FACETS Home Health

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

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

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

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

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

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

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

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Type – C (Commercial)

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Mode – R (Regular)

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Form – UB-04

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

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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 4

Type of Bill

Select the Print the bill type as 32X 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 14–15

Admission Type/Point of Origin

Select the Print '3' and '1' Admission Type/Src 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 39–41

Value Codes Amounts

Select the Suppress printing Value Code '44' print variation.

N/A

Fee-for-service Claims

Select the following print variations:

FL 50

Payer Name

Select the Print the Coverage Description print variation.

FL 51

Health Plan Identification Number

Select the Only print value for current claim payer line print variation.

FL 60

Insured's Unique ID

Select the Only print value for current claim payer line print variation.

Field

Description

Payer Address

Enter the RMHP payer address, city, state and ZIP Code as follows: P.O. Box 10600, Grand Junction, CO 81502-5600 in Patient>General>Payers.

Insurance ID

Enter the subscriber's RMHP 11-digit Member ID in the Insurance ID 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.

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 organization's assigned 12-digit RMHP provider ID in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (Payer)

Enter 840614905 in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter Rocky Mountain Health Plans 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 sender code assigned by RMHP 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.

File Names

Because Rocky Mountain Health Plans only accept files with a .txt extension, rename your files to contain a .txt extension.

Note: In addition, Rocky Mountain Health Plans require unique file names to transmit more than once within a 24-hour period.

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

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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

Payer Address

Enter the RMHP payer address, city, state and ZIP Code as follows: P.O. Box 10600, Grand Junction, CO 81502-5600 in Patient>General>Payers.

Insurance ID

Enter the subscriber's RMHP 11-digit Member ID in the Insurance ID 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.

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 organization's assigned 12-digit RMHP provider ID in the Provider No field in Administration>Financial>Insurance Codes>General.

Receiver ID (Payer)

Enter 840614905 in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter Rocky Mountain Health Plans 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 sender code assigned by RMHP 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.

File Names

Because Rocky Mountain Health Plans only accept files with a .txt extension, rename your files to contain a .txt extension.

Note: In addition, Rocky Mountain Health Plans require unique file names to transmit more than once within a 24-hour period.