a paper clip.
3) Mail the supporting documentation as per the instructions on
the form.
5.16 To Initiate A Practitioner/Provider may be contacted by Kaiser Permanente and
encouraged to submit claims electronically.
Electronic
Claims
1) Written Request/Call
Submissions
Alternately, a Practitioner/Provider may initiate the call (or may
submit a written request) to our Provider Contracting & Relations
Department, asking that they be set up to transmit claims
electronically to Kaiser Permanente. This information will be
relayed to the Regional EDI Coordinator.
2) Verifying Connection Is Established
Upon receipt of the EDI request from the Practitioner/Provider, the
Regional EDI Coordinator from Kaiser Permanente will contact the
Practitioner/Provider to confirm that they have established a
connection with a Clearinghouse that Kaiser Permanente contracts
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Topic
Instructions
with. If not, Kaiser Permanente will assist in informing the
Practitioner/Provider in the steps to take.
3) EDI Set-Up
Once the Practitioner’s/Provider’s billing information and verification
processes are complete, a representative from either the selected
Clearinghouse and/or Kaiser Permanente’s Regional EDI
Coordinator will contact the Practitioner/Provider to work through
the technical components of electronic claim testing and
submissions.
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Topic
5.17
Electronic
Submission
Process
Instructions
1) Practitioners’/Providers’ EDI Responsibilities:
Once a Practitioner/Provider has entered all of the required data
elements (i.e., all of the required data for a particular claim) into a
computer system, the Practitioner/Provider then electronically
“sends” all of this information to a Clearinghouse for further data
sorting and distribution.
2) Clearinghouse’s EDI Responsibilities:
The Clearinghouse receives information electronically from a
variety of Practitioners and Providers, who have chosen that
particular Clearinghouse as their data sorter and distributor.
The Clearinghouse “batches” all of the information it has received
from the various Practitioners and Providers, sorts the information,
and then electronically “sends” the information to the correct payer
for processing. Data content required by HIPAA Transaction
Implementation Guides is the responsibility of the
Practitioner/Provider and the Clearinghouse. The Clearinghouse
should ensure HIPAA Transaction Set Format compliance with
HIPAA rules.
In addition, Clearinghouses:
•
Frequently supply the required PC software to enable direct
data entry in the Practitioner’s/Provider’s office.
•
Edit the data which is electronically submitted to the
Clearinghouse by the Practitioner’s/Provider’s office, so that
the data submission will be accepted by the appropriate payer
for processing.
•
Transmit the data to the correct payer in a format easily
understood by the payer’s computer system.
•
Transmit electronic claim status reports from payers to
Practitioners/Providers.
3) Kaiser Permanente’s EDI Responsibilities:
Kaiser Permanente receives EDI information after the
Practitioner/Provider sends it to the Clearinghouse for distribution.
The data is loaded into Kaiser Permanente’s computer electronically
and is prepared for further processing.
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KAISER PERMANENTE
Topic
Instructions
On the same business day that Kaiser Permanente receives the EDI
claims, Kaiser Permanente EDI Transaction Solution (KPEDITS)
prepares a 997 electronic acknowledgement which is transmitted
back to the Clearinghouse.
NOTE: If you do not receive Kaiser Permanente’s 997
electronic claim acknowledgements from the Clearinghouse,
contact your billing service or the Clearinghouse and request
that this be routinely forwarded to you.
Additionally, Kaiser Permanente provides a Kaiser Permanente EDI
Transaction Solutions (KP EDITS) Reject Detail Report for those
claims which were rejected by KP EDITS because of “fatal” front-end
errors. Any rejected claims may be re-submitted electronically once
the claims have been corrected by the Practitioner/Provider.
NOTE: See the Claims Status Category and Reason Codes at
http://www.wpc-edi.com for a list of common Insurance
Business Process Application error codes that prevent a claim
from being accepted by Kaiser Permanente.
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Topic
5.18
KP Contracted
Clearinghouses
Instructions
Clearinghouse Payer IDs as of 11/07/2006
Clearing House
Cortex EDI
Emdeon (WebMD, Envoy)
Gateway EDI
MedAvant (ProxyMed)
Medisoft
NDCHealth
Office Ally
Payer Connection
Per Se
RelayHealth
THIN (Thinedi)
Zirmed
Payer IDs as of 11/07/2006
93079
93079
KS007 (837P)
KS007 (837P) or 93079 (837I)
KS007 (837P)
93079 (837P) or 00153 (837I)
93079
KS007 (837P)
93079 (837P)
RH002 (837I and 837P)
KS007 (837P) or 93079 (837I)
Z1059
Providers should access their Clearinghouses to identify the Payer Id for Kaiser Foundation
NW.
PLEASE NOTE: Payer IDs are for both 837I (UB) and 837P (HCFA)
transactions unless otherwise noted. Also, these Payer IDs are only for
Kaiser Foundation Health Plan of the Northwest. If you wish to submit EDI
claims to another Kaiser Permanente region, you must obtain the
appropriate Payer ID from your Clearinghouse or the appropriate region.
5.19 HIPAA
Requirements
All electronic claim submissions must adhere to all HIPAA requirements.
The following websites (listed in alphabetical order) include additional
information on HIPAA and electronic loops and segments. If a Provider
does not have internet access, HIPAA Implementation Guides can be
ordered by calling Washington Publishing Company (WPC) at (301) 9499740.
•
www.dhhs.gov
•
www.wedi.org
•
www.wpc-edi.com
5.20 Clean
Claims
Kaiser Permanente considers a claim ‘clean’ when the following
requirements are met.
Correct Form - Kaiser Permanente requires all professional claims to be
submitted using the CMS Form 1500(8/05) and all facility claims (or
appropriate ancillary services) to be submitted using the CMS Form CMS
1450 (UB04).
Standard Coding – All fields should be completed using industry standard
coding.
Applicable Attachments – Attachments should be included in your
submission when circumstances require additional information.
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KAISER PERMANENTE
Topic
Instructions
Completed Field Elements for CMS Form 1500 (08/05 ) Or CMS 1450 (UB04) – All applicable data elements of CMS forms should be completed.
A claim is not considered to be “Clean” or payable if one or more of the
following are missing or are in dispute:
The standards or format used in the completion or submission of the claim
The eligibility of a person for coverage
The responsibility of another payor for all or part of the claim
The amount of the claim or the amount currently due under the claim
The benefits covered
The manner in which services were accessed or provided
The claim was submitted fraudulently
Note: Failure to include all information will result in a delay in claim
processing and payment and it will be returned for any missing information.
A claim missing any of the required information will not be considered a
clean claim.
5.21 Claims
Submission
Timeframes
5.22 Claims
Processing
Turn-Around
Time
•
•
•
New Claims: 365 Days from Date of Service(DOS)
COB Claims: 365 Days from date of Primary EOP
Self Funded Claims: 120 Days from DOS
Clean Claims:
Please allow 30 days for Kaiser Permanente to process and adjudicate
your claim(s). Claims requiring additional supporting documentation and/or
coordination of benefits may take longer to process.
NOTE: While Kaiser Permanente may require the submission of
specific supporting documentation necessary for benefit determination
(including medical and/or coordination of benefits information), Kaiser
Permanente may have to make a decision on the claim before such
information is received.
A "complete” or “clean" claim is defined as a claim that has no defect or
impropriety, including lack of required substantiating documentation from
providers, suppliers, or Members or particular circumstances requiring
special treatment that prevents timely payments from being made on the
claim.
5.23 Appeal of
Timely Claims
Submission
Resubmitted claims along with proof of initial timely filing received within
365 days of the original date of denial or explanation of payment, will be
allowed for reconsideration of claim processing and payment. Any claim
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Topic
Instructions
resubmissions received for timely filing reconsideration beyond 365 days of
the original date of denial or explanation of payment will be denied as
untimely submitted.
5.24 Proof of
Timely Claims
Submission
Claims submitted for consideration or reconsideration of timely filing must
be reviewed with information that indicates the claim was initially submitted
within the appropriate time frames. Acceptable proof of timely filing may
include the following documentation and/or situations:
Proof or Documentation
Examples
System generated claim copies, account print-outs, or reports that indicate
the original date that claim was submitted, and to which insurance carrier.
*Hand-written or typed documentation is not acceptable proof of timely
filing. Account ledger posting that includes multiple patient submissions
Individual Patient ledger
CMS UB04 or 1500(8/05) with a system generated date or submission.
EDI Transmission report
Reports from a Provider
Clearinghouse (i.e. WebMD)
Lack of member insurance information. Proof of follow-up with member for
lack of insurance or incorrect insurance information.
*Members are responsible for providing current and appropriate insurance
information each time services are rendered by a provider. Copies of
dated letters requesting information, or requesting correct information from
the member.
Original hospital admission sheet or face sheet with incomplete, absent, or
incorrect insurance information.
Any type of demographic sheet collected by the provider from the member
with incomplete, absent, or incorrect insurance information.
5.25 Claim
Adjustments/
Corrections
CMS-1500 (08/05) Claim Forms:
NOTE: Kaiser Permanente prefers corrections to 837P claims which were
already accepted by Kaiser Permanente to be submitted on paper
claim forms. Corrections submitted electronically may inadvertently be
denied as a duplicate claim. Refer to page Error! Bookmark not
defined. within this GUIDE for further information/instructions.
When submitting a corrected CMS-1500 (08/05) paper claim to Kaiser
Permanente for processing:
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KAISER PERMANENTE
Topic
Instructions
1) Write “CORRECTED CLAIM” in the top (blank) portion of the
standard claim form.
2) Attach a copy of the corresponding page of Kaiser Permanente’s
Explanation of Payment (EOP) to each corrected claim, to prevent
these claims from being rejected by Kaiser Permanente as duplicate
claims. Attach with a paper clip.
3) Mail the corrected claim(s) to Kaiser Permanente using the standard
claims mailing address (see page Error! Bookmark not defined. in
this section).
UB-04 Claim Forms (837I):
NOTE: 837I corrections may be submitted electronically.
When submitting a corrected UB-04 claim to Kaiser Permanente for
processing:
Electronic
Include the appropriate Type of Bill code when electronically submitting
a corrected UB-04/837I claim to Kaiser Permanente for processing.
Paper
When submitting a corrected or UB-04 paper claim to Kaiser Permanente
for processing:
1) Include the appropriate Type of Bill code in Field 4.
