Medicare/Medi-Cal Crossover Claims: UB-04 Billing Examples (Medi Cr Ub Ex)

Medicare/Medi-Cal Crossover Claims:medi cr ub ex

UB-04 Billing Examples1

This section illustrates billing examples of Medicare/Medi-Cal crossover claims for Part B services billed to Part A contractors submitted hard copy on a UB-04 Claim Form and correlating Remittance Advice (RA)examples. Refer to the Medicare/Medi-Cal Crossover Claims: UB-04 section in this manual for detailed policy information. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual.

Note:A crossover claim reflects what was billed to Medicare, but only Medi-Cal-required fields are used for claims processing.

Billing Tips:When completing claims, do not enter the decimal points in ICD-10-CM codes or dollar

amounts. If requested information does not fit neatly in the Remarks area of the claim, type it on an 8½ x 11-inch sheet of paper and attach it to the claim.

Hard Copy Billing ExamplesThe following examples show how to bill hard copy Medicare/Medi-Cal crossover claims:

Figures 1a and 1b. Billing Medi-Cal for Part B Services Billed

to a Part A Contractor, Medical Transportation Services.

Figures 2a and 2b. Billing Medi-Cal for Part B Services Billed

to a Part A Contractor, Rehab Services.

Figures 3a, 3b, 3c and 3d. Billing for More Than 15 Line Items

for Part B Services Billed to a Part A Contractor With

Deductible and/or Coinsurance.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 480

UB-04 Billing ExamplesSeptember 2015

medi cr ub ex

Figure 1a. Billing Medi-Cal for Part B Services Billed to a Part A Contractor Example,

Medical Transportation Services.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 480

UB-04 Billing ExamplesSeptember 2015

medi cr ub ex

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Medicare National Standard Intermediary Remittance Advice

Uptown Medical CenterFPE:10/30/16MEDICARE CONTRACTOR

140 Second StreetPAID:12/30/165151-B Camillo Ruiz

Anytown, CA 95823-1000CLM#:152CAMARILLO, CA 93012-8645

01101TOB:131805-367-1163

======

PATIENT: DOE, JOHNPCN: 123456789

MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638

PAT STAT: 07 CLAIM STAT: 1THRU: 10/01/2016ICN: 12345678901234

======

CHARGES:PAYMENT DATA: =DRG0.340=REIM RATE

2052.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER

0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT

0.00=CLAIM ADJS1849.65=LINE ADJ AMT 0.00=ESRD AMOUNT

2492.00=COVERED0.00=OUTLIER (C)642.35=PROC CD AMOUNT

DAYS/VISITS:0.00=CAP OUTLIER447.77=ALLOW/REIM

0=COST REPT0.00=CASH DEDUCT 0.00=G/R AMOUNT

0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST

0=NON-COVERED194.58=COINSURANCE0.00=CONTRACT ADJ

0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT

0=NCOV VISITS0.00=MSP LIAB MET447.77=NET REIM AMT

ADJ REASON CODES: OA 930

REMARK CODES:MA01N114

======

REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES

054010/16A0426HN QN12012.00365.69CO421488.09

PR2158.22

054010/16A0425HN QN12480.0082.08CO42361.56

PR236.36

======

Figure 1b. Medicare Remittance Advice Example.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 510

UB-04 Billing ExamplesMarch 2018

medi cr ub ex

Figure 2a. Billing Medi-Cal for Part B Services Billed to a Part A Contractor Example, Rehab Services.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 510

UB-04 Billing ExamplesMarch 2018

medi cr ub ex

======

Medicare National Standard Intermediary Remittance Advice

Uptown Medical CenterFPE:10/30/15MEDICARE CONTRACTOR

140 Second StreetPAID:12/30/155151-B Camillo Ruiz

Anytown, CA 95823-1000CLM#:152CAMARILLO, CA 93012-8645

01101TOB:131805-367-1163

======

PATIENT: DOE, JANEPCN: 123456789

MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2015MRN: 000193638

PAT STAT: 30 CLAIM STAT: 1THRU: 10/03/2015ICN: 12345678901234

======

CHARGES:PAYMENT DATA: =DRG0.800=REIM RATE

272.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER

0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT

0.00=CLAIM ADJS60.78=LINE ADJ AMT 0.00=ESRD AMOUNT

272.00=COVERED0.00=OUTLIER (C)211.22=PROC CD AMOUNT

DAYS/VISITS:0.00=CAP OUTLIER147.60=ALLOW/REIM

0=COST REPT26.72=CASH DEDUCT 0.00=G/R AMOUNT

0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST

0=NON-COVERED36.90=COINSURANCE0.00=CONTRACT ADJ

0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT

0=NCOV VISITS0.00=MSP LIAB MET147.60=NET REIM AMT

ADJ REASON CODES:

REMARK CODES:MA01

======

REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES

041010/01G02375125.0066.84CO4229.35

PR216.71

112.10

041010/03G02375125.0066.84CO4229.35

PR216.71

112.10

041010/01G0238122.0022.00CO422.08

PR23.48

12.52

======

Figure 2b. Medicare Remittance Advice Example.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 510

UB-04 Billing ExamplesMarch 2018

medi cr ub ex

Figure 3a. Billing for More Than 15 Line Items for Part B Services Billed to Part A Contractors.
Split Bill Claim 1 of 2. (see also Figure 3b).

