Rasmussen College SEC1 MOD5 Completing Hospitalization Claims Case Study

M150HIM1507 Medical Billing and Insurance

Rasmussen College

Question Description

Correctly Completing Hospitalization Claims

The objective of this exercise is to correctly complete a UB-04 claim form for this hospitalization.

In order to complete the claim you will need the following:

  1. Case Information which includes the Facility Information, Patient Information, Insurance Information, and the Patient Services.
  2. Fillable UB-04 Claim Form
    • Download this fillable UB-04 form and use it for filling in and saving a claim form for each case.
    • You can fill in this version of the form electronically, using Adobe Form Filler, as long as you have Adobe Acrobat Reader. (If you need the latest version of the free reader, you can download it from Note: Do not try to complete the form within your browser. First, save the file to your computer. Once you have completed the form, be sure to select "save as" from the File menu and re-name the file per the instructions below. If you experience issues with this process, you may need to try another browser.

Unformatted Attachment Preview

__ __ 1 __ 4 3a PAT. CNTL # b. MED. REC. # 2 6 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 10 BIRTHDATE 11 SEX 31 OCCURRENCE CODE DATE 12 DATE a c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 32 OCCURRENCE CODE DATE 33 OCCURRENCE DATE CODE 18 7 STATEMENT COVERS PERIOD FROM THROUGH b b TYPE OF BILL 19 20 34 OCCURRENCE CODE DATE CONDITION CODES 24 22 23 21 35 CODE 25 26 27 36 CODE OCCURRENCE SPAN FROM THROUGH d 28 e 29 ACDT 30 STATE 37 OCCURRENCE SPAN FROM THROUGH a a b b 38 39 CODE 40 CODE VALUE CODES AMOUNT 41 CODE VALUE CODES AMOUNT VALUE CODES AMOUNT a b c d 42 REV. CD. 44 HCPCS / RATE / HIPPS CODE 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 PAGE 23 OF TOTALS CREATION DATE 50 PAYER NAME 52 REL. INFO 51 HEALTH PLAN ID 53 ASG. BEN. 23 55 EST. AMOUNT DUE 54 PRIOR PAYMENTS A 56 NPI 57 A B OTHER B C PRV ID C 58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 62 INSURANCE GROUP NO. 61 GROUP NAME A A B B C C 65 EMPLOYER NAME 64 DOCUMENT CONTROL NUMBER 63 TREATMENT AUTHORIZATION CODES A A B B C C 66 DX 67 I A J 69 ADMIT 70 PATIENT DX REASON DX PRINCIPAL PROCEDURE a. 74 CODE DATE B K a b OTHER PROCEDURE CODE DATE C L b. c D M 71 PPS CODE OTHER PROCEDURE CODE DATE E N 75 72 ECI F O a 76 ATTENDING G P b NPI LAST c. OTHER PROCEDURE CODE DATE d. OTHER PROCEDURE DATE CODE e. OTHER PROCEDURE CODE DATE 77 OPERATING 81CC a UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 78 OTHER b LAST c 79 OTHER d LAST NUBC ™ National Uniform Billing Committee 73 QUAL FIRST NPI LAST 80 REMARKS H Q c 68 QUAL FIRST NPI QUAL FIRST NPI QUAL FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S). Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: 1. If third party benefits are indicated, the appropriate assignments by the insured /beneficiary and signature of the patient or parent or a legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the patient or the patient’s legal representative. 2. If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file. 3. Physician’s certifications and re-certifications, if required by contract or Federal regulations, are on file. 4. For Religious Non-Medical facilities, verifications and if necessary recertifications of the patient’s need for services are on file. 5. Signature of patient or his representative on certifications, authorization to release information, and payment request, as required by Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other applicable contract regulations, is on file. 6. The provider of care submitter acknowledges that the bill is in conformance with the Civil Rights Act of 1964 as amended. Records adequately describing services will be maintained and necessary information will be furnished to such governmental agencies as required by applicable law. 7. For Medicare Purposes: If the patient has indicated that other health insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon request, necessary authorization is on file. The patient’s signature on the provider’s request to bill Medicare medical and non-medical information, including employment status, and whether the person has employer group health insurance which is responsible to pay for the services for which this Medicare claim is made. 8. For Medicaid purposes: The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are subject to prosecution under applicable Federal or State Laws. 9. For TRICARE Purposes: (a) The information on the face of this claim is true, accurate and complete to the best of the submitter’s knowledge and belief, and services were medically necessary and appropriate for the health of the patient; (b) The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility, or if the patient resides within a catchment area of such