2) Attach a copy of the corresponding page of Kaiser Permanente’s
Explanation of Payment (EOP) to each corrected claim, to prevent
these claims from being rejected by Kaiser Permanente as duplicate
claims. Attach with a paper clip.
3) Mail the corrected claim(s) to Kaiser Permanente using the standard
claims mailing address (see page Error! Bookmark not defined. in
this section).
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5.26 Incorrect
Claims
Payments
If you receive an incorrect payment (i.e., either an overpayment or an
underpayment), please do one of the following:
Option 1: Do not cash or deposit the incorrect payment check.
• Mail the incorrect payment check back to Kaiser Permanente, along
with a copy of the Explanation of Payment (EOP) and a brief note
explaining the payment error to:
Kaiser Permanente
Claims Administration
500 Multnomah St, Suite 100
Portland, OR 97232-2099
NOTE: If Kaiser Permanente’s EOP is not available, please record the
Member’s Health Record Number and/or Claim Number on the
payment check you are returning.
• Kaiser Permanente will re-issue and mail you a new, corrected
payment check within 30 days.
Option 2: Deposit the incorrect Kaiser Permanente payment check in
your account.
• For an Underpayment Error:
Write or call our Claims Inquiry Unit and explain the error. Upon
verification of the error, appropriate corrections will be made to Kaiser
Permanente’s accounting system and the underpayment amount
owed will be reflected in a Kaiser Permanente reimbursement check
within 30 days.
y For an Overpayment Error: Please do the following:
1) Write a refund check to Kaiser Permanente for the excess amount
paid to you by Kaiser Permanente. Attach a copy of Kaiser
Permanente’s Explanation of Payment to your refund check, as well
as a brief note explaining the error. Attach with a paper clip.
NOTE: If Kaiser Permanente’s EOP is not available, please
record the Member’s Health Record Number on the payment
check you are returning.
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2) Mail your refund check (and brief note) to:
Kaiser Permanente
Claims Administration, Recoveries Unit
500 NE Multnomah St, Suite 100
Portland, OR 97232-2099
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5.27 Rejected
Claims Due to
EDI Claims
Error
5.28 Federal
Tax ID Number
Instructions
Electronic Claim Acknowledgement: Kaiser Permanente sends an
electronic claim acknowledgement to the Clearinghouse. This claims
acknowledgement will be forwarded to you as confirmation of all claims
received by Kaiser Permanente.
NOTE: If you are not receiving Kaiser Permanente’s electronic claim receipt
from the Clearinghouse, contact the Clearinghouse and request that this be
routinely forwarded to you.
The Federal Tax ID Number as reported on any and all claim form(s) must
match the information filed with the Internal Revenue Service (IRS).
1 When completing IRS Form W-9, please note the following:
• Name: This should be the equivalent of your “entity name,”
which you use to file your tax forms with the IRS.
• Sole Provider/Proprietor: List your name, as registered with
the IRS.
• Group Practice/Facility: List your “group” or “facility” name,
as registered with the IRS.
2 Business Name: Leave this field blank, unless you have registered
with the IRS as a “Doing Business As” (DBA) entity. If you are doing
business under a different name, enter that name on the IRS Form
W-9.
3 Address/City, State, Zip Code: Enter the address where Kaiser
Permanente should mail your IRS Form 1099.
4 Taxpayer Identification Number (TIN): The number reported in this
field (either the social security number or the employer identification
number) MUST be used on all claims submitted to Kaiser
Permanente.
• Sole Provider/Proprietor: Enter your taxpayer identification
number, which will usually be your social security number
(SSN), unless you have been assigned a unique employer
identification number (because you are “doing business as”
an entity under a different name).
• Group Practice/Facility: Enter your taxpayer identification
number, which will usually be your unique employer
identification number (EIN).
If you have any questions regarding the proper completion of IRS Form W-
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9, or the correct reporting of your Federal Taxpayer ID Number on your
claim forms, please contact the IRS help line in your area or refer to the
following website:
http://www.irs.gov/formspubs/
Completed IRS Form W-9 should be mailed to the following address:
Kaiser Permanente
<Provider Contracting and Relations
500 NE Multnomah Ste 100
Portland, OR 97232>
5.29 Changes
in Federal Tax
ID Number
If your Federal Tax ID Number should change, please notify us
immediately, so that appropriate corrections can be made to Kaiser
Permanente’s files.
5.30 National
Provider
Identification
(NPI)
The Health Insurance Portability and Accountability Act of 1996 (HIPPA)
mandates that all providers use a standard unique identifier on all electronic
transactions. Your National Provider Identifier (NPI) must be used on all
HIPPA-standard electronic transactions by May 23, 2007.
For additional information regarding the National Provider Identifier (NPI),
how to apply and report please contact the Center for Medicare & Medicaid
Services (CMS) or refer to the following website:
http://www.cms.hhs.gov/NationalProvIdentStand/
5.31 Member
Cost Share
Depending on the benefit plan, Kaiser Permanente Members may be
responsible to share some cost of the services provided. Copayment, coinsurance and deductible (collectively, “Member Cost Share”) are the fees
a Member is responsible to pay a Provider for certain covered services.
This information varies by plan and all Providers are responsible for
collecting Member Cost Share in accordance with Kaiser Permanente
Member’s benefits unless explicitly stated otherwise in your Agreement.
Please verify applicable Member Cost Share at the time of service.
Member Cost Share information can be obtained from:
Member Services at 503-813-2000 or 1-800-813-2000.
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5.32 Member
Claims
Inquiries
Please direct Member to call Member Services at 503-813-2000 or 1-800813-2000
5.33 Visiting
Members
For Visiting Member Claims:
•
All non Medicare claims and claims from Medicare Choice
Members should be submitted directly to Kaiser Permanente for
processing, as per the claims submission instructions set forth
in this Manual.
•
For Medicare claims from Medicare FFS and Medicare Cost
Members, please refer to the section of this Manual that
discusses Coordination of Benefits (COB)
Reimbursement Rates:
•
Providers will be reimbursed for visiting members at the same
rates negotiated for all other Kaiser Permanente Members.
5.34 Coding for It is the Provider’s responsibility to ensure that billing codes used on claims
forms are current and accurate, that codes reflect the services provided and
Claims
they are in compliant with Kaiser Permanente’s coding standards. Incorrect
and invalid coding may result in delays in payment or denial of payment.
5.35 Coding
Standards
Coding – All fields should be completed using industry standard coding as
outlined below.
ICD-9
To code diagnoses and hospital procedures on inpatient claims, use the
International Classification of Diseases- 9th Revision-Clinical Modification
(ICD-9-CM) developed by the Commission on Professional and Hospital
Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or fivedigit codes, depending on the specific disease or injury being described.
Volume 3 hospital inpatient procedure codes appear as two-digit codes and
require a third and/or fourth digit for coding specificity.
CPT-4
The Physicians' Current Procedural Terminology, Fourth Edition (CPT)
code set is a systematic listing and coding of procedures and services
performed by Participating Providers. CPT codes are developed by the
American Medical Association (AMA). Each procedure code or service is
identified with a five-digit code.
If you would like to request a new code or suggest deleting or revising an
existing code, obtain and complete a form from the AMA's Web site at
www.ama-assn.org/ama/pub/category/3112.html or submit your request
and supporting documentation to:
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CPT Editorial Research and Development
American Medical Association
515 North State Street
Chicago IL 60610
HCPCS
The Healthcare Common Procedure Coding System (HCPCS) Level 2
identifies services and supplies. HCPCS Level 2 begin with letters A–V and
are used to bill services such as, home medical equipment, ambulance,
orthotics and prosthetics, drug codes and injections.
Revenue Code
Approved by the Health Services Cost Review Commission for a hospital
located in the State of Maryland, or of the national or state uniform billing
data elements specifications for a hospital not located in that State.
NDC (National Drug Codes)
Prescribed drugs, maintained and distributed by the U.S. Department of
Health and Human Services
ASA (American Society of Anesthesiologists)
Anesthesia services, the codes maintained and distributed by the American
Society of Anesthesiologists
DSM-IV (American Psychiatric Services)
For psychiatric services, codes distributed by the American Psychiatric
Association
5.36 Modifiers
in CPT and
HCPCS
Modifiers submitted with an appropriate procedure code further define
and/or explain a service provided. Valid modifiers and their descriptions can
be found in the most current CPT or HCPCS coding book. Note CMS-1500
Submitters: Kaiser Permanente processes up to four modifiers per claim
line.
When submitting claims, use modifiers to:
•
Identify distinct or independent services performed on the same
day
•
Reflect services provided and documented in a patient's
medical record
Modifiers for Professional and Technical Services
Most commonly used modifiers are:
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Modifier -25
Significant, Separately Identifiable Evaluation and Management Service
by the Same Physician on the Same Day of the Procedure or Other
Service: It may be necessary to indicate that on the day a procedure or
service identified by a CPT code was performed, the patient's condition
required a significant, separately identifiable E/M service above and
beyond the other service provided or beyond the usual preoperative and
postoperative care associated with the procedure that was performed. A
significant, separately identifiable E/M service is defined or substantiated
by documentation that satisfies the relevant criteria for the respective
E/M service to be reported (see Evaluation and Management Services
Guidelines for instructions on determining level of E/M service). The E/M
service may be prompted by the symptom or condition for which the
procedure and/or service was provided. As such, different diagnoses are
not required for reporting of the E/M services on the same date. This
circumstance may be reported by adding modifier 25 to the appropriate
level of E/M service. Note: This modifier is not used to report an E/M
service that resulted in a decision to perform surgery. See modifier 57.
For significant, separately identifiable non-E/M services, see modifier 59.
Modifier -26
Professional Component: Certain procedures are a combination of a
physician component and a technical component. When the physician
component is reported separately, the service may be identified by
adding the modifier '-26' to the usual procedure number.
Modifier -TC
Technical Component - The modifier TC is submitted with a CPT procedure
code to bill for equipment and facility charges, to indicate the technical
component.
• Use with diagnostic tests; e.g. radiation therapy, radiology, and
pulmonary function tests.
• Indicates the Provider performed only the technical component
portion of the service.]
Modifier 50
Bilateral Procedure: Add Modifier 50 to the service line of a unilateral 5digit CPT procedure code to indicate that a bilateral procedure was
performed. Modifier 50 may be used to bill surgical procedures at the same
operative session, or to bill diagnostic and therapeutic procedures that were
performed bilaterally on the same day.
