Inpatient - Medicare HMO Billing Instructions - UB-04

Medicare HMO Billing Instructions for Inpatient Hospitals/Facilities – UB-04 Claim Form (Paper) 
 

Based on both current billing instructions and assumptions relative to the change requested:

  • Form Locators 18-28 (Condition Codes) – Enter Condition Codes X4 and X5 in Form Locators 18 and 19 (Condition Codes). Use Form Locators 20 through 28 for any other applicable condition codes. (Please note that Condition Code X4 is used to indicate that Medicare A and/or Medicare B denied.)
  • Form Locators 39-41 (Value Codes) – Value Code A1 must be used to denote the amount the Medicare HMO applied toward the recipient’s deductible and Value Code A2 will be used to denote the amount the Medicare HMO applied to the recipient’s Medicare HMO coinsurance and lifetime reserve day responsibility.
  • Form Locator 50 (Payer) – 50a must contain the name of the Medicare HMO (i.e., Unison, Advantage, etc.), to denote the primary Medicare HMO. Do not enter Medicare or Medicare A in this form locator when the recipient has a Medicare HMO.
  • Form Locator 57(Provider No.) – Form Locator 57a must contain the Medicare HMO provider number, while Form Locator 57b will contain the 13-digit Medical Assistance provider number, when MA is secondary to an MA HMO. If MA is tertiary to a Medicare HMO, complete Form Locators 57a, 57b, and 57c accordingly, denoting the primary in Form Locator 57a, the secondary on Form Locator 57b, and the MA provider number in Form Locator 57c.
  • Form Locator 54 (Prior Payments) – Must contain the amount the Medicare HMO paid the hospital.  Form Locator 60 (CERT. – SSN – HIC – ID NO) – Must contain the patient’s Medicare HMO identification number.
  • Form Locator 63 (Treatment Authorization Codes) – This field will be left blank when completing a claim for a recipient where there is a primary Medicare HMO.

All other fields on the UB-04 claim form will be completed as per current billing instruction detailed in the billing guides.
 

Medicare HMO Billing Instructions for Inpatient Internet Claims

Other Insurance Section – When submitting claims via the Internet for recipients who have a primary Medicare HMO, please follow the instructions outlined below.

Step 1

Medicare A – Enter Medicare Part A and the recipient’s applicable Medicare HMO. The first ‘Other Insurance must be Medicare Part A, using Carrier Code 600 and Claim Filing Indicator MA. After completing all of the applicable fields (e.g., Carrier Code, Policy Holder ID, etc), go to the Adjustment Group Code/Reason Code/Amount fields in this section. Enter PR in the first drop down field, Reason Code 50 (Non-Covered Services) in the second drop-down field, and the billed amount in the third field. Enter the date of the Medicare HMO Explanation of Benefits (EOB) Statement in the ‘Paid Date’ field. Leave the ‘Paid Amount’ and ‘Medicare Approved Amount’ fields blank. This indicates that Medicare A did not cover the admission for the recipient.

If there are charges on the claim that would normally be billed to Medicare Part B, go to Step 2 – Medicare Part B Eligible Ancillary Services. If there are no Medicare Part B eligible ancillary services, go to Step 3.

Step 2

Medicare Part B Eligible Ancillary Services – Click on ‘Add’ and enter the second (2) other insurance segment. The second ‘Other Insurance’ must be Medicare Part B when there are Medicare Part B eligible ancillary services. Enter Carrier Code 100 and Claim Filing Indicator MB. After completing all of the applicable fields (e.g., Carrier Code, Policy Holder ID, etc), go to the Adjustment Group Code/Reason Code/Amount fields in this section. Enter PR in the first drop down field, Reason Code 50 (Non-Covered Services) in the second drop-down field, and the billed amount in the third field. Enter the date of the Medicare HMO Explanation of Benefits (EOB) Statement in the ‘Paid Date’ field. Leave the ‘Paid Amount’ and ‘Medicare Approved Amount’ fields blank. This indicates that Medicare B did not cover the admission for the recipient.

Click on ‘Add’ and enter the third (2) other insurance segment. Use one of the applicable 500 series Medicare HMO Carrier Codes to denote that recipient’s Medicare HMO with Claim Filing Code 16 (Health Maintenance Organization – HMO), completing all other applicable fields (e.g. Carrier Code, Policy Holder ID, etc). Go to the Adjustment Group Code/Reason Code/Amount fields in this section and enter ‘PR’ in the first drop-down field, Reason Code 1 (Deductible), 2 (Coinsurance), or 3 (Copay) in the second drop-down field. Enter the amount of deductible, copay, or coinsurance in the third field. Enter the Medicare HMO EOB statement date in the ‘Paid Date’ field and the amount the Medicare HMO paid in the ‘Paid Amount’ field.

Step 3

Click on ‘Add’ and enter the second (2) other insurance segment. Use one of the applicable 500 series Medicare HMO Carrier Codes to denote that recipient’s Medicare HMO with Claim Filing Code 16 (Health Maintenance Organization – HMO), completing all other applicable fields (e.g. Carrier Code, Policy Holder ID, etc). Go to the Adjustment Group Code/Reason Code/Amount fields in this section and enter ‘PR’ in the first drop-down field, Reason Code 1 (Deductible) and/or 2 (Coinsurance) in the second drop-down field. Enter the amount of deductible, copay, or coinsurance in the third field. Enter the Medicare HMO EOB statement date in the ‘Paid Date’ field and the amount the Medicare HMO paid in the ‘Paid Amount’ field.
 

Medicare HMO Billing Instructions for PES Inpatient Institutional Transaction

  • On the "Hdr 5" screen, make sure that the "Other Insurance Ind" and "Crossover Ind" fields are "Y". This will display the "OI" and "Crossover" screens.
  • Fill out the "OI" screen to indicate the Medicare HMO/Advantage Plan payment.
  • Use claim filing indicator code "16" for Medicare HMO/Advantage Plan. Use adjustment reason codes "1" for deductible (enter amount of deductible in the next field), "2" for coinsurance and lifetime reserve day responsibility (enter coinsurance + LTR amt. in next field). Also, complete the Paid Date/Amount fields. Complete the Policy Holder Information using the correct carrier code for the plan.
  • Fill out the "Crossover" screen to indicate a Medicare "A" denial (adjustment reason code 50) or Medicare A exhausted (adjustment reason code 35). When indicating an exhaustion or denial of benefits, please enter the amount you would have billed Medicare in the field following the adjustment reason code.
  • Use claim filing indicator code "MA" for Medicare A.
  • If you do not have a Medicare ICN use 1111111111111 • Complete the Policy Holder information (use Carrier Code 600).