Medicare HMO Billing Instructions for Ambulatory Surgical Centers/Hospital Short Procedure Units — UB-04 Claim Form

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.
  • 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.
  • Form Locator 50 (Payer) – 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-92 claim form will be completed as per current billing instruction detailed in the billing guides.

Medicare HMO Billing Instructions for Institutional Outpatient Internet Claims

Other Insurance Section – Enter Medicare Part B and the recipient's applicable Medicare HMO. The first 'Other Insurance must be Medicare Part B, using Carrier Code 100 and Claim Filing Indicator MB. Click on 'Add' and enter the second (2) other insurance segment. Use on of the applicable 500 series Medicare HMO Carrier Codes to denote the recipient's Medicare HMO with Claim Filing Code 16 (Health Maintenance Organization – HMO). Do not complete the Medicare Approved Amount' field.

Service Adjustment for Service Line fields

  • Click on the first claim detail and go to 'Service Adjustment for Service Line 1'. The first segment on the service adjustment line should be for Medicare B. The first two drop-down fields need to contain PR/50 for Medicare B (Carrier Code 100). The third field must contain the billed amount for the applicable claim detail. The 'Paid Date' field must contain the date of the Medicare HMO Explanation of Benefits (EOB) Statement. Do not complete the 'Paid Amount' field when indicating a Medicare denial.

  • Add a second adjustment by clicking on 'Add Adjustment'. The second adjustment must be used to indicate the results of billing the Medicare HMO. Enter PR in the first drop-down, Reason Code 1 (Deductible), 2 (Coinsurance), or 3 (Copay) in the second dropdown. The third field must contain the amount of deductible, coinsurance, or copayment due from the recipient. The 'Paid Date' must contain the date of the Medicare HMO EOB. Enter the amount the Medicare HMO paid in Paid Amount field.

Medicare HMO Billing Instructions for the PES Outpatient Institutional Transaction

  • On the "Hdr 3" 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 Ind. Code "16". Complete the Paid Date/ Amount fields. Also, complete the Policy Holder information (use the correct carrier code for the plan).
  • Fill out the "Crossover" screen to indicate the Medicare B denial. Use Claim Filing Ind. Code MB. Complete the Paid Date field with the date of denial.
  • On the "Srv 3" screen make sure that the "Service Adjustment Ind" field is "Y", this will display the "Srv Adj" screen for the detail that you are completing.
  • When completing the "Srv Adj" screen indicate a Medicare Part B denial using adj. reason code "50" and indicate the amount you would have billed Medicare B in the following field.
  • On the same "Srv Adj" screen, click the "Add Srv Adj" button and complete the payment information for the Medicare HMO/Advantage plan. Use adjustment reason code "1" for deductible (enter the amt. of deductible in the following field), "2" for coinsurance (enter the amt. of coinsurance in the following field), and "3" for copay (enter the amt. of copay in the following field). Be sure to complete the Carrier information for each insurance.