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Modifier 51
Multiple Procedures: Multiple Procedures: When multiple procedures, other
than E/M services, physical medicine and rehabilitation services, or
provision of supplies (eg, vaccines), are performed at the same session by
the same provider, the primary procedure or service may be reported as
listed. The additional procedure(s) or service(s) may be identified by
appending modifier 51 to the additional procedure or service code(s). Note:
This modifier should not be appended to designated "add-on" codes.
Modifier 52
Reduced Services: Under certain circumstances a service or procedure
is partially reduced or eliminated at the physician's discretion. Under
these circumstances the service provided can be identified by its usual
procedure number and the addition of the modifier '-52', signifying that
the service is reduced. This provides a means of reporting reduced
services without disturbing the identification of the basic service. Note:
For hospital outpatient reporting of a previously scheduled
procedure/service that is partially reduced or cancelled as a result of
extenuating circumstances or those that threaten the well-being of the
patient prior to or after administration of anesthesia, see modifiers '-73'
and '-74' (see modifiers approved for ASC hospital outpatient use).
Modifier 57
Decision for Surgery: An evaluation and management service that
resulted in the initial decision to perform the surgery may be identified by
adding the modifier '-57' to the appropriate level of E/M service.
Modifier 59
Distinct Procedural Service: Distinct Procedural Service: Under certain
circumstances, it may be necessary to indicate that a procedure or
service was distinct or independent from other non-E/M services
performed on the same day. Modifier 59 is used to identify procedures or
services, other than E/M services, that are not normally reported
together but are appropriate under the circumstances. Documentation
must support a different session, different procedure or surgery, different
site or organ system, separate incision or excision, separate lesion, or
separate injury (or area of injury in extensive injuries) not ordinarily
encountered or performed on the same day by the same individual.
However, when another already established modifier is appropriate it
should be used rather than modifier 59. Only if no more descriptive
modifier is available and the use of modifier 59 best explains the
circumstances should modifier 59 be used. Note: Modifier 59 should not
be appended to an E/M service. To report a separate and distinct E/M
service with a non-E/M service performed on the same date, see
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modifier 25.
Modifier 62
Two Surgeons: When two surgeons work together as primary surgeons
performing distinct part(s) of a procedure, each surgeon should report
his/her distinct operative work by adding the modifier '-62' to the
procedure code and any associated add-on code(s) for that procedure
as long as both surgeons continue to work together as primary surgeons.
Each surgeon should report the co-surgery once using the same
procedure code. If additional procedure(s) (including add-on
procedure(s) are performed during the same surgical session, separate
code(s) may also be reported with the modifier '-62' added. Note: If a cosurgeon acts as an assistant in the performance of additional
procedure(s) during the same surgical session, those services may be
reported using separate procedure code(s) with the modifier '-80' or
modifier '-82' added, as appropriate.
Modifier 76
Repeat Procedure or Service by Same Physician: Repeat Procedure or
Service by Same Physician: It may be necessary to indicate that a
procedure or service was repeated subsequent to the original procedure
or service. This circumstance may be reported by adding modifier 76 to
the repeated procedure or service
Modifier 78
Return to the Operating Room for a Related Procedure During the
Postoperative Period: Unplanned Return to the Operating/Procedure
Room by the Same Physician Following Initial Procedure for a Related
Procedure During the Postoperative Period: It may be necessary to
indicate that another procedure was performed during the postoperative
period of the initial procedure (unplanned procedure following initial
procedure). When this procedure is related to the first and requires the
use of an operating or procedure room, it may be reported by adding
modifier 78 to the related procedure. (For repeat procedures, see
modifier 76.)
This list is not all-inclusive.
Durable Medical Equipment (DME) Modifiers
NU= new equipment
RP= replacement and repair
RR= Rental of DME equipment
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5.37 Modifier
Review
Kaiser Permanente reserves the right to review use of modifiers to ensure
accuracy and appropriateness, to include review of supporting
documentation. Improper use of modifiers may cause claims to pend and/or
be returned for correction. Documentation may be requested from various
units within the claims department.
5.38 Coding &
Billing
Validation
Kaiser Permanente uses code editing software from third party vendors to
assist in determining the appropriate handling and reimbursement of
claims. Currently, Kaiser Permanente has selected IntelliClaim as our
claim editing source, which in turn uses software from McKesson and
McKesson Knowledgebase. From time to time, Kaiser Permanente may
change this coding editor or the specific rules that it uses in analyzing
claims submissions. Kaiser Permanente’s goal is to help ensure the
accuracy of claims payments.
IntelliClaim is a code editor software application designed to evaluate
professional claims data including HCPCS and CPT codes as well as
associated modifiers. IntelliClaim is a rule-based application; some of
these rules have been chosen to meet Kaiser Permanente’s goals of
increased accuracy in claims payment.
IntelliClaim assists Kaiser Permanente in identifying various categories of
claims coding and possible inconsistencies. Claims with coding
errors/inconsistencies are pended to the Claim Review staff for manual
review. Each claim is validated against Kaiser Permanente’s payment
criteria, and then is subsequently released for processing. This process
has a goal of improving the accuracy of coding and consistency in claims
payment procedures.
In order to help illustrate how this process works, examples have been
provided where appropriate. If you have questions about the application of
these rules, please contact our Claims Inquiry Unit.
5.39 Coding
Edit Rules
An example of the Coding Edit Rules is provided below. Please see
Appendix A for entire listing of Rules.
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5.40 Medical
Claims Review
Major Categories of Claim Coding Errors/Inconsistencies
Procedure Unbundling
Definition: Procedure unbundling occurs when two or more procedure
codes are used to describe a procedure performed, when a single – more
comprehensive –procedure code exists that accurately describes the entire
procedure performed.
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[Example 1: Laboratory unbundling occurs when certain laboratory tests are
billed separately when a pre-defined panel exists that contains all of the
individual tests billed. These tests should NOT be billed separately, but
should be billed using ONE panel code.
Example 2: Billing the following 2 codes together is considered
“unbundling.”
93005 Electrocardiogram, routine ECG with at least 12 leads; tracing
only, without interpretation and report
93010 Electrocardiogram, routine ECG with at least 12 leads;
interpretation and report only.
When 93005 and 93010 are performed on the same day the
appropriate comprehensive procedure code would be 93000.]
Incidental Procedures
Definition: An incidental procedure is typically performed at the same time
as a more complex primary procedure. However, the incidental procedure
requires little additional physician resources, and/or is clinically integral to
the performance of the primary procedure. Therefore, incidental procedures
are NOT reimbursed separately.
Appendectomy with other abdominal procedures is not billable when the
appendix was removed solely for incidental reasons, in other words, since
the surgeon was in the abdominal cavity he removed the appendix.
Separate Procedures
Definition: Procedures designated as a “separate procedure” in the CPT
code book are commonly performed as an integral part of a total, larger
procedure, and normally do NOT warrant separate identification. Therefore,
these services are typically included as part of the “global” charges
submitted for the related, larger procedure.
However, when the procedure is performed as a separate, independent
service not in conjunction with any normally related procedure it may be
billed as a “separate procedure.” If the procedure is performed alone for a
specific purpose, it may be eligible for separate reimbursement.
Tracheotomy performed in an emergent situation is warranted for separate
reimbursement. Yet, tracheotomy performed to create a permanent
tracheostomy is part of the larger procedure.
Mutually Exclusive Procedures
Definition: Mutually exclusive procedures are two or more procedures that
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are usually NOT performed at the same operative session on the same
patient on the same date of service. Mutually exclusive rules may also
include different procedure code descriptions for the same type of
procedure(s), for which the physician should be submitting only ONE of the
procedure codes.
An example of a mutually exclusive situation is when the repair of an organ
can be performed by two different methods. One repair method must be
chosen to repair the organ and must be reported.
A second example is the reporting of an “initial” service and a “subsequent”
service. It is contradictory for a service to be classified as an initial and a
subsequent service at the same time.
CPT codes that are mutually exclusive of one another based either on the
CPT definition or the medical impossibility/improbability that the procedures
could be performed at the same session can be identified as code pairs.
Age and Gender (Sex) Conflicts
Definition: An age conflict occurs when the Provider bills an age-specific
procedure code for a patient outside of the designated age range. Similarly,
a gender conflict occurs when a gender-specific procedure is assigned to a
patient of the opposite gender.
[Example 1: The Provider assigns the code for surgical opening of the
stomach, for newborns (43831), to a 45-year-old patient.
Example 2: Code 58150 Total abdominal hysterectomy is submitted for a
male patient. Exception: Initial Newborn Care (99431, 99432, 99435) are
payable under the mother’s contract and are excluded from the age
processing rules.
The following age categories are examined for conflicts:
• Newborn (age less than 1 year old)
• Pediatric (age 1-17 years old)
• Maternity (age 12-55 years old)
• Adult (age over 14 years old)]
Obsolete/Deleted Codes
Claims submitted with obsolete or deleted codes may be denied. Obsolete
or deleted codes are updated each calendar year and will be end dated as
specified by CMS. Kaiser Permanente does not pay against deleted codes
following the end date.
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Example: An old code is deleted effective 12/31/2007 and a replacement
code is in effect on 01/01/2008. If the provider bills with the deleted code in
2008, that procedure will be denied.
Multiple/ Duplicate Component Billing
When procedures are billable for professional and technical components
(i.e. with modifiers 26 and TC), Kaiser Permanente monitors that the total
amount paid for the service does not exceed what would have been paid if
the procedure had been billed without the modifier(s). Kaiser Permanente
reserves the right to adjust claims that are paid in excess of the total.
Example: 71020-26 (Interpretation and report of chest x-ray) billed by
provider A and 71020 billed by provider B for the same patient same day.
Since 71020 encompasses both the technical and the professional
component of the chest x-ray, claim from provider A could be denied as a
partial duplicate unless supported by documentation or another supporting
modifier
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5.41 Other
Party Liability
(OPL)
Other Party Liability (OPL) is a way of determining the order in which
benefits are paid and the amounts which are payable when a claimant is
covered under more than one plan (individual or group). It is intended to
prevent duplication of benefits when an individual is covered by multiple
plans or payers providing benefits or services for medical, dental or other
care and treatment. Other Party Liability includes Coordination of Benefits
(COB), Third Party Liability (TPL), Worker’s Compensation (WC), TRICARE
(also known as Champus), Medicare Primary and dual coverage.
