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UpdateNEWS & ANNOUNCEMENTS JUNE 29, 2018 UPDATE 18-444 Medical Paper Claims SubmissionRejections and ResolutionsThe preferred and most efficient way for fast turnaround and claims accuracy is to submitmedical claims electronically to Health Net of California, Inc., Health Net CommunitySolutions, Inc. and Health Net Life Insurance Company (Health Net). However, whenadditional documentation or attachments are required, paper claims will be accepted. Thefollowing information applies to medical paper claims and does not apply to pharmacypaper claims. All paper claims sent to the Health Net Claims Department must first passspecific edits prior to acceptance. Claim records that do not pass these edits are invalidand will be rejected or denied. Claims missing the necessary requirements are notconsidered clean claims and will be returned to providers with a written notice describingthe reason for return. The following information will assist providers in submitting cleanpaper claims. The following topics are outlined and addressed in this provider update: Acceptable forms Claims rejection reasons and their resolutions Mandatory line items for claims submission Paper claims submission address change (reminder)- Using correct Health Net entity name Appendix A – CMS-1500 (02/12) form billing instructions Appendix B – CMS-1450 (UB-04) billing instructionsACCEPTABLE FORMSAs a reminder Health Net is required to comply with requirements for providing completeclaims information to regulatory agencies. Accordingly, claims must reflect complete andaccurate data in all the required fields on the Centers for Medicare & Medicaid Services(CMS)-1500 or UB-04 original Flint OCR Red, J6983 ink claim forms in order to beaccepted as complete or clean claims. Nonstandard forms include any that have beendownloaded from the Internet or photocopied, which do not have the samemeasurements, margins, and colors as commercially available printed forms.Nonstandard forms will be rejected upon initial receive as non-clean claims. Providersmust adhere to the claims submission requirements below to ensure that submittedclaims have all the required information, which results in timely claims processing.13 PAGESTHIS UPDATE APPLIES TOCALIFORNIA PROVIDERS: Physicians Participating Physician Groups Hospitals Ancillary ProvidersLINES OF BUSINESS: HMO/POS/HSP PPO EPO Medicare Advantage (HMO) Medi-Cal Kern Los Angeles Molina Riverside Sacramento San Bernardino San Diego San Joaquin Stanislaus TularePROVIDER SERVICESprovider [email protected] PPO mEnhancedCare PPO (SBG)1-844-463-8188provider.healthnet.comHealth Net Employer Group HMO, POS,HSP, PPO, & EPO1-800-641-7761provider.healthnet.comIFP – Community Care HMO, PPO,PureCare HSP, PureCare One edicare rnia.comMedicare (employer group)1-800-929-9224provider.healthnet.comMedi-Cal – 1-800-675-6110provider.healthnet.comPROVIDER mfax 1-800-937-6086Health Net of California, Inc., Health Net Community Solutions, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. and Centene Corporation. Health Net is a registeredservice mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies.OTH020877EH00 (6/18)
AcceptableNot acceptable/will be rejectedProfessional ClaimsCMS-1500 (02/12) formCompleted in accordance with the guidelines in the National UniformClaim Committee (NUCC) 1500 Claim Form Reference InstructionManual Version 5.0 7/17 at www.nucc.orgAny other form will be rejected with a lettersent to the provider indicating the reason forrejectionInstitutional ClaimsUB-04 form. The form must be completed in accordance with theNational Uniform Billing Committee (NUBC) Official UB-04 DataSpecifications Manual 2018 at www.nubc.orgAny other form will be rejected with a lettersent to the provider indicating the reason forrejectionAll Claims1. Flint optical character recognition (OCR) Red, J6983 (or exactmatch) ink form2. Required original red form with the backer instructions3. Typed in black ink4. 