Appendix
Appendix 1 UB-92 (CMS 1450) Claim Form Instructions for Hospice Services
Use the following claim form completion instructions, not the form locator descriptions printed on the claim form, to avoid denied claims or inaccurate claim payment. Complete all required form locators as appropriate. Do not include attachments unless instructed to do so.
These instructions are for the completion of the UB-92 (CMS 1450) claim for Wisconsin Medicaid. For complete billing instructions, refer to the National UB-92 Uniform Billing Manual prepared by the National Uniform Billing Committee (NUBC). The National UB-92 Uniform Billing Manual contains important coding information not available in these instructions. Providers may purchase the National UB-92 Uniform Billing Manual by writing or calling:
American Hospital Association
National Uniform Billing Committee
29th Fl
1 N Franklin
Chicago IL 60606
(312) 422-3390
For more information, go to the NUBC Web site at www.nubc.org/.
Wisconsin Medicaid recipients receive a Medicaid identification card upon being determined eligible for Wisconsin Medicaid. Always verify a recipients eligibility before providing nonemergency services by using the Eligibility Verification System (EVS) to determine if there are any limitations on covered services and to obtain the correct spelling of the recipients name. Refer to the Informational Resources section of the All-Provider Handbook or the Medicaid Web site for more information about the EVS.
Submit completed paper claims to the following address:
Wisconsin Medicaid
Claims and Adjustments
6406 Bridge Rd
Madison WI 53784-0002
Form Locator 1 Provider Name, Address, and Telephone Number
Enter the name of the provider submitting the claim and the complete mailing address. The minimum requirement is the providers name, street, city, state, and ZIP code. The name in Form Locator 1 should correspond with the provider number in Form Locator 51.
Form Locator 2 ERO Assigned Number (not required)
Form Locator 3 Patient Control No. (not required)
Form Locator 4 Type of Bill
Enter the three-digit type of bill number. The first digit identifies the type of facility. The second digit classifies the type of care. Hospice providers should use bill types 81X (non-hospital-based hospice) and 82X (hospital-based hospice). The third digit (X) indicates the billing frequency, and providers should enter one of the following for X:
- 1 = Admit through discharge claim.
- 2 = Interim first claim.
- 3 = Interim continuing claim.
- 4 = Interim final claim.
Form Locator 5 Fed. Tax No. (not required)
Form Locator 6 Statement Covers Period (From - Through) (not required)
Form Locator 7 Cov D. (not required)
Form Locator 8 N-C D. (not required)
Form Locator 9 C-I D. (not required)
Form Locator 10 L-R D. (not required)
Form Locator 11 Unlabeled Field (not required)
Form Locator 12 Patient Name
Enter the recipients last name, first name, and middle initial. Use the EVS to obtain the correct spelling of the recipients name. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spelling from the EVS.
Form Locator 13 Patient Address (not required)
Form Locator 14 Birthdate (not required)
Form Locator 15 Sex (not required)
Form Locator 16 MS (not required)
Form Locator 17 Admission Date (not required)
Form Locator 18 Admission Hr (not required)
Form Locator 19 Admission Type (not required)
Form Locator 20 Admission Src (not required)
Form Locator 21 D Hr (not required)
Form Locator 22 Stat (not required)
Form Locator 23 Medical Record No.
This is an optional field. Enter the number assigned to the patients medical/health record by the provider. This number will appear on the Remittance and Status Report and/or the 835 Health Care Claim Payment/Advice transaction.
Form Locators 24-30 Condition Codes (required, if applicable)
If appropriate, enter a code to identify conditions relating to this claim.
Form Locator 31 Unlabeled Field (not required)
Form Locators 32-35 a-b Occurrence Code and Date (required, if applicable)
If appropriate, enter the code and associated date defining a significant event relating to this claim that may affect payer processing. Enter dates in MM/DD/YY format (e.g., January 1, 2004, would be 010104).
Form Locator 36 a-b Occurrence Span Code (From - Through) (not required)
Form Locator 37 A-C Internal Control Number/Document Control Number (not required)
Form Locator 38 Responsible Party Name and Address (not required)
Form Locators 39-41 a-d Value Code and Amount (required, if applicable)
Wisconsin Medicaid uses the following value codes.
| Code | Description |
| 81 | Medicare Part B Charges When Part A Exhausted. Enter the full amount of Medicare Part B charges when billing for services after Medicare Part A has been exhausted. |
| 83 | Medicare Part A Charges When Part A Exhausted. Enter the sum of the Medicare paid amount, the coinsurance amount, and the deductible when billing for services after Medicare Part A has been exhausted. |
Form Locator 42 Rev. Cd.