Kaiser Permanente follows the National Association of Insurance
Commissioners (NAIC) model regulations for coordinating benefits, except
in those instances where the NAIC model regulations differ from Oregon or
Washington state law, state law supersedes the NAIC model regulations.
If you have any questions relating to the coordination of benefits, please
call the appropriate number listed below for assistance.
COB Local Telephone #: (503) 813-4332
COB Toll-Free Telephone #: (888) 454-4332
TPL Local Telephone #: (503) 813-2703
TPL Toll-Free Telephone #: (866) 374-0929
Worker’s Compensation, TRICARE & Medicare Primary Local
Telephone #:
(503) 735-2727
Worker’s Compensation, TRICARE & Medicare Primary Toll-Free
Telephone #:
(866) 441-1221
5.42 Workers’
Compensation
If you have questions, please call 503-735-2727 or 1-866-441-1221
5.43 Provider If your office/facility has questions or concerns about the way a particular
Claims Appeals claim was processed by Kaiser Permanente, please contact our Claims
Inquiry Unit at 503-732-2727. Many questions and issues regarding claim
payments, coding, and submission policies can be resolved quickly over the
phone or via fax.
If your issue cannot be resolved through this initial contact, you will be
instructed as follows:
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Provider Claim Payment Appeals Process:
If your concern is determined to be a claim payment appeals issue, you will
be advised to submit your concern in writing to:
Kaiser Permanente Provider Appeals
Provider Contracting and Relations
500 NE Multnomah Blvd Ste 100
Portland, OR 97232
503-813-3376
503-813-2017 Fax
Please note that all claim payment appeal requests must be filed within 365
days of the date the claim was originally processed or denied, in order to be
considered for payment by Kaiser Permanente.
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5.44 CMS-1500 (08/05) FIELD DESCRIPTIONS
The fields identified in the table below as “Required” must be completed when submitting a
CMS-1500 (08/05) claim form to Kaiser Permanente for processing:
Note: The required fields for submission shown below are required by Kaiser Permanente but
not necessarily required by CMS or other payers. For Medicare Members, please refer to
Medicare Billing Requirements for appropriate field requirements and instructions/examples.
Note: The new CMS-1500 (08/05) form is revised to accommodate National Provider
Identifiers (NPI). Kaiser currently accepts both forms.
FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
1
MEDICARE/ MEDICAID/
TRICARE CHAMPUS/
CHAMPVA/ GROUP HEALTH
PLAN/FECA BLK LUNG/OTHER
Not Required
Check the type of health insurance
coverage applicable to this claim by
checking the appropriate box.
1a
INSURED’S I.D. NUMBER
Required
2
PATIENT’S NAME
Required
Enter the subscriber’s plan identification
number.
Enter the patient’s name. When submitting
newborn claims, enter the newborn’s first
and last name.
3
PATIENT'S BIRTH DATE AND
SEX
Required
Enter the patient’s date of birth and gender. The date of
birth must include the month, day and FOUR DIGITS for
the year (MM/DD/YYYY). Example: 01/05/2008
4
INSURED'S NAME
Required
Enter the name of the insured (Last Name, First Name,
and Middle Initial), unless the insured and the patient are
the same—then the word “SAME” may be entered.
5
PATIENT'S ADDRESS
Required
Enter the patient’s mailing address and telephone
number. On the first line, enter the STREET ADDRESS;
the second line is for the CITY and STATE; the third line
is for the ZIP CODE and PHONE NUMBER.
6
PATIENT'S RELATIONSHIP TO
INSURED
Check the appropriate box for the patient’s
relationship to the insured.
7
INSURED'S ADDRESS
Required
if Applicable
Required
if Applicable
8
PATIENT STATUS
Required
if Applicable
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Enter the insured’s address (STREET ADDRESS, CITY,
STATE, and ZIP CODE) and telephone number. When
the address is the same as the patient’s—the word
“SAME” may be entered.
Check the appropriate box for the patient’s
MARITAL STATUS, and check whether
the patient is EMPLOYED or is a
STUDENT.
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FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
9
OTHER INSURED'S NAME
Required
if Applicable
When additional insurance coverage exists, enter the
last name, first name and middle initial of the insured.
9a
OTHER INSURED’S POLICY OR
GROUP NUMBER
Required
if Applicable
Enter the policy and/or group number of the insured
individual named in Field 9 (Other Insured’s
Required
if Applicable
Enter the “other” insured’s date of birth and sex. The
date of birth must include the month, day, and FOUR
DIGITS for year (MM/DD/YYYY). Example:
9b
OTHER INSURED’S DATE OF
BIRTH/SEX
Name) above. NOTE: For each entry in
Field 9A, there must be a corresponding
entry in Field 9d.
01/05/2008
9c
9d
10a-c
EMPLOYER”S NAME OR
SCHOOL NAME
Required
INSURANCE PLAN NAME OR
PROGRAM NAME
Required
IS PATIENT CONDITION
RELATED TO
Required
if Applicable
if Applicable
Enter the name of the “other” insured’s EMPLOYER or
SCHOOL NAME (if a student).
Enter the name of the “other” insured’s
INSURANCE PLAN or program.
Check “Yes” or “No” to indicate whether
employment, auto liability, or other accident
involvement applies to one or more of the services
described in field 24.
NOTE: If “yes” there must be a
corresponding entry in Field 14 (Date of
Current Illness/Injury).
Place (State) - enter the State postal code.
10d
RESERVED FOR LOCAL USE
Not Required
Leave blank.
11
INSURED’S POLICY NUMBER
OR FECA NUMBER
Not Required
If there is insurance primary to Medicare, enter the
insured’s policy or group number.
11a
INSURED’S DATE OF BIRTH
Not Required
Enter the insured’s date of birth and sex, if
different from Field 3. The date of birth
must include the month, day, and FOUR
digits for the year (MM/DD/YYYY).
Example: 01/05/2008
11b
EMPLOYER’S NAME OR
SCHOOL NAME
Not Required
Enter the name of the employer or school
(if a student), if applicable.
11c
INSURANCE PLAN OR
PROGRAM NAME
Not Required
Enter the insurance plan or program
name.
11d
IS THERE ANOTHER HEALTH
BENEFIT PLAN?
Required
Check “yes” or “no” to indicate if there is
another health benefit plan. For example,
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
37
KAISER PERMANENTE
FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
the patient may be covered under
insurance held by a spouse, parent, or
some other person.
If “yes” then fields 9 and 9a-d must be
completed.
12
PATIENT'S OR AUTHORIZED
PERSON'S SIGNATURE
Not Required
Have the patient or an authorized
representative SIGN and DATE this block,
unless the signature is on file. If the
patient’s representative signs, then the
relationship to the patient must be
indicated.
13
INSURED'S OR AUTHORIZED
PERSON'S SIGNATURE
Not Required
Have the patient or an authorized
representative SIGN this block, unless the
signature is on file.
14
DATE OF CURRENT ILLNESS,
INJURY, PREGNANCY
Required
if Applicable
Enter the date of the current illness or injury. If
pregnancy, enter the date of the patient’s last menstrual
period. The date must include the month, day, and
FOUR DIGITS for the year (MM/DD/YYYY).
Example: 01/05/2008
15
IF PATIENT HAS HAD SAME OR
SIMILAR ILLNESS
Not Required
Enter the previous date the patient had a
similar illness, if applicable. The date
must include the month, day, and FOUR
DIGITS for the year (MM/DD/YYYY).
Example: 01/05/2008
16
DATES PATIENT UNABLE TO
WORK IN CURRENT
OCCUPATION
Not Required
Enter the “from” and “to” dates that the
patient is unable to work. The dates must
include the month, day, and FOUR
DIGITS for the year (MM/DD/YYYY).
Example: 01/05/2008
17
NAME OF REFERRING
PHYSICIAN OR OTHER
SOURCE
OTHER ID #
Required
if Applicable
Not Required
Enter the FIRST and LAST NAME of the
referring or ordering physician.
17a
Kaiser Permanente Provider Manual
2009
In the shaded area, enter the non-NPI ID number of the
physician whose name is listed in Field 17. Enter the
qualifier identifying the number in the field to the right of
17a. The NUCC defines the following qualifiers:
0B - State License Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
Section 5: Billing and Payment
38
KAISER PERMANENTE
FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
1H - CHAMPUS Identification Number
EI - Employer’s Identification Number
G2 - Provider Commercial Number
LU - Location Number
N5 - Provider Plan Network Identification
Number
SY - Social Security Number
X5 - State Industrial Accident Provider Number
ZZ - Provider Taxonomy
17b
NPI NUMBER
Required
In the non-shaded area enter the NPI
number of the referring provider
18
HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
Not Required
Complete this block when a medical
service is furnished as a result of, or
subsequent to, a related hospitalization.
19
RESERVED FOR LOCAL USE
Required
if Applicable
If you are “covering” for another physician,
enter the name of the physician (for whom
you are covering) in this field.
If a non-contracting Provider/Provider will be covering
for you in your absence, please notify that individual of
this requirement.
20
OUTSIDE LAB CHARGES
21
DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
22
MEDICAID RESUBMISSION
Not Required
23
PRIOR AUTHORIZATION
NUMBER
Required
if Applicable
Enter the prior authorization number for
those procedures requiring prior approval.
SUPPLEMENTAL INFORMATION
Required
Supplemental information can only be entered with a
corresponding, completed service line.
24a-g
Not Required
Required
SUPPLEMENTAL
INFORMATION, con’t.
Enter the diagnosis/condition of the
patient, indicated by an ICD-9-CM code
number. Enter up to 4 diagnostic codes,
in PRIORITY order (primary, secondary
condition).
The top area of the six service lines is shaded and is the
location for reporting supplemental information. It is not
intended to allow the billing of 12 lines of service.
When reporting additional anesthesia services
information (e.g., begin and end times), narrative
description of an unspecified code, NDC, VP – HIBCC
codes, OZ – GTIN codes or contract rate, enter the
applicable qualifier and number/code/information starting
with the first space in the shaded line of this field. Do not
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
39
KAISER PERMANENTE
FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
enter a space, hyphen, or other separator between the
qualifier and the number/code/information.
