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Home Health Services UB-04 Billing GuidelinesAn ETIN and a Certification Statement are required to submit paper claims. Providerswho have a valid ETIN for the submission of electronic claims do not need an additionalETIN for paper submissions. The ETIN and associated certification qualifies theprovider to submit claims in both electronic and paper formats.General Instructions for Completing Paper ClaimsSince the information entered on the claim form is captured via an automated datacollection process (imaging), it is imperative that it be legible and placed appropriately inthe required fields. The following guidelines will help ensure the accuracy of theimaging output: All information should be typed or printed. Alpha characters (letters) should be capitalized. Numbers should be written as close to the example below as possible:1234567890 Circles (the letter O, the number 0) must be closed. Avoid unfinished characters. For example:Written As6.0 0Intended As6.00Interpreted As6.60 Zero interpreted as six When typing or printing, stay within the box provided; ensure that no characters(letters or numbers) touch the claim form lines. For example:Written AsIntended AsInterpreted As227323 Two interpreted as sevenThree interpreted as two Characters should not touch each other. For example:Written As23Version 2008 – 3 (11/11/08)Intended As23Interpreted Asillegible Entry cannot beinterpreted properlyPage 9 of 51

Home Health Services UB-04 Billing Guidelines Do not write between lines. Do not use arrows or quotation marks to duplicate information. Do not use the dollar sign ( ) to indicate dollar amounts; do not use commas toseparate thousands. For example, three thousand should be entered as 3000, not as3,000. For writing, it is best to use a felt tip pen with a fine point. Avoid ballpoint pens thatskip; do not use pencils, highlighters, or markers.acceptable.Only blue or black ink is If entering information through a computer, ensure that all information is alignedproperly, and that the printer ink is dark enough to provide clear legibility. Do not submit claim forms with corrections, such as information written overcorrection fluid or crossed out information. If mistakes are made, a new form shouldbe used. Separate forms using perforations; do not cut the edges. Do not fold the claim forms. Do not use adhesive labels (for example for address); do not place stickers on theform.The address for submitting claim forms is:COMPUTER SCIENCES CORPORATIONP.O. Box 4601Rensselaer, NY 12144-4601UB-04 Claim FormTo view the UB-04 claim form please click on the link provided below. The displayedclaim form is a sample and the information it contains is for illustration purposes only.Home Health – UB-04 Sample ClaimGeneral Information About the UB-04 FormThe UB-04 CMS-1450 is a CMS standard form; therefore CSC does not supply it. Theform can be obtained from any of the national suppliers.Version 2008 – 3 (11/11/08)Page 10 of 51

Home Health Services UB-04 Billing GuidelinesThe UB-04 Manual (National Uniform Billing Data Element Specifications as Developedby the National Uniform Billing Committee – Current Revision) should be used inconjunction with this Provider Billing Guideline as a reference guide for the preparationof claims to be submitted to NYS Medicaid. The UB-04 manual is available atwww.nubc.org.Form Locators in this manual for which no instruction has been provided have noMedicaid application. These Form Locators are ignored when the claim is processed.Billing Instructions for Home Health ServicesThis subsection of the Billing Guidelines covers the specific NYS Medicaid billingrequirements for Home Health providers. Although the instructions that follow arebased on the UB-04 paper claim form, they are also intended as a guideline forelectronic billers who should refer to these instructions for finding out what informationthey need to provide in their claims, what codes they need to use, etc.It is important that providers adhere to the instructions outlined below. Claims that donot conform to the eMedNY requirements as described throughout this document maybe rejected, pended, or denied.Field-by-Field (UB-04) InstructionsPROVIDER NAME, ADDRESS, AND TELEPHONE NUMBER (Form Locator 1)Enter the billing provider’s name and address, using the following rules for submittingthe ZIP code: Paper claim submissions: Enter the 5 digit ZIP code or the ZIP plus four. Electronic claim submissions: Enter the 9 digit ZIP code.Note: It is the responsibility of the provider to notify Medicaid of any change ofaddress or other pertinent information within 15 days of the change. Forinformation on where to direct address change requests, refer to Information forAll Providers, Inquiry section which can be found on the web page for thismanual.Version 2008 – 3 (11/11/08)Page 11 of 51