10 or 12 point5. Times New Roman fontAny of the following formats will be rejected.1. Submitted on black and white or formsother than CMS-1500 (02/12) and UB-042. Handwritten3. Highlighted, italics, bold text, or staples formultiple page submissions4. Copies of the formHealth Net does not supply claim forms to providers. Providers should purchase these forms from a supplier of their choice.CLAIMS REJECTION REASONS AND RESOLUTIONSThe following are some claims rejection reasons, challenges and possible resolutions.Rejectcode010206Reject reasonMember's DOB is missing or invalidIncomplete or invalid member informationMissing/invalid tax IDRequirementsCMS-1500 orUB-04Enter the patient’s 8-digit date of birth(MM/DD/YYYY)CMS-1500 box 3Enter the patient’s Health Net memberidentification (ID) for Commercial and Medicareor Client Identification Number (CIN) forMedi-Cal. Social Security number (SSN) shouldnot be used. Check eligibility online,electronically, or refer to the patient’s current IDcard to determine ID numbersCMS-1500 box1aInclude complete 9-character tax identificationnumber (TIN)CMS-1500 box25UB-04 box 10UB-04 box 60UB-04 box 517Diagnosis indicator is missingPOA indicator is not validDRG code is not validEnsure 9/0 (“9” for ICD-9 or “0” for ICD-10)appears in field 66 for all claims.Ensure present on admission (POA) indicatorsare valid when billed.Ensure a valid DRG code is used in field 71.POA valid values are: Page 2 of 13UB-04 box 66-70UB-04 box 71Y – Diagnosis was present at time ofinpatient admission.N – Diagnosis was not present at time ofinpatient admission.Leave blank if cannot be determinedJune 29, 2018 Health Net Update 18-444
RejectcodeReject reasonRequirementsCMS-1500 orUB-0475The claim(s) submitted has missing,illegible or invalid value for anesthesiaminutesWhen box 24 is completed, then box 24G mustbe completed as wellCMS-1500 box24D and 24G76Original claim number and frequencycode requiredResubmission code is required for all correctedclaims. If resubmission code is 6, 7, or 8 (field22 on the CMS-1500 and field 4 on the UB-04),the original claim number is required (field 22on CMS-1500 and field 64 on UB-04)CMS-1500 box22Enter the appropriate type of bill (TOB) code asspecified by the NUBC UB-04 Uniform BillingManual minus the leading “0” (zero). A leading“0” is not needed. Digits should be reflected asfollows:UB-04 box 477Type of bill or place of service invalid ormissingUB-04 box 4 and641st digit – Indicating the type of facility2nd digit – Indicating the type of care3rd digit – Indicating the bill sequence(frequency code)87One or more of the REV codes submittedis invalid or missingInclude complete 3–4 character revenue code.Drop leading 0 if sending only 3 charactersUB-04 box 4292Missing or invalid NPIEnter provider’s 10-character National ProviderIdentifier (NPI) IDCMS-1500 box24J and 33AUB-04 box 56A5A7NDC or UPIN information missing/invalidInvalid/missing ambulance point of pickup ZIP codeProviders must bill the UPIN qualifier, number,quantity, and type or National Drug Code(NDC) qualifier, number, quantity, andunit/basis of measure. If any of these elementsare missing, the claim will rejectCMS-1500 box24DWhen box 24 D is completed, include thepickup/drop off address in attachmentsCMS-1500 box24 or box 32.UB-04 box 43Medicare claimsrequire a point ofpick (POP) ZIP inbox 23 in additionto the addressesin 24 shadedarea or box 32A9Provider name and address required atall levelsInclude complete billing provider addressincluding city, state and ZIP codeCMS-1500 box33UB-04 box 1C8Valid POA required for all DX fieldsPage 3 of 13Do not include the POA of 1. The valid valuesfor this field are Y or N or blank (for descriptionsee Reject code 17)UB-04 box 67–67Q and 72A–72CJune 29, 2018 Health Net Update 18-444
RejectCodeReject ReasonRequirementsCMS-1500 orUB-04B7Review NUCC guidelines for properbilling of the CMS-1500 versions (08/05)and (02/12). Claims will be rejected ifdata is not submitted and/or formattedappropriatelyOnly CMS-1500 02/12 version is acceptedN/AC6Other Insurance fields 9, 9a, 9d, and 11dare missing appropriate dataIf the member has other health insurance, box9, 9a and 9d must be populated, and box 11Dmust be marked as yes. If this is not provided,the claim will be rejectedCMS-1500 box 9,9a, 9d and 11dAVPatient's Reason For Visit should not beused when claim does not involveoutpatient visitsInclude patient reason for visit on all inpatientclaimsUB-04 box 70a,b, cHPICD-10 is mandated for this date ofserviceSubmit with the ICD indicator of 9/0 on bothUB-04 and CMS-1500 claim forms according tothe 5010 Guidelines requirement to bill thisinformation. (for description see Reject code17)CMS-1500 box21Use proper CMS-1500 or UB-04 form typed inblack ink in 10 or 12 point Times New RomanfontN/AREBlack/white, handwriting