The following qualifiers are to be used when reporting
these services.
7 - Anesthesia information
ZZ - Narrative description of unspecified code
N4 - National Drug Codes (NDC)
VP - Vendor Product Number Health Industry Business
Communications Council (HIBCC) Labeling Standard
OZ - Product Number Health Care Uniform Code
Council – Global Trade Item Number (GTIN)
CTR - Contract rate
24a
DATE(S) OF SERVICE
Required
Enter the month, day, and year
(MM/DD/YY) for each procedure, service,
or supply. Services must be entered
chronologically (starting with the oldest
date first).
For each service date listed/billed, the
following fields must also be entered:
Units, Charges/Amount/Fee, Place of
Service, Procedure Code, and
corresponding Diagnosis Code.
IMPORTANT: Do not submit a claim with
a future date of service. Claims can only
be submitted once the service has been
rendered (for example: durable medical
equipment).
24b
PLACE OF SERVICE
Required
Enter the place of service code for each
item used or service performed.
24c
EMG
Not Required
Enter Y for "YES" or leave blank if "NO" to indicate an
EMERGENCY as defined in the electronic 837
Professional 4010A1 implementation guide.
24d
PROCEDURES, SERVICES, OR
SUPPLIES: CPT/HCPCS,
MODIFIER
Required
Enter the CPT/HCPCS codes and MODIFIERS (if
applicable) reflecting the procedures performed, services
rendered, or supplies used.
IMPORTANT: Enter the anesthesia time, reported
as the “beginning” and “end” times of anesthesia in
military time above the appropriate procedure code.
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
40
KAISER PERMANENTE
FIELD
NUMBER
24e
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
DIAGNOSIS POINTER
Required
INSTRUCTIONS/EXAMPLES
Enter the diagnosis code reference number
(pointer) as it relates the date of service and the
procedures shown in Field 21, When multiple services
are performed, the primary reference number for each
service should be listed first, and other applicable
services should follow. The reference number(s) should
be a 1, or a 2, or a 3, or a 4; or multiple numbers as
explained.
IMPORTANT: (ICD-9-CM diagnosis codes must be
entered in Item Number 21 only. Do not enter them in
24E.)
24f
24g
$ CHARGES
DAYS OR UNITS
Required
Required
Enter the FULL CHARGE for each listed service.
Any necessary payment reductions will be made during
claims adjudication (for example, multiple surgery
reductions, maximum allowable limitations, co-pays etc).
Do not use commas when reporting dollar amounts.
Negative dollar amounts are not allowed. Dollar signs
should not be entered. Enter 00 in the cents area if the
amount is a whole number.
Enter the number of days or units in this block. (For
example: units of supplies, etc.)
When entering the NDC units in addition to the HCPCS
units, enter the applicable NDC ‘units’ qualifier and
related units in the shaded line. The following qualifiers
are to be used:
F2 - International Unit
ML - Milliliter
GR - Gram UN Unit
24h
EPSDT FAMILY PLAN
Not Required
24i
ID. QUAL
Required
Kaiser Permanente Provider Manual
2009
Enter in the shaded area of 24I the qualifier identifying if
the number is a non-NPI. The Other ID# of the rendering
provider is reported in 24J in the shaded area. The
NUCC defines the following qualifiers:
0B - State License Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
1H - CHAMPUS Identification Number
EI - Employer’s Identification Number
G2 - Provider Commercial Number
LU - Location Number
N5 - Provider Plan Network Identification Number
SY - Social Security Number (The social security number
may not be used for Medicare.)
X5 - State Industrial Accident Provider Number
ZZ - Provider Taxonomy
Section 5: Billing and Payment
41
KAISER PERMANENTE
FIELD
NUMBER
24j
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
RENDERING PROVIDER ID #
Required
INSTRUCTIONS/EXAMPLES
Enter the non-NPI ID number in the shaded area of the
field. Enter the NPI number in the non-shaded area of
the field.
Report the Identification Number in Items 24I and 24J
only when different from data recorded in items 33a and
33b.
25
FEDERAL TAX ID NUMBER
Required
Enter the physician/supplier federal tax
I.D. number or
Social Security number. Enter an X in the appropriate
box to indicate which number is being reported. Only one
box can be marked.
IMPORTANT: The Federal Tax ID
Number in this field must match the
information on file with the IRS.
26
PATIENT'S ACCOUNT NO.
Required
Enter the Members account number assigned by the
Provider’s/provider’s accounting system.
IMPORTANT: This field aids in patient identification
by the Provider/Provider.
27
ACCEPT ASSIGNMENT
Not Required
28
TOTAL CHARGE
Required
Enter the total charges for the services rendered (total of
all the charges listed in Field 24f).
29
AMOUNT PAID
Required
if Applicable
Enter the amount paid (i.e., Member copayments or
other insurance payments) to date in this field for the
services billed.
30
BALANCE DUE
Not Required
Enter the balance due (total charges less amount paid).
31
SIGNATURE OF PHYSICIAN OR
SUPPLIER INCLUDING
DEGREES OR CREDENTIALS
Required
Enter the signature of the physician/supplier or his/her
representative, and the date the form was signed.
For claims submitted electronically, include a computer
printed name as the signature of the health care Provider
or person entitled to reimbursement.
32
SERVICE FACILITY LOCATION
INFORMATION
Required
if Applicable
The name and address of the facility where services
were rendered (if other than patient’s home or
physician’s office).
Enter the name and address information in the following
format:
1st Line – Name
2nd Line – Address
3rd Line – City, State and Zip Code
Do not use commas, periods, or other punctuation in the
address (e.g., “123 N Main Street 101” instead of “123 N.
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
42
KAISER PERMANENTE
FIELD
NUMBER
REQUIRED FIELDS
FOR CLAIM
SUBMISSIONS
FIELD NAME
INSTRUCTIONS/EXAMPLES
Main Street, #101”). Enter a space between town name
and state code; do not include a comma. When entering
a 9 digit zip code, include the hyphen.
32a
NPI #
Required
Enter the NPI number of the service facility.
32b
OTHER ID #
Required
Enter the two digit qualifier identifying the non-NPI
number followed by the ID number. Do not enter a
space, hyphen, or other separator between the qualifier
and number.
33
Required
33a
BILLING PROVIDER
INFO & PH #
NPI #
Enter the name, address and phone number of the billing
entity.
Enter the NPI number of the service facility location in
32a.
33b
OTHER ID #
Required
Required
Kaiser Permanente Provider Manual
2009
Enter the two digit qualifier identifying the non-NPI
number followed by the ID number. Do not enter a
space, hyphen, or other separator between the qualifier
and number.
Section 5: Billing and Payment
43
KAISER PERMANENTE
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
44
KAISER PERMANENTE
5.45 CMS-1450 (UB-04) FIELD DESCRIPTIONS
The fields identified in the table below as “Required” must be completed when submitting a
CMS-1450 (UB-04) claim form to Kaiser Permanente for processing:
Please Note: The fields required for submission below are required by Kaiser Permanente
but not necessarily by CMS or other payers. For Medicare members, please refer to
Medicare’s billing requirements for appropriate field requirements and instructions or
examples.
FIELD
NUMBER
FIELD NAME
REQUIRED FIELDS
FOR CLAIM
INSTRUCTIONS/EXAMPLES
SUBMISSIONS
1
PROVIDER NAME and
ADDRESS
Required
Enter the name and address of the hospital or person who
rendered the services being billed.
2
PAY-TO NAME,
ADDRESS,
CITY/STATE, ID #
Required
Enter the name and address of the hospital or person to
receive the reimbursement.
3a
PATIENT CONTROL
NUMBER
Required
Enter the member’s control number.
IMPORTANT: This field aids in patient identification by
the Provider/Provider.
3b
MEDICAL RECORD
NUMBER
Not Required
Enter the number assigned to the patient’s medical/health
record by the provider.
4
TYPE OF BILL
Required
Enter the appropriate code to identify the
specific type of bill being submitted. This
code is required for the correct identification
of inpatient vs. outpatient claims, voids, etc.
5
FEDERAL TAX
NUMBER
Required
Enter the federal tax ID of the hospital or person entitled to
reimbursement.
6
STATEMENT COVERS
PERIOD
Required
Enter the beginning and ending date of service included in
the claim.
7
BLANK
Not Required
Leave blank.
8
PATIENT NAME
Required
Enter the member’s name.
9
PATIENT ADDRESS
Required
Enter the member’s address.
10
PATIENT BIRTH DATE
Required
Enter the member’s birth date.
11
PATIENT SEX
Required
Enter the member’s gender.
12
ADMISSION DATE
Required
For inpatient claims only, enter the date of admission.
13
ADMISSION HOUR
Required
For either inpatient OR outpatient care, enter
the 2-digit code for the hour during which the
member was admitted or seen.
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
45
KAISER PERMANENTE
FIELD
NUMBER
FIELD NAME
REQUIRED FIELDS
FOR CLAIM
INSTRUCTIONS/EXAMPLES
SUBMISSIONS
14
ADMISSION TYPE
Required
Indicate the type of admission (e.g. emergency, urgent,
elective, and newborn).
15
ADMISSION SOURCE
Required
Enter the source of the admission type code.
16
DISCHARGE HOUR
(DHR)
Required if
Applicable
Enter the two-digit code for the hour during which the
member was discharged.
17
PATIENT STATUS
Required
Enter the discharge status code.
CONDITION CODES
Required if
Applicable
Enter any applicable codes which identify
conditions relating to the claim that may affect
claims processing.
29
ACCIDENT (ACDT)
STATE
Not Required
Enter the two-character code indicating the state in which the
accident occurred which necessitated medical treatment.
30
BLANK
Not Required
Leave blank.
31-34
OCCURRENCE CODES
AND DATES
Required if
Applicable
Enter the code and the associated date
defining a significant event relating to this bill
that may affect claims processing.
35-36
OCCURRENCE SPAN
CODES AND DATES
Required if
Applicable
Enter the occurrence span code and associated dates
defining a significant event relating to this bill that may affect
claims processing.
37
BLANK
Not Required
Leave blank.
38
RESPONSIBLE PARTY
Not Required
Enter the responsible party name and address.
VALUE CODES and
AMOUNT
Required if
Applicable
Enter the code and related amount/value
which is necessary to process the claim.