Home Health Services UB-04 Billing GuidelinesPATIENT CONTROL NO. (Form Locator 3a)For record-keeping purposes, the provider may choose to identify a patient by using anaccount/patient control number. This field can accommodate up to 30 alphanumericcharacters. If an account/patient control number is indicated on the claim form, the first20 characters will be returned on the paper Remittance Advice. Using anaccount/patient control number can be helpful for locating accounts when there is aquestion on patient identification.TYPE OF BILL (Form Locator 4)Completion of this field is required for all provider types. All entries in this field mustcontain three digits. Each digit identifies a different category as follows: 1st Digit – Type of Facility 2nd Digit – Bill Classification 3rd Digit – FrequencyType of FacilityEnter the value 3 (Home Health) as the first digit of this field. The source of this code isthe UB-04 Manual, Form Locator 4, Type of Facility category.Bill ClassificationEnter the value 4 (Other) as the second digit of this field. The source of this code is theUB-04 Manual, Form Locator 4, Bill Classification (Except Clinics and Special Facilities)category.Example:Frequency - Adjustment/Void CodeNew York State Medicaid uses the third position of this field only to identify whether theclaim is an original, a replacement (adjustment) or a void. If submitting an original claim, enter the value 0 in the third position of this field.Example:Version 2008 – 3 (11/11/08)Page 12 of 51

Home Health Services UB-04 Billing Guidelines If submitting an adjustment (replacement) to a previously paid claim, enter the value 7in the third position of this field.Example: If submitting a void to a previously paid claim, enter the value 8 in the third position ofthis field.Example:STATEMENT COVERS PERIOD FROM/THROUGH (Form Locator 6)Enter the date(s) of service claimed in accordance with the instructions provided below. When billing for one date of service, enter the date in the FROM box. TheTHROUGH box may contain the same date or may be left blank. When billing for multiple services dates, enter the first service date of the billingperiod in the FROM box and the last service date in the THROUGH box. TheFROM/THROUGH dates must be in the same calendar month. Instructions for billingmultiple dates of service are provided below in Form Locators 42 – 47.Dates must be entered in the format MMDDYYYY.Notes: The provider’s paper remittance statement will only contain the date of servicein the “FROM” box with the total number of units for the sum of all dates ofservice reported below. Providers who receive an electronic 835 remittancewill receive only the claim level dates of service (from and through) as reportedon the incoming claim transaction. Claims must be submitted within 90 days of the earliest date (From date)entered in this field unless acceptable circumstances for the delay can bedocumented. For more information about billing claims over 90 days or twoyears from the Date of Service, refer to Information for All Providers, GeneralBilling section, which can be found on the web page for this manual.Version 2008 – 3 (11/11/08)Page 13 of 51

Home Health Services UB-04 Billing GuidelinesPATIENT NAME (Form Locator 8 – Line b)Enter the patient’s last name followed by the first name.BIRTHDATE (Form Locator 10)Enter the patient’s birth date. The birth date must be in the format MMDDYYYY.Example: Mary Brandon was born on March 5, 1935. Enter the birth date as 03051935.10 BIRTHDATE03051935SEX (Form Locator 11)Enter M for male or F for female to indicate the patient’s sex.ADMISSION (Form Locators 12-15)Leave all fields blank.STAT [Patient Status] (Form Locator 17)This field is used to indicate the specific condition or status of the patient as of the lastdate of service indicated in Form Locator 6. Select the appropriate code (except for 43and 65) from the UB-04 Manual.CONDITION CODES (Form Locators 18–28)NYS Medicaid uses Condition Codes to indicate the following: Possible Disability EPSDT/CTHP Family Planning Abortion/SterilizationNote: EPSDT/CTHP, Family Planning, and Abortion Sterilization Codes are notapplicable to Home Health services.Possible Disability – A5If applicable, enter Condition Code A5 to indicate that the patient’s condition appearedto be of a disabling nature. Otherwise leave this field blank.Version 2008 – 3 (11/11/08)Page 14 of 51

