Empire Blue Cross New York

>

Complete all required areas of the UB-04 claim form.

>

Use only original UB-04 claim forms with the red drop-out ink or file electronically.

>

When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>

The value for all check boxes on the form is X.

>

If a field is not completed, leave the items empty on the form.

>

Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

>

Claims are split into items based on the Revenue/HCPC Codes.

>

Type – C (Commercial)

>

Mode – R (Regular)

>

Form – UB-04

>

In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

>

In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the following print variations:

FL 3b

Medical Health Record Number

Select the Print Patient ID print variation.

FL 6

Statement Cover Period From/Through Dates

Select the Use the first and last Dates of Service print variation.

FL 8

Patient Name/Identifier

Select the Print the middle initial only print variation.

FL 10

Patient Birth Date

Select the Print Birth Date in MM/DD/YY format print variation.

FL 17

Patient Discharge Status

Select the Print '01' (discharged), '30' (still active) or '40' (died) print variation.

FL 18–28

Condition Code

Select the Suppress printing of Condition Codes print variation.

FL 31ab–34ab

Occurrence Code

Select the Print '27' occurrence code with admit date print variation.

FL 38

Responsible Party Name and Address (Claim Addressee)

Select the Print insured name & address print variation.

FL 52–53

Release of Information Certification Indicator

Select the Print 'Y' in release and info print variation.

FL 80

Remarks

Select the Print physician name, address & telephone no. print variation.

Field

Description

Group Code

Enter the subscriber's Empire Blue Cross group number in the Group Code field in Patient>General>Payers. Do not include any prefix alpha characters.

Group Name

Enter the subscriber's Empire Blue Cross group name in the Group Name field in Patient>General>Payers.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Federal Tax ID

-AND-

Provider Taxonomy Code

For the attending physician, enter the physician's federal tax ID; otherwise, 999999999 is automatically printed.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Functional Limits and Mental Status

Specify the other type of functional limitations and mental status for treatment plans in the Other (specify) field in Patient>Clinical>General Clinical>Functional Limits and Patient>Clinical>General Clinical>Mental Status. The data from these fields is included in the HIPAA electronic claim file for Empire Blue Cross as a claim note for the patient.

Operators

Enter the resource ID for each operator creating electronic billing files in the ID column in Administration>Configuration>Operators>Basic.

Permitted Home Health Activity

Select the type of permitted Home Health activity different from Other to submit the information in the electronic file because Other is not a valid value under HIPAA.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Provider No

Enter the provider number assigned by Empire Blue Cross in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (File Recipient)

The Receiver ID (File Recipient) field is prefilled with 00303 in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter EMPIRE BLUE CROSS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the agency's submitter ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

>

In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

>

Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Group Code

Enter the subscriber's Empire Blue Cross group number in the Group Code field in Patient>General>Payers. Do not include any prefix alpha characters.

Group Name

Enter the subscriber's Empire Blue Cross group name in the Group Name field in Patient>General>Payers.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Federal Tax ID

-AND-

Provider Taxonomy Code

For the attending physician, enter the physician's federal tax ID; otherwise, 999999999 is automatically printed.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Functional Limits and Mental Status

Specify the other type of functional limitations and mental status for treatment plans in the Other (specify) field in Patient>Clinical>General Clinical>Functional Limits and Patient>Clinical>General Clinical>Mental Status. The data from these fields is included in the HIPAA electronic claim file for Empire Blue Cross as a claim note for the patient.

Operators

Enter the resource ID for each operator creating electronic billing files in the ID column in Administration>Configuration>Operators>Basic.

Permitted Home Health Activity

Select the type of permitted Home Health activity different from Other to submit the information in the electronic file because Other is not a valid value under HIPAA.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Provider No

Enter the provider number assigned by Empire Blue Cross in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (Payer)

Enter EMPIRENY in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver ID (File Recipient)

The Receiver ID (File Recipient) field is prefilled with 00303 in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter EMPIRE BLUE CROSS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the agency's submitter ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Voided or Replaced Claims

If this is a voided or replaced claim (third digit of the type of bill is a 7 or 8), enter the document control number or the ICN of the original claim in Claims>Process>Annotate Claims.

If your organization uses electronic remittances, the system will automatically provide this number. The first three positions must contain one of the following values to indicate the reason for the voided or replaced claim and must be entered along with the ICN in Claims>Process>Annotate Claims:

>

Complete all required areas of the UB-04 claim form.

>

Use only original UB-04 claim forms with the red drop-out ink or file electronically.

>

When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>

The value for all check boxes on the form is X.

>

If a field is not completed, leave the items empty on the form.

>

Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

>

Claims are split into items based on the Revenue/HCPC Codes.