42
REVENUE CODE
Required
Identify the specific accommodation, ancillary
service, or billing calculation, by assigning an
appropriate revenue code.
43
REVENUE
DESCRIPTION
Not Required
Enter the revenue description.
44
PROCEDURE CODE
AND MODIFIER
Required
For ALL outpatient claims, enter BOTH a
revenue code in Field 42 (Rev. CD.), and the
corresponding CPT/HCPCS procedure code
in this field.
18-28
39-41
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
46
KAISER PERMANENTE
FIELD
NUMBER
45
FIELD NAME
SERVICE DATE
REQUIRED FIELDS
FOR CLAIM
INSTRUCTIONS/EXAMPLES
SUBMISSIONS
Required
Outpatient Series Bills:
A service date must be entered for all
outpatient series bills whenever the “from”
and “through” dates in Field 6 (Statement
Covers Period: From/Through) are not the
same. Submissions that are received without
the required service date(s) will be rejected
with a request for itemization.
Multiple/Different Dates of Service:
Multiple/different dates of service can be
listed on ONE claim form. List each date on a
separate line on the form, along with the
corresponding revenue code (Field 42),
procedure code (Field 44), and total charges
(Field 47).
46
UNITS OF SERVICE
Required
The units of service.
47
TOTAL CHARGES
Required
Indicate the total charges pertaining to the
related revenue code for the current billing
period, as listed in Field 6.
49
BLANK
Not Required
Leave blank.
48
NON COVERED
CHARGES
Not Required
Enter any non-covered charges.
50
PAYER NAME
Required
Enter (in appropriate ORDER on lines A, B,
and C) the NAME and NUMBER of each
payer organization from whom you are
expecting payment towards the claim.
51
HEALTH PLAN ID
Required
Enter the provider number.
52
RELEASE OF
INFORMATION (RLS
INFO)
Not Required
Enter the release of information certification number
53
ASSIGNMENT OF
BENEFITS (ASG BEN)
Required if
Applicable
Enter the assignment of benefits certification number.
PRIOR PAYMENTS
Required if
Applicable
If payment has already been received toward
the claim by one of the payers listed in Field
50 (Payer) prior to the billing date, enter the
amounts here.
ESTIMATED AMOUNT
DUE
Not Required
Enter the estimated amount due.
54a-c
55
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
47
KAISER PERMANENTE
FIELD
NUMBER
FIELD NAME
REQUIRED FIELDS
FOR CLAIM
INSTRUCTIONS/EXAMPLES
SUBMISSIONS
56
NATIONAL PROVIDER
IDENTIFIER (NPI)
Required
Enter the service provider’s National Provider Identifier (NPI).
57
OTHER PROVIDER ID
Required
Enter the service provider’s Kaiser-assigned provider ID.
58
INSURED’S NAME
Required
Enter the subscriber’s name.
59
PATIENT’S RELATION
TO INSURED
Required if
Applicable
Enter the member’s relationship to the subscriber.
60
INSURED’S UNIQUE ID
Required
Enter the insured person’s unique individual
member identification number (medical/health
record number), as assigned by Kaiser.
61
INSURED’S GROUP
NAME
Required if
Applicable
Enter the insured’s group name.
62
INSURED’S GROUP
NUMBER
Required if
Applicable
Enter the insured’s group number as shown on the
identification card. For Prepaid Services claims enter "PPS".
63
TREATMENT
AUTHORIZATION
CODE
Required if
Applicable
For ALL inpatient and outpatient claims, enter
the referral number.
64
DOCUMENT CONTROL
NUMBER
Not Required
Enter the document control number related to the member or
the claim.
65
EMPLOYER NAME
Required if
Applicable
Enter the employer’s name.
66
DX VERSION
QUALIFIER
Not Required
Indicate the type of diagnosis codes being reported.
Note: At the time of printing, Kaiser only accepts ICD-9-CM
diagnosis codes on the UB-04.
PRINCIPAL DIAGNOSIS
CODE
Required
Enter the principal diagnosis code, on all
inpatient and outpatient claims.
OTHER DIAGNOSES
CODES
Required if
Applicable
Enter other diagnoses codes corresponding to additional
conditions. Diagnosis codes must be carried to their highest
degree of detail.
68
BLANK
Not Required
Leave blank.
69
ADMITTING
DIAGNOSIS
Required
Enter the admitting diagnosis code on all inpatient claims.
REASON FOR VISIT
(PATIENT REASON DX)
Not Required
Enter the diagnosis codes indicating the patient’s reason for
outpatient visit at the time of registration.
PPS CODE
Required if
Applicable
Enter the DRG number which the procedures
group, even if you are being reimbursed
under a different payment methodology.
67
67 A-Q
70
(a-c)
71
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2009
Section 5: Billing and Payment
48
KAISER PERMANENTE
FIELD
NUMBER
FIELD NAME
REQUIRED FIELDS
FOR CLAIM
INSTRUCTIONS/EXAMPLES
SUBMISSIONS
72
EXTERNAL CAUSE OF
INJURY CODE (ECI)
Required if
Applicable
Enter an ICD-9-CM “E-code” in this field (if
73
BLANK
Not required
Leave blank.
74
PRINCIPAL
PROCEDURE CODE
AND DATE
Required if
Applicable
Enter the ICD-9-CM procedure CODE and
DATE on all inpatient AND outpatient claims
for the principal surgical and/or obstetrical
procedure which was performed (if
applicable).
OTHER PROCEDURE
CODES AND DATES
Required if
Applicable
Enter other ICD-9-CM procedure CODE(S)
and DATE(S) on all inpatient AND outpatient
claims (in fields “A” through “E”) for any
additional surgical and/or obstetrical
procedures which were performed (if
applicable).
75
BLANK
Not required
Leave blank.
76
ATTENDING
PHYSICIAN / NPI /
QUAL / ID
Required
Enter the National Provider Identifier (NPI) and the name of
the attending physician for inpatient bills or the physician that
requested the outpatient services.
74
(a–e)
applicable).
Inpatient Claims—Attending Physician
Enter the full name (first and last name) of the
physician who is responsible for the care of
the patient.
Outpatient Claims—Referring Physician
For ALL outpatient claims, enter the full name
(first and last name) of the physician who
referred the Member for the outpatient
services billed on the claim.
77
OPERATING
PHYSICIAN / NPI/
QUAL/ ID
Required If
Applicable
Enter the National Provider Identifier (NPI) and the name of
the lead surgeon who performed the surgical procedure.
OTHER PHYSICIAN/
NPI/ QUAL/ ID
Required if
Applicable
Enter the National Provider Identifier (NPI) and name of any
other physicians.
80
REMARKS
Not Required
Special annotations may be entered in this
field.
81
CODE-CODE
Not required
Enter the code qualifier and additional code, such as martial
status, taxonomy, or ethnicity codes, as may be appropriate.
78-79
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2009
Section 5: Billing and Payment
49
KAISER PERMANENTE
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
50
KAISER PERMANENTE
5.46 Billing Requirements and Instruction for Specific Services
Topic
Instructions
5.46.1
Evaluation
Management
(E/M) Services
CMS-1500 (8/05)
•
Field 19Æ When “covering” for another physician, enter the name of the physician you are
covering for.
NOTE: If a non-participating Practitioner/Provider will be covering for you in your
absence, please notify that individual of this requirement.
Inpatient E/M Services:
•
If a patient is admitted for observation following the performance of a major/minor “surgical
package” procedure, do not report hospital observation service codes, because all postoperative E/M services are included as part of the global surgical package.
Consultations:
•
Kaiser Permanente will reimburse for initial consultations when billed with any surgical
procedure done on the same day of service.
•
For office/outpatient: If the consultant assumes patient management responsibilities
following the initial consultation, office E/M (established patient) visit codes should be used
for all subsequent patient encounters, NOT office consultation codes.
•
For inpatient: If the consultant assumes patient management responsibilities, use
subsequent hospital care codes (NOT follow-up inpatient consultation codes) to report all
additional E/M encounters with the patient.
Surgery and E/M Services:
•
•
Reimbursement will generally NOT be made for a pre- or post-operative E/M visit provided
on the same day as major/minor surgery, or an endoscopic procedure, unless Kaiser
Permanente agrees that there was a significant, separately identifiable E/M service
provided in addition to the procedure. In these instances, the provider must bill for the E/M
visit using the appropriate modifier.
If E/M services are performed during the post-operative period for a reason unrelated to the
original procedure (such as for other disease or injuries), you may bill for these services
using modifier 24 (Unrelated E/M service by the same physician during a post-operative
period), and you must list a corresponding diagnosis code which reflects that the E/M
services were for a problem other than the surgical diagnosis.
Urgent or Emergency Services Provided in the Office:
•
For urgent or emergency services provided in the office setting, use code Office services
provided on an emergency basis in addition to the appropriate E/M office visit code.
Non-Surgical Procedure that Include E/M Services:
•
There are certain instances where Kaiser Permanente will deny medical visits when billed
with certain non-surgical procedures, because the codes for these procedures include
admission to the hospital and/or daily visits. The non-surgical procedures which fall into this
category include:
Kaiser Permanente Provider Manual
2009
Section 5: Billing and Payment
51
KAISER PERMANENTE
Topic
Instructions
• Clinical brachytherapy
• End stage renal disease services
• Allergy immunotherapy services
Preventive Medicine Services:
•
Preventive medicine codes -- NOT office evaluation/management codes -- should be used
to report the routine evaluation and management of adults and children, in the absence of
patient complaints. For example, preventive medicine codes should be used for:
• Well-baby check ups
• Routine pediatric visits
• Camp or school physicals
• Routine, annual gynecological exams
5.46.2
Emergency
Rooms
UB-04
•
Field 15 (UB-04)Æ Enter the code indicating the source of the admission or outpatient
registration
•
Field 44Æ The emergency department E/M visit codes should ONLY be used if the patient
is seen in the emergency department.
Emergency department E/M visit codes should be used for E/M services provided in the
emergency department, even if these were “non-emergency” services. The only requirement for
using “emergency department” codes is that the patient must be registered in the emergency
department. Office visit E/M codes should be used if the patient is seen in the ER as a
convenience to the physician and/or patient, but the patient is not registered in the emergency
department.
NOTE: If both an “emergency department” physician and an “attending” physician are involved in
admitting a patient from the ER, the ER physician should bill for services utilizing the emergency
department E/M codes, and the attending physician should
bill for services using the initial hospital visit codes. The two physicians cannot each bill for both
the ER services rendered and the hospital admission.