Home Health Services UB-04 Billing GuidelinesOCCURRENCE CODE/DATE (Form Locators 31–34)NYS Medicaid uses Occurrence Codes to report an Accident Code. This field has twocomponents: Code and Date; both are required when applicable.CodeIf applicable, enter the appropriate Accident Code to indicate whether the servicerendered to the patient was for a condition resulting from an accident or crime. Selectthe code from the UB-04 Manual, Form Locators 31–34, Accident Related Codes.DateIf an entry was made under Code, enter the date when the accident occurred in theformat MMDDYY.VALUE CODES (Form Locators 39–41)NYS Medicaid uses Value Codes to report the following information: Locator Code (required: see note for conditions) Rate Code (required) Medicare Information (only if applicable) Other Insurance Payment (only if applicable) Patient Participation/Spend-down (only if applicable)Value Codes have two components: Code and Amount. The Code component is usedto indicate the type of information reported. The Amount component is used to enterthe information itself. Both components are required for each entry.Locator Code - Value Code 61Locator Codes are assigned to the provider for each service address registered at thetime of enrollment in the Medicaid program or at anytime, afterwards, that a newlocation is added.Value CodeCode 61 should be used to indicate that a Locator Code is entered under Amount.Value AmountLocator codes 001 and 002 are for administrative use only and are not to be entered inthis field. The entry may be 003 or a higher locator code. Enter the locator code thatcorresponds to the address where the service was performed.Version 2008 – 3 (11/11/08)Page 15 of 51

Home Health Services UB-04 Billing GuidelinesThe example below illustrates a correct Locator Code entry.Example:Notes: Until NPI implementation by NYS Medicaid, the Locator Code field must becompleted on both 837I electronic transactions and on UB-04 paper claimsubmissions. After NPI implementation, the Locator Code field is only requiredfor UB-04 paper claim submissions. The provider is reminded of the obligation to notify Medicaid of all servicelocations as well as changes to any of them. For information on where todirect Locator Code updates, refer to Information for All Providers, Inquirysection on the web page for this manual.Rate Code - Value Code 24Rates are established by the Department of Health and other State agencies. At thetime of enrollment in Medicaid, providers receive notification of the rate codes and rateamounts assigned to their category of service. Any time that rate codes or amountschange, providers also receive notification from the Department of Health.Value CodeCode 24 should be used to indicate that a rate code is entered under Amount.Value AmountEnter the rate code that applies to the service rendered. The four-digit rate code mustbe entered to the left of the dollars/cents delimiter.The example below illustrates a correct Rate Code entry.Example:Version 2008 – 3 (11/11/08)Page 16 of 51

Home Health Services UB-04 Billing GuidelinesMedicare Information (See Value Codes Below)If the patient is also a Medicare beneficiary, it is the responsibility of the provider todetermine whether the service being billed for is covered by the patient's Medicarecoverage. If the service is covered or if the provider does not know if the service iscovered, the provider must first submit a claim to Medicare, as Medicaid is always thepayer of last resort.Value Code If applicable, enter the appropriate code, as listed below, to indicate that one (ormore) of the following items is entered under Amount. Medicare Deductible – A1 or B1 Medicare Co-insurance – A2 or B2 Medicare Co-payment – A7 or B7 Enter code A3 or B3 to indicate that the Medicare Payment is entered under Amount.Note: The line (A or B) assigned to Medicare in Form Locator 50 determines thechoice of codes AX or BX.Value Amount Enter the corresponding amount for each value code entered. Enter the amount that Medicare actually paid for the service. If Medicare deniedpayment or if the provider knows that the service would not be covered by Medicare,or has received a previous denial of payment for the same service, enter 0.00.Proof of denial of payment must be maintained in the patient's billing record.Other Insurance Payment – Value Code A3 or B3If the patient has insurance other than Medicare, it is the responsibility of the provider todetermine whether the service being billed for is covered by the patient's OtherInsurance carrier. If the service is covered or if the provider does not know if the serviceis covered, the provider must first submit a claim to the Other Insurance carrier, asMedicaid is always the payer of last resort.Value CodeIf applicable, code A3 or B3 should be used to indicate that the amount paid by aninsurance carrier other than Medicare is entered under Amount. The line (A or B)assigned to the Insurance Carrier in Form Locator 50 determines the choice of codesA3 or B3.Version 2008 – 3 (11/11/08)Page 17 of 51