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 363

UB-04 Billing ExamplesJanuary 2006

medi cr ub ex

Figure 3b(continued from 3a). Billing for More Than 15 Line Items for Part B Services

Billed to Part A Contractors. Split Bill Claim 2 of 2. (see also Figure 3c).

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 480

UB-04 Billing ExamplesSeptember 2015

medi cr ub ex

======

Medicare National Standard Intermediary Remittance Advice

Uptown Medical CenterFPE:10/30/16MEDICARE CONTRACTOR

140 Second StreetPAID:12/30/165151-B Camillo Ruiz

Anytown, CA 95823-1000CLM#:152CAMARILLO, CA 93012-8645

01101TOB:131805-367-1163

======

PATIENT: DOE, JOHNPCN: 123456789

MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638

PAT STAT: 30 CLAIM STAT: 1THRU: 10/16/2016ICN: 12345678901234

======

CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE

2317.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER

133.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT

0.00=CLAIM ADJS0.00=LINE ADJ AMT 0.00=ESRD AMOUNT

2174.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT

DAYS/VISITS:0.00=CAP OUTLIER416.44=ALLOW/REIM

0=COST REPT0.00=CASH DEDUCT 0.00=G/R AMOUNT

0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST

0=NON-COVERED105.59=COINSURANCE1765.23=CONTRACT ADJ

0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT

0=NCOV VISITS0.00=MSP LIAB MET416.44=NET REIM AMT

ADJ REASON CODES:

REMARK CODES:MA01

======

REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES

042010/01G0238GP1101.009.70CO4288.87

PR22.43

042010/02G0238GP1101.009.70CO4288.87

PR22.43

042010/03G0238GP1101.009.70CO4288.87

PR22.43

042010/08G0238GP1101.009.70CO4288.87

PR22.43

042010/09G0238GP1101.009.70CO4288.87

PR22.43

042010/11G0238GP1101.009.70CO4288.87

PR22.43

042010/16G0238GP1101.009.70CO4288.87

PR22.43

042010/0197018GP166.500.00COB1566.50

042010/0297018GP166.500.00COB1566.50

042010/0197018GP183.0010.65CO4269.69

PR22.66

042010/0397110GP1109.0024.86CO4277.92

PR26.22

042010/0897110GP1109.0024.86CO4277.92

PR26.22

042010/0997110GP1109.0024.86CO4277.92

PR26.22

042010/1197110GP1109.0024.86CO4277.92

PR26.22

042010/1697110GP2218.0049.73CO42155.84

PR212.43

042010/0397140GP2191.5045.95CO42134.06

PR211.49

042010/0897140GP2191.5045.95CO42134.06

PR211.49

042010/0997140GP2191.5045.95CO42134.06

PR211.49

042010/1197140GP182.5022.98CO4252.78

PR211.48

======

Figure 3c. MedicareRemittance Advice Example Split Bill Claim 1 of 2.

======

Medicare National Standard Intermediary Remittance Advice

Uptown Medical CenterFPE:10/30/16MEDICARE CONTRACTOR

140 Second StreetPAID:12/30/165151-B Camillo Ruiz

Anytown, CA 95823-1000CLM#:152CAMARILLO, CA 93012-8645

01101TOB:131805-367-1163

======

PATIENT: DOE, JOHNPCN: 123456789

MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638

PAT STAT: 30 CLAIM STAT: 1THRU: 10/16/2016ICN: 12345678901234

======

CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE

2317.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER

133.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT

0.00=CLAIM ADJS0.00=LINE ADJ AMT 0.00=ESRD AMOUNT

2174.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT

DAYS/VISITS:0.00=CAP OUTLIER416.44=ALLOW/REIM

0=COST REPT0.00=CASH DEDUCT 0.00=G/R AMOUNT

0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST

0=NON-COVERED105.59=COINSURANCE1765.23=CONTRACT ADJ

0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT

0=NCOV VISITS0.00=MSP LIAB MET416.44=NET REIM AMT

ADJ REASON CODES:

REMARK CODES:MA01

======

REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES

042010/01G0238GP1101.009.70CO4288.87

PR22.43

042010/02G0238GP1101.009.70CO4288.87

PR22.43

042010/03G0238GP1101.009.70CO4288.87

PR22.43

042010/08G0238GP1101.009.70CO4288.87

PR22.43

042010/09G0238GP1101.009.70CO4288.87

PR22.43

042010/11G0238GP1101.009.70CO4288.87

PR22.43

042006/16G0238GP1101.009.70CO4288.87

PR22.43

042010/0197018GP166.500.00COB1566.50

042010/0297018GP166.500.00COB1566.50

042010/0197018GP183.0010.65CO4269.69

PR22.66

042010/0397110GP1109.0024.86CO4277.92

PR26.22

042010/0897110GP1109.0024.86CO4277.92

PR26.22

042010/0997110GP1109.0024.86CO4277.92

PR26.22

042010/1197110GP1109.0024.86CO4277.92

PR26.22

042010/1697110GP2218.0049.73CO42155.84

PR212.43

042010/0397140GP2191.5045.95CO42134.06

PR211.49

042010/0897140GP2191.5045.95CO42134.06

PR211.49

042010/0997140GP2191.5045.95CO42134.06

PR211.49

042010/1197140GP182.5022.98CO4252.78

PR211.48

======

Figure 3d. MedicareRemittance Advice Example Split Bill Claim 2 of 2.

2 – Medicare/Medi-Cal Crossover Claims:Allied Health 510

UB-04 Billing ExamplesMarch 2018