or nonstandardformatUB-04 box 66MANDATORY ITEMS FOR CLAIMS SUBMISSIONThe attached Appendix A – CMS-1500 Billing Instructions on page 6 and Appendix B – UB-04 Billing Instructions on page 10provide the mandatory items for both claim forms. For complete claims submission instructions, providers can refer to theHealth Net provider operations manual Claims and Provider Reimbursement Billing Submission Claims SubmissionRequirements.PAPER CLAIMS SUBMISSION ADDRESS CHANGEAs a reminder, effective January 1, 2018, the addresses to submit paper claims were changed. All paper claims must besubmitted to the addresses below with the exact entity names as provided.Using correct Health Net entity nameIf claims are submitted to the previous Lexington, KY address using inappropriate entity names other than what is providedbelow, the United States Postal Service (USPS) will return the claim back to the sender.Additionally, USPS has been forwarding claims received at the Lexington, KY address to the correct address. StartingDecember 31, 2018, USPS will discontinue automatic forwarding of claims. Claims received at the previous Lexington, KYaddress starting December 31, 2018, will be returned to the sender via the USPS.Page 4 of 13June 29, 2018 Health Net Update 18-444
Providers must submit claims to the correct address using the appropriate entity names as identified below.Line of businessPaper claims addressMEDICARE ADVANTAGEHealth Net of California, Inc.Medicare ClaimsPO Box 9030Farmington, MO 63640-9030MEDI-CALHealth Net Community Solutions, Inc.Medi-Cal ClaimsPO Box 9020Farmington, MO 63640-9020HMO/POS/HSP, PPO, & EPOHealth Net of California, Inc. (and/or)Health Net Life Insurance CompanyCommercial ClaimsPO Box 9040Farmington, MO 63640-9040MEDICARE ADVANTAGE PHARMACY PAPER CLAIMSMedicare Advantage (MA) pharmacy paper claims may be submitted to:Health Net of California, Inc.Attention: Pharmacy ClaimsP.O. Box 419069Rancho Cordova, CA 95741-9069ADDITIONAL INFORMATIONIf you have questions regarding the information contained in this update, contact the Health Net Provider Services Center byemail at provider [email protected] within 60 days, by telephone or through the Health Net provider website as listed inthe right-hand column of page one.Page 5 of 13June 29, 2018 Health Net Update 18-444
APPENDIX A – CMS-1500 BILLING INSTRUCTIONSField numberField descriptionRequired, conditional or not required1Insurance program identificationRequired1AInsured identification (ID) numberRequired2Patient’s name (last name, first name,middle initial)Required3Patient’s birth date and sexRequired4Insured’s nameConditional – Needed if different than patient5Patient’s address (number, street, city,state, ZIP code)Telephone number (include area code)Conditional6Patient’s relationship to insuredConditional – Always mark to indicate self if the same7Insured’s address(number, street, city, state, ZIP code)Telephone number (include area code)Conditional8Reserved for NUCCNot required9Other insured’s name (last name, firstname, middle initial)Conditional refers to someone other than the patient.Other insured’s policy or group numberConditional9AREQUIRED if patient is covered by another insuranceplanREQUIRED if field 9 is completed. Enter the policy forgroup number of the other insurance plan9BReserved for NUCCNot required9CReserved for NUCCNot required9DInsurance plan name or program nameConditionalREQUIRED if field 9 is completed10 A, B, CIs patient’s condition related toRequired10DClaims codes(designated by NUCC)Conditional11Insured policy or FECA numberConditionalREQUIRED when other insurance is available11APage 6 of 13Insured date of birth and sexConditionalJune 29, 2018 Health Net Update 18-444
Field numberField descriptionRequired, conditional or not required11BOther claims ID(designated by NUCC)Conditional11CInsurance plan name or program numberConditional11DIs there another health benefit plan?Required12Patient’s or authorized person’s signatureConditional – Enter “Signature on File,” “SOF,” or theactual legal signature13Insured’s or authorized person’s signatureNot required14Date of current:Illness (first symptom) or injury (accident)or pregnancy (LMP)Conditional15If patient has same or similar illness, givefirst dateConditional16Dates patient unable to work in currentoccupationConditional17Name of referring physician or othersourceConditional – Enter the name of the