Florida Medicaid

[Pages:175]Florida Medicaid

Provider Reimbursement Handbook, UB-04

Agency for Health Care Administration

CHARLIE CRIST GOVERNOR

Better Health Care for all Floridians

December 1, 2008

HOLLY BENSON SECRETARY

Dear Medicaid Provider:

Please find the enclosed Florida Medicaid Provider Reimbursement Handbook, UB-04, effective July 2008. We added the time limit for submission of a claim to Chapter 1. We also added a new Chapter 3, which contains additional filing requirements, such as prior authorizations, authorization for hospital admissions, and special forms that must be submitted with claims for certain types of services. Please use this new handbook in place of the advance draft that was posted on the Medicaid fiscal agent's Web Portal on May 29, 2008.

Please contact your area Medicaid office if you have any questions. The area Medicaid offices' phone numbers and addresses are available on the Agency's website at . Click on Medicaid, and then on Area Offices. They are also listed in Appendix A of the Florida Medicaid Provider General Handbook. All the Medicaid handbooks are available on EDS' Web Portal at . Click on Public Information for Providers, then on Provider Support, and then on Provider Handbooks.

We appreciate the services that you provide to Florida's Medicaid recipients.

Sincerely,

Beth Kidder Chief, Bureau of Medicaid Services

2727 Mahan Drive, MS# Tallahassee, Florida 32308

Visit AHCA online at

UPDATE LOG MEDICAID PROVIDER REIMBURSEMENT HANDBOOK

UB-04

How to Use the Update Log

Introduction

The current Medicaid provider handbooks are posted on the Medicaid fiscal agent's Web Portal at . Click on Public Information for Providers, then on Provider Support, and then on Provider Handbooks. Changes to a handbook are issued as handbook updates. An update can be a change, addition, or correction to policy. An update may be issued as either replacement pages in an existing handbook or a completely revised handbook.

It is very important that the provider read the updated material and if he maintains a paper copy, file it in the handbook. It is the provider's responsibility to follow correct policy to obtain Medicaid reimbursement.

Explanation of the Update Log

Providers can use the update log to determine if they have received all the updates to the handbook.

Update No. is the month and year that the update was issued.

Effective Date is the date that the update is effective.

Instructions

When a handbook is updated, the provider will be notified by a postcard or notice. The notification instructs the provider to obtain the updated handbook from the Medicaid fiscal agent's Web Portal at . Click on Public Information for Providers, then on Provider Support, and then on Provider Handbooks.

Providers who are unable to obtain an updated handbook from the Web Portal may request a paper copy from the Medicaid fiscal agent's Provider Support Contact Center at 800-289-7799.

UPDATE NO. May07 New Handbook Jul08 Revised Handbook

May 2007 July 2008

EFFECTIVE DATE

FLORIDA MEDICAID PROVIDER REIMBURSEMENT HANDBOOK UB-04

Table of Contents

Chapter/Topic

Page

Introduction

Handbook Use and Format ........................................................................................... ii Characteristics of the Handbook .................................................................................. iii Handbook Updates ...................................................................................................... iii

Chapter 1 - Completing the UB-04 Claim Form

Providers Who Bill on the UB-04 Claim Form ........................................................... 1-2 Time Limit for Submission of a Claim ....................................................................... 1-4 Basic Guidelines for Completing a Claim Form ........................................................ 1-9 How to Complete the UB-04 Claim Form................................................................ 1-10 Samples of Completed UB-04 Claim Forms ........................................................... 1-49 Claims Submission Checklist .................................................................................. 1-55 Claims Mailing Checklist ......................................................................................... 1-55 Where to Send Claim Forms................................................................................... 1-56 Electronic Claims Submission................................................................................. 1-57

Chapter 2 - Claims Processing

Claims Processing .................................................................................................... 2-1 Remittance Advice (RA) ............................................................................................ 2-2 How to Read the Remittance Advice......................................................................... 2-6 Sample Remittance Voucher .................................................................................... 2-7 How to Resubmit a Denied Claim ........................................................................... 2-19 Resolving an Incorrect Payment ............................................................................. 2-20 How to File a Void Request on a Paper Claim ........................................................ 2-22 Sample Void Request--UB-04 Claim Form ............................................................ 2-25 How to File an Adjustment Request on a Paper Claim ........................................... 2-26 Sample Adjustment Request--UB-04 Claim Form ................................................. 2-29 Identifying Adjustments and Voids on the Remittance Voucher ............................. 2-30 Billing Medicaid When There is a Third Party Liability Discount Contract............... 2-31

Chapter 3 ? Additional Filing Requirements

Prior Authorization Requirements ............................................................................. 3-2 Authorization for Inpatient Medical Admissions......................................................... 3-3 Prior Authorization for Inpatient Psychiatric and Substance Abuse Services ......... 3-10 Authorization for Organ Transplants ....................................................................... 3-13 Prior Authorization for Other Out-of-State Services ................................................ 3-15 Prior Authorization Request Form ........................................................................... 3-17 Checklist for the Prior Authorization Request Form ................................................ 3-23 Prior Authorization for Medically Needy Recipients................................................. 3-24 Special Billing for Medically Needy Recipients ........................................................ 3-26 Out-of-State Claims................................................................................................. 3-30 Nursing Facility Supplemental Payments for Medically Fragile Recipients ............. 3-31 Nursing Facility Supplement Payments for Recipients with AIDS........................... 3-33

Chapter 3 ? Additional Filing Requirements, continued

Consent for Sterilization Form ................................................................................. 3-35 Hysterectomy Acknowledgment Form .................................................................... 3-44 Exception to Hysterectomy Acknowledgment Requirement Form .......................... 3-48 Abortion Certification Form ..................................................................................... 3-52 Florida's Healthy Start Prenatal Risk Screening ..................................................... 3-55

Appendices

Appendix A: Internal Control Number (ICN) Region Codes ..................................... A-1

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