Enter the national four-digit revenue code that identifies a specific accommodation, ancillary service, or billing calculation. Enter revenue code 0001 on the line with the sum of all the charges.
Form Locator 43 Description
Enter the date of service (DOS) in MM/DD/YY format in Form Locator 43 or Form Locator 45.
When series billing (i.e., billing from two to four DOS on the same line), indicate the DOS in the following format: MM/DD/YY MM/DD MM/DD MM/DD. Indicate the dates in ascending order. Providers may enter up to four DOS for each revenue code if:
- All DOS are in the same calendar month.
- All procedures performed are identical.
- All procedures were performed by the same provider.
- The number of units indicated in Form Locator 46 must be divisible by the number of DOS.
If it is necessary to indicate more than four DOS per revenue code, indicate the dates on the subsequent lines. On paper claims, no more than 23 lines may be submitted on a single claim including the Total Charges line.
Form Locator 44 HCPCS/Rates (not required)
Form Locator 45 Serv. Date
Enter the DOS in MM/DD/YY format in Form Locator 45 or Form Locator 43. Multiple DOS must be indicated in Form Locator 43.
Form Locator 46 Serv. Units
Enter the number of reimbursable accommodations days, ancillary units of service, or visits, where appropriate. Units are measured in days for revenue codes 0169, 0651, 0655, and 0656, and in hours for revenue code 0652.
Form Locator 47 Total Charges
Enter the usual and customary charge for each line item. Enter revenue code 0001 to report the sum of all charges in Form Locator 47.
Form Locator 48 Non-covered Charges (not required)
Form Locator 49 Unlabeled Field (not required)
Form Locator 50 A-C Payer
Enter all health insurance payers here. For example, enter T19 for Wisconsin Medicaid and/or the name of private insurance. Enter patient liability amount to identify any patient liability.
Form Locator 51 A-C Provider No.
Enter the number assigned to the provider by the payer indicated in Form Locator 50 A-C. For Wisconsin Medicaid, enter the eight-digit provider number. The provider number in Form Locator 51 should correspond with the name in Form Locator 1.
Form Locator 52 A-C Rel Info (not required)
Form Locator 53 A-C Asg Ben (not required)
Form Locator 54 A-C & P Prior Payments (required, if applicable)
Enter the actual amount paid by commercial insurance. (If the dollar amount indicated in Form Locator 54 is greater than zero, OI-P must be indicated in Form Locator 84.) If the commercial insurance denied the claim, enter 000. Do
not enter Medicare-paid amounts in this field, but attach a copy of the Medicare remittance information.
Form Locator 55 A-C & P Est Amount Due (required, if applicable)
Enter the dollar amount of any patient liability.
Form Locator 56 Unlabeled Field (not required)
Form Locator 57 Unlabeled Field (not required)
Form Locator 58 A-C Insureds Name (not required)
Form Locator 59 A-C P. Rel (not required)
Form Locator 60 A-C Cert. - SSN - HIC. - ID No.
Enter the recipients 10-digit Medicaid identification number. Do not enter any other numbers or letters. Use the Medicaid identification card or EVS to obtain the correct identification number.
Form Locator 61 A-C Group Name (not required)
Form Locator 62 A-C Insurance Group No. (not required)
Form Locator 63 A-C Treatment Authorization Codes (not required)
Form Locator 64 A-C ESC (not required)
Form Locator 65 A-C Employer Name (not required)
Form Locator 66 A-C Employer Location (not required)
Form Locator 67 Prin. Diag Cd.
Enter the full International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (up to five digits) describing the principal diagnosis (e.g., the condition established after study to be chiefly responsible for causing the admission or other health care episode). Do not enter manifestation codes as the principal diagnosis; code the underlying disease first. The principal diagnosis may not include E codes.
Form Locators 68-75 Other Diag. Codes
Enter valid ICD-9-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Diagnoses that relate to an earlier episode and that have no bearing on this episode are to be excluded. Providers should prioritize diagnosis codes as relevant to this claim.