referring physicianor professional (first name, middle initial, last name, andcredentials)17AID number of referring physicianConditionalREQUIRED if field 17 is completed17BNPI of referring physicianConditionalREQUIRED if field 17 is completed. If unable to obtainreferring NPI, servicing NPI may be used18Hospitalization on dates related to currentservicesConditional19Reserved for local use – new form:Additional claim informationConditional20Outside lab/chargesConditional21Diagnosis or nature of illness or injury(related items A–L to item 24E by line).New form allows up to 12 diagnoses andICD indicatorRequired – Include the ICD indicator22Resubmission code/original REFConditional – For resubmissions or adjustments, enterthe original claim number of the original claimPage 7 of 13June 29, 2018 Health Net Update 18-444
Field number23Field descriptionPrior authorization number or ClinicalLaboratory Improvement Amendments(CLIA) numberRequired, conditional or not requiredIf authorization, then conditionalIf CLIA, then requiredIf both, submit the CLIA numberEnter the authorization or referral number. Refer to theprovider operations manual for information on servicesrequiring referral and/or prior authorization.CLIA number for CLIA waived or CLIA certifiedlaboratory services24 A–G SHADEDSupplemental informationConditional – The shaded top portion of each serviceclaim line is used to report supplemental informationfor:NDCNarrative description of unspecified codesContract rate24A UNSHADEDDates of serviceRequired24B UNSHADEDPlace of serviceRequired24C UNSHADEDEMGNot required24D UNSHADEDProcedures, services or suppliesCPT/HCPCS modifierRequired – Ensure NDC or UPIN is included ifapplicable24 E UNSHADEDDiagnosis codeRequired24 F UNSHADEDChargesRequired24 G UNSHADEDDays or unitsRequired24 H SHADEDEPSDT (family planning)Conditional – Leave blank or enter “Y” if the serviceswere performed as a result of an Early and PeriodicScreening, Diagnostic and Treatment (EPSDT) referral24 H UNSHADEDEPSDT (family planning)Conditional – Enter the appropriate qualifier for EPSDTvisit24 I SHADEDID qualifierRequired24 J SHADEDNon-NPI provider ID#Required24 J UNSHADEDNPI provider IDRequired25Federal tax ID number and SSN/EINRequired26Patient’s account NOConditional – Enter the provider’s billing account numberPage 8 of 13June 29, 2018 Health Net Update 18-444
Field numberField descriptionRequired, conditional or not required27Accept assignment?Conditional – Enter an X in the YES box. Submission ofa claim for reimbursement of services provided to arecipient using state funds indicates the provideraccepts assignment28Total chargeRequired29Amount paidConditionalREQUIRED when another carrier is the primary payer.Enter the payment received from the primary payer priorto invoicing30Balance dueConditionalREQUIRED when field 29 is completed.Enter the balance due (total charges minus the amountof payment received from the primary payer)31Signature of physician or supplierincluding degrees or credentialsRequired32Service facility location informationConditionalREQUIRED if the location where services wererendered is different from the billing address listed infield 3332ANPI – Services renderedConditionalTypical providers ONLY: REQUIRED if the locationwhere services were rendered is different from the billingaddress listed in field 3332BOther provider IDConditionalREQUIRED if the location where services wererendered is different from the billing address listed infield 3333Billing provider INFO & PH#Required33AGroup billing NPIRequired33BGroup billing other IDRequiredPage 9 of 13June 29, 2018 Health Net Update 18-444
APPENDIX B – UB-04 BILLING INSTRUCTIONSField numberField descriptionRequired, conditional or not required1Unlabeled fieldRequired2Unlabeled fieldNot required3APatient control noNot required3BMedical record numberRequired4Type of billRequired5Fed tax noRequired6Statement covers period from/throughRequired7Unlabeled fieldNot required8APatient nameNot required8BPatient addressRequired9Patient addressRequired – Except line 9e county code10BirthdateRequired – Ensure DOB of patient is entered andnot the insured)11SexRequired12Admission dateRequired13Admission hourRequired14Admission typeRequired15Admission sourceRequired16Discharge hourConditional – Enter the time using two-digit militarytimes (00-23) for the time of the inpatient oroutpatient discharge17Patient statusRequired18-28Condition codesConditionalREQUIRED when condition codes are used toidentify conditions relating to the bill that may affectpayer processing29Page 10 of 13Accident stateNot requiredJune 29, 2018 Health Net Update 18-444