5.46.3
Durable
Medical
Equipment
Description:
Durable Medical Equipment is medically necessary equipment that is:
•
•
•
•
CMS-1500
•
Appropriate for use at home
Primarily and customarily used to service a medical purpose
Not useful to a person in absence of an illness
Able to withstand repeated use
Field 24d Æ CPT codes are required for all professional services. Use HCPCS Level II
codes to define DME. Use modifiers, if applicable.
UB-92 or UB-04
•
Field 42Æ Enter the appropriate revenue code
•
Field 44Æ HCPCS/Rates required
•
Field 46Æ Number of rental months
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Topic
5.46.4
Injection/
Immunizations
Instructions
•
Field 54Æ DME cost sharing amounts collected from the Member are reported in this field.
•
Field 84 (UB-92) or Field 80 (UB-04)Æ For DME billing, rental rate costs and anticipated
months of usage should be inserted in this field.
CPT codes are required for all professional services. Use HCPCS Level II codes to define Injections/
Immunizations.
NOTE: If there was no identifiable E/M service rendered by the nurse or the provider, and the
patient received only an injection during the encounter, it is permissible to report an injection
administration code in lieu of the E/M visit code and the appropriate HCPCS code (specifying the
drug administered).
Unlike injections, immunization procedures include the supply of materials. Additionally, injection
administration fees are not eligible for reimbursement when billed with immunization codes.
5.46.5
Newborn
Services
CMS-1500 (8/05)
•
Field 2Æ Enter the first and last name of the newborn
•
Field 3 Æ Enter the newborn’s date of birth
UB-04
•
Field 8 (UB-04)Æ Enter the first and last name of the newborn
•
Field 10 (UB-04) Æ Enter the newborn’s date of birth
NOTE: If the Health Record Number is not established, contact the Membership Services
Department at 800-813-2000 or (503) 813-2000.
5.46.6
Expanded
Care
CMS-1500 (8/05)
•
Field 21Æ Diagnosis code V66.9 should always be used when billing expanded care
services
•
Field 24 dÆ Enter the appropriate procedure codes per your Provider Contract
UB-04
•
•
•
Field 67Æ Diagnosis code V66.9 should always be used when billing expanded care
services
Field 42Æ Enter the appropriate procedure codes per your Provider Contract
Field 44Æ Enter the appropriate HCPC and/or CPT code
NOTE: Services provided for Expanded care, hospice and home health should be billed on a
separate CMS-1500 (8/05) or UB04 claim forms. The claim may inadvertently be denied if these
services are submitted on one claim form.
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KAISER PERMANENTE
5.47 Anesthesia
GLOBAL ANESTHESIA
PACKAGE
The “global” anesthesia package includes:
• The performance of a pre-anesthetic examination and
evaluation (even if the exam is done on a date different from
the date of surgery)
• The administration of the anesthetic
• The administration of fluids and/or blood incidental to the
delivery of anesthesia (or the procedure being performed)
• The usual monitoring services (ECG, blood pressure, etc.)
• The provision of post-operative anesthesia care (postoperative visit)
OFFICE-BASED
SURGICAL
PROCEDURES
When an office-based surgical procedure is performed,
reimbursement for the procedure includes reimbursement for
anesthesia services as part of the global surgical fee, because it
is expected that appropriate anesthesia will be administered with
the office-based procedure.
ANESTHESIA
REPORTING
REQUIREMENTS &
REIMBURSEMENT
Kaiser Permanente reimburses participating providers for
anesthesia services based on nationally recognized criteria for
reporting of anesthesia services, including:
The American Medical Association (AMA) CPT codes
(00100 – 01999)
American Society of Anesthesiologists’ (ASA) Relative Value
Guide (RVG)
Medicare Guidelines
BASE UNITS:
Providers are NOT to indicate the ASA base unit values in the
Days/Units field (Item 24, Box G). Base units are determined as
defined by the American Society of Anesthesiologists Relative
Value Guide. The base units assigned to a procedure are intended
to demonstrate the relative complexity of a specific procedure and
include the value of all anesthesia services, except the value of the
actual time spent administering the anesthesia. Kaiser
Permanente stores the base unit value within our claims
system and will calculate the anesthesia payment of the base
units according to the information provided on the claim.
ANESTHESIA
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KAISER PERMANENTE
REPORTING
REQUIREMENTS &
REIMBURSEMENT
Con’t.
REPORTING OF ANESTHESIA TIME:
Anesthesia time begins when the anesthesiologist starts to prepare
the patient for the induction of anesthesia in the operating room or
in an equivalent area. Anesthesia time ends when the
anesthesiologist is no longer in personal attendance, which is when
the patient may be safely placed under postoperative supervision.
Time units are calculated by allowing 1 unit for each 15 minute
interval or remaining fraction thereof. Providers are to show time
as total number of minutes in the Units field (Item 24, Box G).
REIMBURSEMENT:
Payment for most anesthesia services is based on:
The base unit value
Plus anesthesia time units
Multiplied by the fee schedule conversion factor, as
appropriate.
Other services are reimbursed based upon the CPT code.
EXCEPTIONS TO
BILLING ANESTHESIA
CODES
MULTIPLE SURGICAL PROCEDURES:
When multiple surgical procedures are performed during a single
anesthetic administration, the anesthesia code representing the
most complex procedure is reported. The time reported is the
combined total of all procedures reported on the primary
procedure.
Anesthesiologists should bill using anesthesia codes only, unless
one or more of the following services was performed by the
anesthesiologist (in which case the appropriate “non-anesthesia”
CPT code(s) may be reported and billed in accordance with CMS
guidelines):
•
•
•
•
•
•
•
•
•
Evaluation and management services
Hospital inpatient services
Consultations
Critical care services
Pain management
Nerve blocks
Destruction by neurolytic agents
Services not included in the global anesthesia fee
Other miscellaneous services
QUALIFYING CIRCUMSTANCES:
CPT codes 99100, 99116, 99135 and 99140 represent various
patient conditions that may impact the anesthesia service provided.
Such codes may be billed in addition to the anesthesia being billed.
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KAISER PERMANENTE
Charges for these codes are to be shown on the same line as the
CPT Qualifying Circumstances Code in Item 24, Box F.
PATIENT-CONTROLLED ANALGESIA (PCA):
Benefits may be available for the administration of patientcontrolled analgesia (PCA) following a surgical procedure. PCA
billed by a surgeon is covered as part of the global surgical
package and is not separately reimbursable. PCA reimbursements
are limited to anesthesiologists only.
EXCEPTIONS TO
BILLING ANESTHESIA
CODES Con’t.
An anesthesiologist’s services for PCA should be submitted as a
single line on the claim form as follows:
Span the dates to include the entire care for the PCA
(reimbursement will be made as a global allowance, and
will include the entire course of PCA).
Any “hospital care” provided by the anesthesiologist
subsequent to the initial day of PCA will be considered
covered under the global PCA fee.
Use CPT code 01996 when billing for PCA services.
CONSCIOUS SEDATION:
Sedation with or without analgesia (conscious sedation),
intravenous, intramuscular or inhalation (CPT code 99143-99145)
are considered eligible for reimbursement when billed by an
anesthesiologist, pain management or certified registered nurse
anesthetist.
ANESTHESIA
MODIFIERS
Personally Performed or Medically-Directed/Supervised
Anesthesia Services:
Use an appropriate HCPCS anesthesia modifier to denote whether
the anesthesia services were personally performed, medically
directed, or medically supervised:
AA - Anesthesia service performed personally by the
Anesthesiologist
AD - Medical supervision by a physician of more than four
concurrent procedures
QK - Medical direction of two, three, or four concurrent
anesthesia procedures involving qualified individuals
QX - CRNA service with medical direction by a physician
QY - Medical direction of one CRNA by the
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QZ - CRNA service without medical direction by a physician
QS - Monitored anesthesia care service (can be billed by a
CRNA or a physician)
Physical Status Modifiers:
As indicated in the CPT book, the following physical status
modifiers should be appended to the CPT anesthesia code to
distinguish between the various levels of complexity of the
anesthesia service(s) provided:
- A normal healthy patient
- A patient with mild systemic disease
- A patient with severe systemic disease
- A patient with severe systemic disease that is a
constant threat to life
P5 - A moribund patient who is not expected to survive
without the operation
P6 - A declared brain-dead patient whose organs are being
removed for donor purposes
P1
P2
P3
P4
DO NOT enter additional minutes for the Physical Status modifier.
If eligible for reimbursement, the additional unit(s) will be calculated
by our claims system. The patient cannot be billed for Physical
Status modifiers not allowed by Kaiser Permanente.
Other CPT Modifiers/Qualifying Circumstances Codes:
Other modifiers and “qualifying circumstances” codes may be used
as appropriate. Follow the instructions in the CPT/HCPCS books
when reporting these additional modifiers and/or codes.
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KAISER PERMANENTE
5.48 Coordination of Benefits (COB)
Coordination of Benefits (COB) is a method for determining the order in which benefits
are paid and the amounts which are payable when a Member is covered under more
than one plan. It is intended to prevent duplication of benefits when an individual is
covered by multiple plans providing benefits or services for medical or other care and
treatment.
Kaiser Permanente Providers are responsible for determining the primary payor and for
billing the appropriate party. If Kaiser Permanente is not the primary carrier, an EOB is
required with the claim CMS 1500 (HCFA 1500) submission.
Topic
5.48.1 How to
Determine the
Primary Payor
Instructions
1 The benefits of the plan that covers an individual as an
employee, Member or subscriber other than as a
dependent are determined before those of a plan that
covers the individual as a dependent.
2 When both parents cover a child, the “birthday rule”
applies – the payor for the parent whose birthday falls
earlier in the calendar year (month and day) is the
primary payor.
When determining the primary payor for a child of separated
or divorced parents, inquire about the court agreement or
decree. In the absence of a divorce decree/court order
stipulating parental healthcare responsibilities for a dependent
child, insurance benefits for that child are applied according to
the following order:
Insurance carried by the
1 Natural parent with custody pays first
2 Step-parent with custody pays next
3 Natural parent without custody pays next
4 Step-parent without custody pays last
If the parents have joint custody of the dependent child, then
benefits are applied according to the birthday rule referenced
above. If this does not apply, call the Member Services
Department at 503-813-2000 or 1-800-813-2000.
