Prior Authorizations

							Billing Tips to Help Providers Avoid
Common Billing Problems - Overview
 Proper Forms and the Fields Causing The
  Most Problems
 Provider Number Usage
 Top 5 Reasons a Bill Is Returned
 Common Bill Denial Reasons & What To
  Do About Them
 How To Request an Adjustment

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HCFA 1500
 Also called OWCP–1500 and CMS - 1500
 Submitted by:
      Physicians

      DME Vendors

      Therapists

      Rural Health Clinics

      Chiropractors

      Other specialized medical providers,
       excluding dentists
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HCFA 1500

Fields that cause the
most problems are
highlighted.




                        3
HCFA 1500 Problematic Fields
 Box 1a or 11 – Claimant Case Number
 Boxes 12 & 13 – “Signature on File”
 Box 21 – ICD-9 Diagnosis Codes
 Box 24A – Dates of Service
 Box 24D – CPT/HCPCS Procedure Codes
  and modifiers if applicable


                                        4
HCFA 1500 Problematic Fields
 Box 24E – Diagnosis pointers
 Box 24F – Line Charges
 Box 24G – Units
 Box 25 – Provider Federal Tax ID #
 Box 28 – Total Charge
 Box 31 – Signature of physician and bill
  date
                                             5
BOX 31 – Treating Provider
   Appropriate signature
   Bill date must be after last date of service


BOX 32 – Service Address
   Address where service was rendered
   Include Zip Code


                                                   6
BOX 33 – Billing Address
 Address where payment is sent
 Provider number (generated by enrollment)


From a provider perspective this is
the most important field on a HCFA.
This information is vital to pay the
correct provider.
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UB-92
   Submitted by:
            -General Hospitals
            -Nursing Homes
            -Hospices
            -Skilled Nursing Facilities



                                          8
      UB-92

Fields that cause the
most problems are
highlighted.




                        9
UB-92 Problematic Fields
 Box 1 – Billing Address
 Box 4 – Type of bill
 Box 5 – Provider Federal Tax ID #
 Box 6 – Statement covers period
 Box 17 to 20 – Admission
  (date/hour/type/source)
 Box 21 & 22 – Discharge hour and
  Discharge status
                                      10
UB-92 Problematic Fields
 Box 42 to 47 – Detail line items (Provide
  HCPCS for required RCC’s)
 Box 51 – Provider number and Medicare
  number
 Box 60 – Claimant’s case number
 Box 67 to 75 – ICD-9 Diagnosis codes
 Box 80 to 81 – Appropriate procedure codes

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Provider Number/ID Usage

   Identifies proper provider for authorizations and
    payment
   Use it when you bill
   Use it on the web portal
   Use it when you call in to get information from
    our call center

    Please Learn it and Use it!
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Top 5 Reasons A Bill is Returned
1.   No signature on file in box 12 and 13 on
     HCFA-1500
2.   Claimant ID missing
3.   Tax ID missing
4.   Doctors billing for prescriptions dispensed
     in office MUST to use J8499 and the NDC
     code
5.   Revenue codes missing on UB-92
                                              13
Return letter contains
specific information
about why the bill
was returned.




                         14
Resubmit Returned Bills for
Processing
 Correct items noted in letter
 Resubmit the bill for processing




                                     15
Common Bill Denial Reasons &
What to Do About Them
 Claimant is ineligible
 Disagreements with accepted condition
 Treatment Suite
 No authorization
 Improper CPT codes




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Claimant Eligibility
 Each claimant must be eligible on date of
  service
 Claimant case status is determined by DOL
 Claimants are responsible for contacting the
  district office if there are questions
  regarding case status
 Resubmit bills for processing once claim is
  approved or reopened

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Disagreement With Accepted
Conditions
 Claimants are responsible for providing
  their treating physicians with the accepted
  condition(s) on the claim
 Providers need to acquire this information
  from the claimant
 OWCP pays only for services related to the
  accepted conditions on the claim
 Bill with the accepted conditions

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Treatment Suite
   Services that greatly differ from expected
    services to treat an injury will deny
      Billing for a hand x-ray when the

       claimant has a cut lip will trigger this
       denial code




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No Authorization
   Certain procedures require prior authorization
   Submitting a request does not guarantee approval.
   If an authorization was not previously requested, a retro-
    authorization may be requested for services already
    provided
      Follow same guidelines as for requesting an
        authorization prior to service
      Dates MUST be specific for retro-authorizations

   Once the authorization is approved, resubmit the bill



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Authorization EOB Codes
   EOB code 529 - Case is denied
   EOB code 530 - No authorization on file
   EOB Code 531 - Authorization for claimant, not
    for provider
   EOB Code 532 - Authorization for claimant and
    provider, not for dates of service
   EOB Code 533 - Authorization for claimant,
    provider, and dates of service; not for procedure

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How to Request an Adjustment
– Two Options
1.    Resubmit a corrected bill - At the top of the
      form write “Corrected Bill” or “Adjustment”.
OR

2.      Submit your RV
     a.   Block out all information not pertaining to
          your adjustment.
     b.   Write what you need adjusted.




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