Field numberField descriptionRequired, conditional or not required30Unlabeled fieldNot required31-34 A–BOccurrence code and occurrence dateConditionalREQUIRED when occurrence codes are used toidentify events relating to the bill that may affectpayer processing35-36 A–B37Occurrence SPAN code and occurrencedateConditionalUnlabeled fieldConditionalREQUIRED when occurrence codes are used toidentify events relating to the bill that may affectpayer processingREQUIRED for resubmissions or adjustments. Enterthe DCN (document control number) of the originalclaim38Responsible party name and addressNot required39-41 A–DValue codes and amountsConditionalREQUIRED when value codes are used to identifyevents relating to the bill that may affect payerprocessing42 LINES 1–22REV CDRequired42 LINE 23Page of , Creation Date, Totals(for both columns)Required43 LINES 1–22DescriptionRequired43 LINE 23PAGE OFConditional – Enter the number of pages. (Limited to4 pages per claim)44 LINES 1–22HCPCS/ratesConditionalREQUIRED for outpatient claims when anappropriate CPT/HCPCS code exists for the serviceline revenue code billed45 LINES 1–22Service dateConditionalREQUIRED on all outpatient claims. Enter the dateof service for each service line billed (MMDDYY).Multiple dates of service may not be combined foroutpatient claims45 LINE 23Creation dateRequired46 LINES 1–22Service unitsRequiredPage 11 of 13June 29, 2018 Health Net Update 18-444
Field numberField descriptionRequired, conditional or not required47 LINES 1–22Total chargesRequired47 LINE 23TotalsRequired48 LINES 1–22Noncovered chargesConditional – Enter the noncovered charges included infield 47 for the revenue code listed in field 42 of theservice line. Do not list negative amounts48 LINE 23TotalsConditional – Enter the total noncovered charges for allservice lines49Unlabeled fieldNot required50 A–CPayerRequired51 A–CHealth plan identification numberNot required52 A–CREL informationRequired53ASG. BEN.Required54Prior paymentsConditional – Enter the amount received from theprimary payer on the appropriate line when Health Netis listed as secondary or tertiary55EST amount dueNot required56National Provider Identifier or provider IDRequired57Other provider IDRequired58Insured’s nameRequired59Patient relationshipNot required60Insured unique IDRequired61Group nameNot required62Insurance group no.Not required63Treatment authorization codeConditional – Enter the prior authorization or referralwhen services require precertification64Document control numberConditional – Enter the 12-character original claimnumber of the paid/denied claim when submitting areplacement or void on the corresponding A, B, C linereflecting Payer from field 5065Employer nameNot requiredPage 12 of 13June 29, 2018 Health Net Update 18-444
Field numberField descriptionRequired, conditional or not required66DX version qualifierRequired67Principal diagnosis codeRequired67 A–QOther diagnosis codeConditional – Enter additional diagnosis or conditionsthat coexist at the time of admission68Present on admission indicatorRequired69Admitting diagnosis codeRequired70Patient reason codeRequired71PPS/DRG codeNot required72 A, B, CExternal cause codeNot required73Unlabeled fieldNot required74Principal procedure code/dateConditional – Enter the ICD-10 procedure code thatidentifies the principal/primary procedure performed.Do not enter the decimal between the 2nd or 3rd digitsof code; it is implied. DATE: Enter the date the principalprocedure was performed (MMDDYY)74 A–EOther procedure code dateConditionalREQUIRED on inpatient claims when a procedure isperformed during the date span of the bill75Unlabeled fieldNot required76Attending physicianRequired77Operating physicianConditionalREQUIRED when a surgical procedure is performed.Enter the NPI and name of the physician in charge ofthe patient care78 & 79Other physicianConditional80RemarksNot required81CCRequired82Attending physicianRequiredPage 13 of 13June 29, 2018 Health Net Update 18-444
Health Net of California, Inc., Health Net Community Solutions, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. and Centene Corporation. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the pro
