Submitting an Institutional Claim Submitting Claims via Your Portal

and click on “info for” then “nurses”. This Instructional Power Point is intended for Professional Homecare Providers (PHP) Members ONLY. This should NOT be shared with non-members! This is intended to be a resource to assist you in submitting an Institutional Claim. Please note that Forward Health may change the format or requirements and you should also refer to your online handbook. PHP is not liable for any Claim submitted not in compliance with Forward Health requirements. If you are not a current PHP member, you may obtain membership information at Wisconsinphp.org and click on “info for” then “nurses”.

Before You Begin, You Will Need: Your pa/cpa (Plan of Care) Know the NPI number of the Referring physician (see slide 4 for terminology) List of the dates and hours you have worked (see slide 5 for start of shift modifiers) If your client has any Commercial Insurance, know that information. You should do an Enrollment Verification at least monthly to make sure no changes have been made. Click on the Enrollment Verification tab while logged into your portal, enter your clients MA number, change the search dates to the entire month, click search. Write down the verification tracking number in a log. Scroll down to view any insurance information.

The Rendering Provider is YOU. The Prescribing, Referring or Ordering Provider requirement: Claims and PA’s need to have the NPI number of the md who is the prescribing physician. The Prescribing Provider is the physician that has signed the current pa-cpa (Plan of Care) with the certification period that covers the date of service in which you are billing. The Referring Provider is the physician that signed the pa-cpa that was submitted with the Prior Authorization Request. This physician will not change until the next Prior Authorization is approved. In most cases, the Prescribing and Referring Providers will be the same unless there is a change in physicians. The Rendering Provider is YOU.

Codes and Modifiers (Cont.) Professional modifiers: TE (LPN/LVN). TD (RN). Shift modifiers: UJ (12:00 a.m. to 5:59 a.m.). UF (6:00 a.m. to 11:59 a.m.). UG (12:00 p.m. to 5:59 p.m.). UH (6:00 p.m. to 11:59 p.m.). Revenue codes: 0550 (Skilled Nursing).

Codes and Modifiers Diagnosis codes: International Classification of Diseases (ICD codes) Clinical Modification codes (on the plan of care pa-cpa signed by physician and submitted with PA). Forward Health requires ICD-9-CM codes be used for any dates of service PRIOR to October 1, 2015 and ICD-10 codes for dates of service on or after October 1, 2015. Procedure codes: 99504 (Home care for mechanical ventilation care) requires both professional and shift modifiers. S9123 (Nursing care, in the home; by registered nurse, per hour) requires shift modifiers. S9124 (Nursing care, in the home; by licensed practical nurse, per hour) requires shift modifiers.

Units of Service Units of Service: Six-minute billing increments. Example: Time worked in Minutes = Billable Units 0-<6 6-<12 0.1 12-<18 0.2 54-<60 0.9 60-<66 1 234-<240 3.9 240-<246 4

Units of Service. (Cont.) Billing units for shifts spanning midnight. Example 1 Day Start of Shift Modifier Time Minutes Billable Units 1 UH 10:00p.m. to Midnight 120 2 UJ Midnight to 10:00 a.m. 600 10

Units of Service. (Cont.) Billing for more than one shift worked in a day. Combining units. Example 1 Day Start of Shift Modifier Time Minutes Billable Units 1 UJ Midnight to 6:15 a.m. 375 6.2 2 UH 6:15 p.m. to Midnight 345 5.7 Billable units if shift minutes are converted separately 11.9 Sum of minutes worked in the day 720 Billable units if the day’s minutes are summed before converting to units 12

Now Let’s Get Started

Click claims from top tab, then…

How to Fill In Header Information

The next 3 Slides are for clients with Commercial Insurance. Please refer to your online handbook for more specifics on Commercial Insurance. Skip this step if your client does not have Commercial Insurance.

Then…..

Commercial Insurance – Paid or Denied Example

Select type of Insurance (most will be CI)

Detail Line….

Top of Page Bottom of Page

You can now click “Copy Claim” from your submitted claim to enter additional claims. Just change the dates, then click in the Detail Section “line 1” and change any hours, charges, or modifiers that need to be changed. You can then click submit and your next claim will process. Note: If Copying Claims for clients with other Commercial Insurance, you must copy a paid claim (already processed and paid out) in order for the insurance information to be saved.