a facility, a copy of Non-Availability Statement (DD Form 1251) is on file, or the physician has certified to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file; (c) The patient or the patient’s parent or guardian has responded directly to the provider’s request to identify all health insurance coverage, and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits; (d) The amount billed to TRICARE has been billed after all such coverage have been billed and paid excluding Medicaid, and the amount billed to TRICARE is that remaining claimed against TRICARE benefits; (e) The beneficiary’s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and, (f) Any hospital-based physician under contract, the cost of whose services are allocated in the charges included in this bill, is not an employee or member of the Uniformed Services. For purposes of this certification, an employee of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent employees, but excluding contract surgeons or other personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty. (g) Based on 42 United States Code 1395cc(a)(1)(j) all providers participating in Medicare must also participate in TRICARE for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, 1987; and (h) If TRICARE benefits are to be paid in a participating status, the submitter of this claim agrees to submit this claim to the appropriate TRICARE claims processor. The provider of care submitter also agrees to accept the TRICARE determined reasonable charge as the total charge for the medical services or supplies listed on the claim form. The provider of care will accept the TRICARE-determined reasonable charge even if it is less than the billed amount, and also agrees to accept the amount paid by TRICARE combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. The provider of care submitter will not attempt to collect from the patient (or his or her parent or guardian) amounts over the TRICARE determined reasonable charge. TRICARE will make any benefits payable directly to the provider of care, if the provider of care is a participating provider. SEE ht t p: //www.n u b c .o r g/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS Case 17.3 Completing Claims Based on the guidelines in the textbook table called "UB-04 Form Completion" (Table 17.1) and the following data, complete a UB-04 for this scenario where the patient is a newborn baby, delivered in the hospital and discharged to home. FACILITY INFORMATION Name: Hanover Regional Hospital Address: 2600 Record St. City/ State/ Zip: Hanover, CT 06783 Telephone: 860-376-2000 Federal Tax ID: 07-1282340 PATIENT INFORMATION Patient Name: Marvin Kelly Patient Address: 46 State St. City/ State/ Zip: Hartford, CT 06516 Patient Control Number: XZ6518 Medical Record Number: 1825695 Date of Birth: 3/15/2016 Sex: Male INSURANCE INFORMATION Insured’s Name: Richard G. Kelly Patient’s Relationship to Insured: Child Insured’s ID Number: 002879366 Health Plan: HMO Blue Care PATIENT SERVICES Date of Service: 3/15/16, 5:45 p.m. Discharged to home: 3/19/16, 3:30 p.m. Services: Lab - Hematology Lab Pathology - Other Nursery/ Newborn Level I Medical/ Surgical Supplies Lab Lab - Chemistry REV Codes 0305 0319 0171 0270 0300 0301 Units 1 1 4 1 1 1 Charges 72.87 35.28 @ 552.00 34.44 35.09 517.04 Principal Dx: Single liveborn, born in hospital (Z38.00) POA: 1 Attending Provider: Thomas Wong, NPI 9100016533 Case Notes/Tips         Field Locator 14 (Type of Admission/Visit): Code 4 indicates the patient is a newborn. When code 4 is used, a point of origin for admission code corresponding to newborns must also be used in FL 15 (Point of Origin for Admission or Visit). o The code reported in Field Locator 15 would be 5, which for newborns indicates that the newborn was born inside this hospital. If the patient were not a newborn, code 5 in FL 15 would indicate the patient was a transfer from an SNF or ICF. Field Locator 42 (Revenue Code): With the exception of revenue code 0001, which is reserved for line 23, revenue codes in the UB-04 should be listed in ascending numeric order. Be sure to calculate the total of the charges on line 23. Field Locator 44: Will contain the cost per unit for items where more than one unit are being billed. Field Locator 52 and 53: Would both be "Yes". Field Locator 66: Code should reflect ICD-10. Field Locator 67: In the Patient Services data, the principal diagnosis code on the claim reports POA indicator 1 (Exempt from POA reporting). Because the claim is for a newborn born in the hospital, the newborn’s condition is considered exempt from POA reporting. Field Locator 69: Code should reflect ICD-10. ...
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Final Answer


Boston College

Return customer, been using sp for a good two years now.

Thanks as always for the good work!

Excellent job

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