SampleHP MC 003 by m4S53q8c

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									Instructions for Completion of the Outpatient Services Medicare – Medicaid Crossover Invoice –
HP-MC-003

   HP Enterprise Services offers providers several options for electronic billing. Therefore, claims
   submitted on paper are paid once a month. The only claims exempt from this process are those
   which require attachments or manual pricing.

   To bill for Medicare – Medicaid crossover outpatient services, use the claim form HP-MC-003. The
   numbered items correspond to fields on the claim form. Each service should be billed separately,
   providing the appropriate information for each.

   Read and carefully adhere to the following instructions. Accuracy, completeness and clarity are
   important. Claims cannot be processed if applicable information is not supplied or is illegible. Paper
   claims should be typed whenever possible.

   Completed claim forms should be forwarded to the HP Enterprise Services Claims Department. View
   or print the HP Enterprise Services Claims Department contact information.

   NOTE:       A provider rendering services without verifying eligibility for each date of service
               does so at the risk of not being reimbursed for the services.

   Field Name and Number                  Instructions for Completion
   Header 1
   1. Medicaid Provider ID                Enter your 9-digit Arkansas Medicaid billing provider ID
                                          number.
   2. Beneficiary
       A. ID                              Enter the patient’s10-digit Medicaid ID number.
       B. First Name                      Enter the first initial of the patient’s first name.
       C. Last Name                       Enter the first two letters of the patient’s last name.
   3. Medical Rec #                       Enter your office identifier.
   4. Patient Status                      Enter the patient status.
   5. Dates of Service
       A. Admission                       Enter the date the patient was admitted to the facility.
       B. From                            Enter the first date of service for the claim.
       C. Through                         Enter the last date of service for the claim.
       D. Days Covered                    Enter the number of covered days for the claim.
   6. Diagnosis                           Enter the diagnosis code for the claim.
   7. Type of Bill                        Enter the type of bill for the claim.
   Header 2
   8. Medicare ICN                        Enter the Internal Control Number (ICN) from the Medicare
                                          Explanation of Benefits (EOB).
   9. Medicare Paid Date                  Enter the date that is printed on the Medicare EOB.
   10. Medicare Amounts
       A. Total Medicare Billed           Enter the total billed amount for the entire claim from the
                                          Medicare EOB.
       B. Medicare Non-Covered            Enter the Medicare Non-Covered amount for the entire
                                          claim from the Medicare EOB information.
Field Name and Number             Instructions for Completion
   C. Medicare Deductible         Enter the deductible amount for the entire claim from the
                                  Medicare EOB.
   D. Medicare Blood Deductible   Enter the blood deductible from the Medicare EOB, if
                                  applicable.
   E. Medicare Coinsurance        Enter the coinsurance amount for the entire claim from the
                                  Medicare EOB.
   F. Other Insurance Amount      Enter the amount paid by a third-party insurance company;
                                  if none, enter 0 (zero). This would be a company like Blue
                                  Cross, Health Advantage, etc.
   G. Net Billed                  Enter the total billed amount minus any other private
                                  insurance payment. This excludes any Medicare or
                                  replacement policy insurance.
   H. Medicare Paid               Enter the Medicare Paid amount for the entire claim from
                                  the Medicare EOB.

								
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