Paper Claims – Instructions and Examples of Supplemental Information in Item 24:

Important Note: All unspecified Procedure or HCPCS codes require a narrative description be reported in the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry of 61 characters from the beginning of 24A to the end of 24G.

The following are types of supplemental information that can be entered in the shaded lines of Item Number 24:

• Anesthesia duration in hours and/or minutes with start and end times
• Narrative description of unspecified codes
• National Drug Codes (NDC) for drugs
• Vendor Product Number – Health Industry Business Communications Council (HIBCC)
* Product Number Health Care Uniform Code council

• Contract rate

The fowing qualifiers are to be when reporting these service

7 Anesthesia information
ZZ Narrative description of uns
N4 National Drug Codes
VP Vendor Product Number Health Industry Business Communications Council (HIBCC)

Some providers who use the UB-92 form need to follow specific instructions for certain Form Locators. If you are a specialty provider, look for Special Instructions: and the appropriate icon for you:

AFC Adult Family Care Homes
ICF-MR Intermediate Care Facilities-Mental Retardation
NF Nursing Facilities
PDN Private Duty Nursing
PNMI Private Non-Medical Institutions

Examples and Additional Help
The instructions for each required Form Locator or field within a Form Locator include an example of what the completed Form Locator or field should look like. In some Form Locators that have special instructions for specific providers, there are additional examples.

The instructions also give you important information and help.
Look for these icons:
ALERT:
TIP:

Additional Tips on Filing

Here’s other important information you need to know before you begin filling out your form:

In addition to the National UB-92 manual, in order to complete the UB-92 form, you must have current CPT (Current Procedural Terminology) of the American Medical Association, ICD-9 (International Classification of Diseases) Diagnostic Codes, or HCPCS (Healthcare Common Procedure Coding System) Codes maintained by the Centers for Medicare and Medicaid Services.

The required format for a birth date is MMDDYYYY. (Example: January 19, 1947 = 01191947)
The alternative date format for dates of service or signature dates is MMDDYY.
DHHS will process your claim if you use that format, but we recommend that you transition to the eight-digit Y2K-compliant format.

Whether you fill in your claim form by typing, computer, or handwriting, keep all information within the designated FL. Do not overlap information into other form locators. Handwritten claims must be legible.

Required, Not Required, and Hospital Only Form Locators – UB 92

In these instructions, FL is Form Locator.

Form Locators that are not shaded are required for all or most providers. You’ll see a notation in the Form Locator if it is required for only certain providers, such as Hospitals or if that Form Locator refers to information entered elsewhere in the claim.

This is an example of a Form Locator required for all providers:
Required:
FL 15: SEX
Enter the patient’s sex as M or F.
Example:
F

Form Locators that are not required are shaded.

Not Required:
This is an example of a Form Locator that is not required for any provider:
FL 31:
Not required.

Please note, although some Form Locators are not required, they are also not shaded. This is because DHHS recommends that you enter special information in these Form Locators. This optional information, such as the patient’s account number, will help you in your recordkeeping.

Also check the Special Instructions to see if your provider type is not required to complete a Form Locator.

Unless these instructions say that a Form Locator must be left blank, you may use Not Required Form Locators for your own business purposes.

If you have been paid, but paid incorrectly for a claim or received payment from a third party after Medical Assistance has made payment, you must complete and submit an Adjustment
Request Form (DHMH 4518A) to correct the payment.

If an incorrect payment was due to a keying error made by Medical Assistance, or you billed the incorrect number of units, you must complete an Adjustment Request Form following the directions on the back of the form.

When completing the Adjustment Form, do not bill only for remaining unpaid amounts or units,
bill for entire amount(s).

Example: You submitted and received payment for three units, but you should have billed for five units. Do not bill for the remaining two units; bill for the full five units.

Total Refunds – If you receive an incorrect payment, return the check issued by the Medical Assistance Program only when every claim payment listed on the remittance advice is incorrect, i.e., none of the recipients listed are your patients. When this occurs, return with a copy of the remittance advice and the check with a complete Adjustment Request Form to the address on the bottom of the form.

Partial Refunds – If you receive a remittance advice, which lists some correct payments and some incorrect payments do not return the Medical Assistance Program check. Deposit the check and file an Adjustment Request Form for each individual claim paid incorrectly.

NOTE: For over payments or refunds, the provider may issue and submit one check to cover more than one Adjustment Request Form.

Before mailing Adjustment Request Forms, be sure to attach any supporting documentation such as remittance advices and CMS-1500 claim forms.

Completion of Medicare/Medicaid Related Claims for CMS-1500

If medical services are provided to a client who is entitled to Medicare under the Social Security Act and also to Medicaid benefits, it is necessary that you file a claim with Medicare first. After you receive payment from Medicare, you may file a claim to Medicaid for reimbursement consideration. Each performing provider’s services must be billed on a separate claim form to Medicare in order to file a Medicare/Medicaid related claim to EDS.

In order to submit a Medicare/Medicaid claim to EDS, you must submit an original CMS-1500 claim with the following fields altered from your Medicare claim:

• Field 1a – complete this field with the client’s identification number;
• Field 24J – complete this field with the performing provider’s NPI or Atypical number;
• Field 29 – do not enter the Medicare Paid Amount. Enter only the total amount of funds received from third party insurance sources, other than Medicare; and,
• Field 31 – each claim must be signed with an original black ink signature;
• Field 33a – complete this field with the billing provider’s NPI or Atypical number.

You must include a copy of the Medicare EOMB to the claim with the client’s name circled. Each Medicare/Medicaid client listed on the EOMB must have a separate claim filed with an EOMB included with their claim form.

Any charges denied by Medicare will not be paid by Medicaid with the exception of:
those services not covered by medicare but covered by Medicaid; or
services covered by both Medicare and Medicaid but with different limits or criteria. In these instances Medicaid will determine coverage on the basis of its own policy.

You must include a copy of the Medicare EOMB to the claim with the client’s name circled. Each Medicare/Medicaid client listed on the EOMB must have a separate claim filed with an EOMB included with his or her claim form. Each performing provider’s services must be billed on a separate claim form with a maximum of six lines and no double details in one box.

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