1 Kaiser Permanente is generally primary for working
Medicare-eligible Members when the CMS Working
Aged regulation applies.
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KAISER PERMANENTE
Topic
Instructions
2 Medicare is generally primary for retired Medicare
Members over age 65, and for employee group health
plan (EGHP) Members with End Stage Renal Disease
(ESRD) for the first thirty (30) months of dialysis
treatment. This does not apply to direct pay Members.
3 In cases of work-related injuries, Workers
Compensation is primary unless coverage for the injury
has been denied.
4 In cases of services for injuries sustained in vehicle
accidents or other types of accidents, primary payor
status is determined on a jurisdictional basis. If the
auto insurance is primary, claims will require an EOB.]
5.48.2 Description of Kaiser Permanente Coordination of Benefits allows benefits
from multiple carriers to be added on top of each other so that
COB Payment
the Member receives the full benefits from their primary carrier
Methodologies
and the secondary carrier pays their entire benefit up to 100%
of allowed charges. When Kaiser Permanente has been
determined as the secondary payor, Kaiser Permanente pays
the difference between the payment by the primary payor and
the amount which would be have been paid if Kaiser
Permanente was primary, less any amount for which the
Member has financial responsibility.
Benefit carve-out calculations are based on whether or not the
Provider accepts Medicare assignment for the provider
contract corresponding to the claim. Medicare assignment
means the provider has agreed to accept the Medicare
allowed amount as payment.
5.48.3 COB Claims
Submission
Requirements and
Procedures
Whenever Kaiser Permanente is the SECONDARY payer,
claims can be submitted EITHER electronically or on one of
the standard paper claim forms:
1 Electronic Claims:
If Kaiser Permanente is the secondary payer, send the
completed electronic claim with the payment fields from
the primary insurance carrier entered as follows:
• 837P claim transaction Enter Amount Paid
• 837I claim transaction Enter Prior Payments
2 Paper Claims
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KAISER PERMANENTE
Topic
Instructions
If Kaiser Permanente is the secondary payer, send the
completed claim form with a copy of the corresponding
Explanation of Benefit (EOB) or Explanation of
Medicare Benefits (EOMB)/Medicare Summary Notice
(MSN) from the primary insurance carrier attached to
the paper claim to ensure efficient claims
processing/adjudication. Kaiser Permanente cannot
process a claim without an EOB or EOMB/MSN from
the primary insurance carrier.
• CMS-1500 claim form: Complete Field 29 (Amount
Paid)
• CMS-1450 claim form: Complete Field 54 (Prior
Payments)
5.48.4 Members
Enrolled in Two
Kaiser Permanente
Plans
Some Members may be enrolled under two separate plans
offered through Kaiser Permanente (dual coverage). In these
situations, Providers need only submit ONE claim under the
primary plan to Kaiser Permanente for processing.
5.48.5 COB Claims
Submission
Timeframes
If Kaiser Permanente is the secondary payer, any
Coordination of Benefits (COB) claims must be submitted for
processing within 45 days of the date of the Explanation of
Benefits (EOB) or EOMB/MSN.]
5.48.6 COB FIELDS ON THE UB-04 CLAIM FORM
The following fields should be completed on the CMS-1450 (UB-04) claim form to
ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB
information in these fields may cause claims to be denied or pended and
reimbursements delayed. For additional information, refer to the current UB-04 National
Uniform Billing Data Element Specifications Manual.
Claims submitted electronically must meet the same data requirements as paper claims.
For electronic claim submissions, refer to a HIPAA website for additional information
on electronic loops and segments .
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837I
LOOP #
2300 H1
FIELD
NUMBER
32-35
(UB-92)
FIELD NAME
INSTRUCTIONS/EXAMPLES
OCCURRENCE CODE/DATE
KAISER PERMANENTE
31-36
(UB-04)
2330B
NM
50
Enter the appropriate occurrence code and date defining the
specific event(s) relating to the claim billing period.
NOTE: If the injuries are a result of an accident, please
complete Field 77 (E-Code)
PAYER
(Payer Identification)
Enter the name and number (if known) for each payer
organization from whom the provider expects (or has
received) payment towards the bill.
List payers in the following order on the claim form:
A = primary payer
B = secondary payer
C = tertiary payer
2320
AMT
54
PRIOR PAYMENTS
(Payers and Patient)
Enter the amount(s), if any, that the provider has received
toward payment of the bill PRIOR to the billing date, by the
indicated payer(s). List prior payments in the following order
on the claim form:
A = primary payer
B = secondary payer
C = tertiary payer
2330A
NM
58
INSURED’S NAME
Enter the name (Last Name, First Name) of the individual in
whose name insurance is being carried. List entries in the
following order on the claim form:
A = primary payer
B = secondary payer
C = tertiary payerNOTE: For each entry in Field 58, there
MUST be corresponding entries in Fields 59 through 62 (UB92 and UB-04) AND 64 through 65 (Field 65 only on the UB04).
2320
SBR
59
Patient’s Relationship To
Insured
Enter the code indicating the relationship of the patient to the
insured individual(s) listed in Field 58 (Insured’s Name). List
entries in the following order:
A = primary payer
B = secondary payer
C = tertiary payer
837I
LOOP #
2330A
NM
2320
SBR
FIELD
NUMBER
60
61
FIELD NAME
INSTRUCTIONS/EXAMPLES
CERT. – SSN – HIC – ID NO.
(Certificate/Social Security
Number/Health Insurance
Claim/Identification Number)
Enter the insured person’s (listed in Field 58) unique
individual Member identification number (medical/health
record number), as assigned by the payer organization. List
entries in the following order:
A = primary payer
B = secondary payer
C = tertiary paper
Enter the name of the group or plan through which the
insurance is being provided to the insured individual (listed in
Field 58). Record entries in the following order:
GROUP NAME
(Insured Group Name)
A = primary payer
B = secondary payer
C = tertiary paper
2320
SBR
62
INSURANCE GROUP NO.
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2320
SBR
64
Enter the identification number, control number, or code
assigned by the carrier or administrator to identify the GROUP
under which the individual (listed in Field 58) is covered. List
entries in the following order:
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61
ESC
(Employment Status Code of
A = primary payer
B = secondary payer
C = tertiary paper
Enter the code used to define the employment status of the
insured individual (listed in Field 58). Record entries in the
KAISER PERMANENTE
5.48.7 COB FIELDS ON THE CMS-1500 (HCFA-1500 (8/05) ) CLAIM FORM
The following fields should be completed on the CMS-1500 (HCFA-1500) (8/05) claim
form, to ensure timely and efficient claims processing. Incomplete, missing, or
erroneous COB information in these fields may cause claims to be denied or pended
and reimbursements delayed.
Claims submitted electronically must meet the same data requirements as paper claims.
For electronic claim submissions, refer to a HIPAA website for additional information on
electronic loops and segments
837P
LOOP #
2330A NM
FIELD
NUMBER
9
FIELD NAME
INSTRUCTIONS/EXAMPLES
OTHER INSURED’S NAME
When additional insurance coverage exists (through a
spouse, parent, etc.) enter the LAST NAME, FIRST NAME,
and MIDDLE INITIAL of the insured.
NOTE: This field must be completed when there is an
entry in Field 11d (Is There Another Health
Benefit Plan?).
2330A NM
9a
OTHER INSURED’S POLICY
OR GROUP NUMBER
Enter the policy and/or group number of the insured
individual named in Field 9. If you do not know the policy
number, enter the Social Security number of the insured
individual.
NOTE: Field 9a must be completed when there is an
entry in Field 11d (Is There Another Health
Benefit Plan?).
NOTE: For each entry in this field, there must be a
corresponding Entry in 9d (Insurance Plan Name
or Program Name).
2320 DMG
9b
OTHER INSURED’S DATE
OF BIRTH/SEX
Enter date of birth and sex, of the insured named in Field 9.
The date of birth must include the month, day, and FOUR
DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971
NOTE: This field must be completed when there is an
entry in Field 11d (Is There Another Health
Benefit Plan?).
N/A
9c
EMPLOYER’S NAME or
SCHOOL NAME
Enter the name of the employer or school name (if a
student), of the insured named in Field 9.
NOTE: This field must be completed when there is an
entry in Field 11d (Is There Another Health
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837P
LOOP #
FIELD
NUMBER
FIELD NAME
INSTRUCTIONS/EXAMPLES
Benefit Plan?).
2330B NM
9d
INSURANCE PLAN NAME or
PROGRAM NAME
Enter the name of the insurance plan or program, of the
insured individual named in Field 9.
NOTE: This field must be completed when there is an
entry in Field 11d (Is There Another Health
Benefit Plan?).
2300 CLM
10
IS PATIENT’S CONDITION
RELATED TO:
a. Employment?
b. Auto Accident?
c. Other Accident?
N/A
11d
Check “yes” or “no” to indicate whether employment, auto
liability, or other accident involvement applies to one or more
of the services described in Field 24.
NOTE: If yes, there must be a corresponding entry in
Field 14 (Date of Current Illness/ Injury) and in
Field 21 (Diagnosis).
PLACE (State) Æ
PLACE (State) Æ Enter the state the Auto Accident
occurred in.
IS THERE ANOTHER
HEALTH BENEFIT PLAN?
Check “yes” or “no” to indicate if there is another health
benefit plan. (For example, the patient may be covered
under insurance held by a spouse, parent, or some other
person).
NOTE: If “yes,” then Field Items 9 and 9a-d must be
completed.
2300 DTP
14
DATE OF CURRENT
--Illness (First symptom)
--Injury (Accident)
--Pregnancy (LMP)
Enter the date of the current illness or injury. The date must
include the month, day, and FOUR DIGITS for the year
(MM/DD/YYYY).
Example: 01/05/2008
2300 H1
21
DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Enter the diagnosis and if applicable, enter the
Supplementary Classification of External Cause of Injury and
Poisoning Code.
NOTE: This field must be completed when there is an
entry in Field 10 (Is The Patient’s Condition
Related To).
2320 AMT
29
AMOUNT PAID
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Enter the amount paid by the primary insurance carrier in
Field 29.
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KAISER PERMANENTE
5.49 Explanation of Payment
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KAISER PERMANENTE
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KAISER PERMANENTE
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KAISER PERMANENTE
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