Home Health Services UB-04 Billing GuidelinesValue AmountEnter the actual amount paid by the other insurance carrier. If the other insurancecarrier denied payment enter 0.00. Proof of denial of payment must be maintained inthe patient’s billing record. Zeroes must also be entered in this field if any of thefollowing situations apply: Prior to billing the insurance company, the provider knows that the service will not becovered because: The provider has had a previous denial for payment for the service from theparticular insurance policy. However, the provider should be aware that theservice should be billed if the insurance policy changes. Proof of denialsmust be maintained in the patient’s billing record. Prior claims denied due todeductibles not being met are not to be counted as denials for subsequentbillings. In very limited situations the Local Department of Social Services (LDSS) hasadvised the provider to zero-fill the Other Insurance payment for the sametype of service. This communication should be documented in the client'sbilling record. The provider bills the insurance company and receives a rejection because: The service is not covered; or The deductible has not been met. The provider cannot directly bill the insurance carrier and the policyholder is eitherunavailable or uncooperative in submitting claims to the insurance company. In thesecases the LDSS must be notified prior to zero-filling. The LDSS has subrogationrights enabling it to complete claim forms on behalf of uncooperative policyholderswho do not pay the provider for the services. The LDSS can direct the insurancecompany to pay the provider directly for the service whether or not the providerparticipates with the insurance plan. The provider should contact the third-partyworker in the LDSS whenever he/she encounters policyholders who areuncooperative in paying for covered services received by their dependents who areon Medicaid. In other cases providers will be instructed to zero-fill the OtherInsurance payment in the Medicaid claim and the LDSS will retroactively pursue thethird-party resource. The patient or an absent parent collects the insurance benefits and fails to submitpayment to the provider. The LDSS must be notified so that sanctions and/or legalaction can be brought against the patient or absent parent.Version 2008 – 3 (11/11/08)Page 18 of 51

Home Health Services UB-04 Billing Guidelines The provider is instructed to zero-fill by the LDSS for circumstances not listed above.The following example illustrates a correct Other Insurance Payment entry.Example:Patient Participation (Spend Down) – Value Code 31Some patients of the Home Health services do not become eligible for Medicaid untilthey pay an overage or monthly amount (spend-down) toward the cost of their medicalcare.Value CodeIf applicable, enter code 31 to indicate that the patient’s spend-down participation isentered under Amount.Value AmountEnter the spend-down paid by the patient.The following example illustrates a correct Patient Participation entry.Example:REV. CD. [Revenue Code] (Form Locator 42)NYS Medicaid uses Revenue Codes to report the following information: Total Amount Charged UnitsTotal Amount ChargedUse Revenue Code 0001 to indicate that total charges for the services being claimed inthe form are entered in Form Locator 47.Version 2008 – 3 (11/11/08)Page 19 of 51

Home Health Services UB-04 Billing GuidelinesUnitsUse an appropriate Revenue Code from the UB-04 manual to indicate that the units ofservice are entered in Form Locator 46.If billing for multiple dates of service, a revenue code must be entered on each line thatcorresponds to Form Locator 45 (Serv. Date) and 46 (Serv. Units).Note: If the number of service lines (dates of service) exceed the number of linesthat can be accommodated on a single UB-04 form, another claim form must beentirely completed. Medicaid cannot process additional claim lines without allthe required information. Each claim form will be processed as a unique claimdocument and must contain only one Total Charges 0001 Revenue Code. Multipaged documents cannot be accepted either.SERV. DATE (Form Locator 45)Enter the service date corresponding to each iteration of a revenue code other than0001. The dates entered here must be contained within the billing period(FROM/THROUGH) in Form Locator 6.SERV. UNITS (Form Locator 46)If billing for more than one unit of service, enter the number of units on the same linewhere a Revenue Code other than Revenue Code 0001 was entered in Form Locator42. For determining the number of units, follow the guidelines below.Hour-based RateIf the rate is based on one-hour service, enter the number of hours that reflect the totalof home health care time being claimed. When billing for Home Health Aide services ona per hour basis, the service units must be reported as full units only. Partial hours ofservice must be rounded to the nearest whole hour. In situations where the totalamount of service rendered is less than 30 minutes, one (1) hour of service may beclaimed.Examples:For a service of three hours and 30 minutes, enter 4 units.For a service of three hours and 25 minutes, enter 3 units.For a service of 15 minutes, enter 1 unit.T

Home Health Services UB-04 Billing Guidelines Version 2008 - 3 (11/11/08) Page 8 of 51 Access to the eMedNY eXchange is obtained through an enrollment process. To enroll in eXchange, you must first complete enrollment in ePACES and at least one login attempt must be successful. FTP