Form Locator 76 Adm. Diag. Cd. (not required)
Form Locator 77 E-Code (not required)
Form Locator 78 Race/Ethnicity (not required)
Form Locator 79 P.C. (not required)
Form Locator 80 Principal Procedure Code and Date (not required)
Form Locator 81 Other Procedure Code and Date (not required)
Form Locator 82 a-b Attending Phys. ID
Enter the Universal Provider Identification Number or license number and name.
Form Locator 83 a-b Other Phys. ID (not required)
Form Locator 84 a-d Remarks (enter information when applicable)
Commercial Health Insurance Billing Information
Commercial health insurance coverage must be billed prior to billing Wisconsin Medicaid, unless the service does not require commercial health insurance billing as determined by Wisconsin Medicaid.
If the recipient has dental (DEN) or has no commercial health insurance, do not indicate an other insurance (OI) explanation code in Form Locator 84.
When the recipient has Wausau Health Protection Plan (HPP), BlueCross & BlueShield (BLU), Wisconsin Physicians Service (WPS), Medicare Supplement (SUP), TriCare (CHA), Vision only (VIS), a health maintenance organization (HMO), or some other (OTH) commercial insurance, and the service requires commercial health insurance billing according to the Coordination of Benefits section of the All-Provider Handbook, then one of the following three OI explanation codes must be indicated in Form Locator 84. The description is not required, nor is the policyholder, plan name, group number, etc.
| Code | Description |
| OI-P | PAID in part or in full by commercial health insurance or commercial HMO. In Form Locator 54 of this claim form, indicate the amount paid by commercial health insurance to the provider or to the insured. |
| OI-D | DENIED by commercial health insurance or commercial HMO following submission of a correct and complete claim, or payment was applied towards the coinsurance and deductible. Do not use this code unless the claim was actually billed to the commercial health insurer. |
| OI-Y | Yes, the recipient has commercial health insurance or commercial HMO
coverage, but it was not billed for reasons including, but not limited
to:
|
| Note: | The provider may not use OI-D or OI-Y if the recipient is covered by a commercial HMO and the HMO denied payment because an otherwise covered service was not rendered by a designated provider. Services covered by a commercial HMO are not reimbursable by Wisconsin Medicaid except for the copayment and deductible amounts. Providers who receive a capitation payment from the commercial HMO may not submit claims to Wisconsin Medicaid for services that are included in the capitation payment. |
Medicare Information
Use Form Locator 84 for Medicare information. Submit claims to Medicare before billing Wisconsin Medicaid.
Do not indicate a Medicare disclaimer code when one or more of the following statements is true:
- Medicare never covers the procedure in any circumstance.
- Wisconsin Medicaid indicates the recipient does not have any Medicare coverage including Medicare Cost (MCC) or Medicare + Choice (MPC) for the service provided. For example, the service is covered by Medicare Part A, but the recipient does not have Medicare Part A.
- Wisconsin Medicaid indicates the provider is not Medicare certified.
- Medicare has allowed the charges. In this case, attach the Explanation of Medicare Benefits or Medicare Remittance Advice, but do not indicate on the claim form the amount Medicare paid.
If none of the previous Medicare information is true, a Medicare disclaimer code is necessary. The following Medicare disclaimer codes may be used when appropriate:
| Code | Description |
| M-5 | Provider is not Medicare certified. This code may be used when providers are identified in Wisconsin Medicaid files as being Medicare certified, but are billing for DOS before or after their Medicare certification effective dates. Use M-5 in the following instances: For Medicare Part A (all three criteria must be met):
|
| M-7 | Medicare disallowed or denied payment. This code applies when Medicare denies the claim for reasons related to policy (not billing errors), or the recipient's lifetime benefit, spell of illness, or yearly allotment of available benefits is exhausted. Use M-7 in the following instances: For Medicare Part A (all three criteria must be met):
|
| M-8 | Noncovered Medicare service. This code may be used when Medicare was not billed because the service is not covered in this circumstance. Use M-8 in the following instances:
For Medicare Part A (all three criteria must be met):
|
Form Locator 85 Provider Representative
The provider or the authorized representative must sign in Form Locator 85.
| Note: | The signature may be a computer-printed or typed name and date or a signature stamp with the date. |
Form Locator 86 Date
Enter the month, day, and year on which the claim is submitted to the payer. The date must be entered in MM/DD/YY or MM/DD/YYYY format.
Next Appendix 2 UB-92 Claim Form Sample
Previous Reimbursement, Hospice Cap on Overall
Reimbursement