>

Type – C (Commercial)

>

Mode – B (Benefit)

>

Form – UB-04

>

In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

>

In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the following print variations:

FL 3b

Medical Health Record Number

Select the Print Patient ID print variation.

FL 6

Statement Cover Period From/Through Dates

Select the Use the first and last Dates of Service print variation.

FL 8

Patient Name/Identifier

Select the Print the middle initial only print variation.

FL 10

Patient Birth Date

Select the Print Birth Date in MM/DD/YY format print variation.

FL 17

Patient Discharge Status

Select the Print '01' (discharged), '30' (still active) or '40' (died) print variation.

FL 18–28

Condition Code

Select the Suppress printing of Condition Codes print variation.

FL 31ab–34ab

Occurrence Code

Select the following print variations:

FL 38

Responsible Party Name and Address (Claim Addressee)

Select the Print insured name & address print variation.

N/A

Benefit and Hybrid Claims

Select the Line item billing print variation.

FL 52–53

Release of Information Certification Indicator

Select the Print 'Y' in release and info print variation.

FL 80

Remarks

Select the Print physician name, address & telephone no. print variation.

Field

Description

Group Code

Enter the subscriber's Empire Blue Cross group number in the Group Code field in Patient>General>Payers. Do not include any prefix alpha characters.

Group Name

Enter the subscriber's Empire Blue Cross group name in the Group Name field in Patient>General>Payers.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

For the patient's attending physician and referring physician, enter either the physician's federal tax ID or Social Security Number.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Inpatient Facility Claims

Enter the appropriate Empire Blue Cross admission type code for FL 19 and admission source code for FL 20 in the Value column in Patient>General>Claim Constants.

Operators

Enter the resource ID for each operator creating electronic billing files in the ID column in Administration>Configuration>Operators>Basic.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Provider No

Enter the provider number assigned by Empire Blue Cross in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (File Recipient)

The Receiver ID (File Recipient) field is prefilled with 00303 in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter EMPIRE BLUE CROSS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the submitter ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

>

In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

>

Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Group Code

Enter the subscriber's Empire Blue Cross group number in the Group Code field in Patient>General>Payers. Do not include any prefix alpha characters.

Group Name

Enter the subscriber's Empire Blue Cross group name in the Group Name field in Patient>General>Payers.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Federal Tax ID

-AND-

Provider Taxonomy Code

For the attending physician, enter the physician's federal tax ID; otherwise, 999999999 is automatically printed.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Inpatient Facility Claims

Enter the appropriate Empire Blue Cross admission type code for FL 14 and admission source code for FL 15 in the Value column in Patient>General>Claim Constants.

Operators

Enter the resource ID for each operator creating electronic billing files in the ID column in Administration>Configuration>Operators>Basic.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Provider No

Enter the provider number assigned by Empire Blue Cross in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (Payer)

Enter EMPIRENY in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver ID (File Recipient)

The Receiver ID (File Recipient) field is prefilled with 00303 in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter EMPIRE BLUE CROSS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the submitter ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Voided or Replaced Claims

If this is a voided or replaced claim (third digit of the type of bill is a 7 or 8), enter the document control number or the ICN of the original claim in Claims>Process>Annotate Claims.

If your organization uses electronic remittances, the system will automatically provide this number. The first three positions must contain one of the following values to indicate the reason for the voided or replaced claim and must be entered along with the ICN in Claims>Process>Annotate Claims:

>

In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

>

Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Group Code

Enter the subscriber's Empire Blue Cross group number in the Group Code field in Patient>General>Payers. Do not include any prefix alpha characters.

Group Name

Enter the subscriber's Empire Blue Cross group name in the Group Name field in Patient>General>Payers.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Federal Tax ID

-AND-

Provider Taxonomy Code

For the attending physician, enter the physician's federal tax ID; otherwise, 999999999 is automatically printed.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Inpatient Facility Claims

Enter the appropriate Empire Blue Cross admission type code for FL 14 and admission source code for FL 15 in the Value column in Patient>General>Claim Constants.

Operators

Enter the resource ID for each operator creating electronic billing files in the ID column in Administration>Configuration>Operators>Basic.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General.

Provider No

Enter the provider number assigned by Empire Blue Cross in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (Payer)

Enter EMPIRENY in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver ID (File Recipient)

The Receiver ID (File Recipient) field is prefilled with 00303 in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter EMPIRE BLUE CROSS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the submitter ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Voided or Replaced Claims

If this is a voided or replaced claim (third digit of the type of bill is a 7 or 8), enter the document control number or the ICN of the original claim in Claims>Process>Annotate Claims.

If your organization uses electronic remittances, the system will automatically provide this number. The first three positions must contain one of the following values to indicate the reason for the voided or replaced claim and must be entered along with the ICN in Claims>Process>Annotate Claims: