United Health Care West (PacifiCare)

United Health Care West Commercial Home Health (HH), UB-04 Hardcopy

United Health Care West Home Health is a regular fee-for-service claim.

Adhere to the following specific United Health Care West Commercial Home Health (HH), UB-04 Hardcopy rules:

>	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.

In Administration>Financial>Insurance Codes>General, define the following items:

>	Type – C (Commercial)

>	Mode – R (Regular)

>	Form – UB-04

In Administration>Financial>Insurance Codes>NPI, define the following items:

>	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.

In Administration>Financial>Insurance Codes>Liability/ Spend Down, make no selection.

In Administration>Financial>Insurance Codes>Print Variations, define the following items for United Health Care West Commercial Home Health (HH), UB-04 Hardcopy.

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:

>	Make separate claims (with totals) for claims

>	Suppress dots & dashes in ICD codes, dates and insured info

>	Print in upper case letters only

FL 17

Patient Discharge Status

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

FL 38

Responsible Party Name

Select the Print the commercial insurance company address print variation.

FL 42–49

Rules for all Claims

Select the Print net charges on the claim print variation.

N/A

Fee-for-service Claims

Select the following print variations:

>	Units = visit count

>	Print services by date within revenue code

FL 52–53

Release of Information Certification Indicator

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

FL 80

Remarks

Select the Print the commercial insurance company address print variation.

All other locators are standard.

United Health Care West (Formerly PacifiCare) Commercial Home Health (HH), 837I 4010A1 Electronic

Refer to the United Health Care West Commercial Home Health (HH), UB-04 Hardcopy instructions for additional setup information.

The following fields in the application are required for United Health Care West (formerly PacifiCare) Commercial Home Health (HH), 837I 4010A1 Electronic.


Field	Description
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 -OR- Social Security Number	For the patient's attending physician, enter either the physician's federal tax ID or Social Security Number. These fields are located in Resource>General>Roles.
Medicare Assign (Medicare Assignment Code)	If needed, change the default A (Assigned) to C (Not Assigned) in the Medicare Assign field in Patient>General>Payers>HIPAA.
Provider Taxonomy Code	Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>Generalor in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
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 assigned by the clearing house 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.
Receiver ID (File Recipient)	Enter the ENS clearing house receiver ID of ENS EDI UB in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC or in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
Pacificare Receiver ID	Enter the Pacificare receiver ID of COPHS in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC or in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
Provider ID	Enter the 11-digit ID (Tax ID followed by 2 characters) assigned to the Agency by Pacificare in the Provider ID field in Administration>Financial>Insurance Companies>Company.

United Health Care West (Formerly PacifiCare) Commercial Home Health (HH), 837I 5010A2 Electronic

Refer to the United Health Care West Commercial Home Health (HH), UB-04 Hardcopy instructions for additional setup information.

For United Health Care West (formerly PacifiCare) Commercial Home Health (HH), 837I 5010A2 Electronic, define the following items:

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

Note: If values other than 3 or 1 are required, enter them in Patient>General>Claim Constants or Administration>Financial>Claim Constants.

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

The following fields in the application are required for United Health Care West (formerly PacifiCare) Commercial Home Health (HH), 837I 5010A2 Electronic.


Field	Description
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 -OR- Social Security Number	For the patient's attending physician, enter either the physician's federal tax ID or Social Security Number. These fields are located in Resource>General>Roles.
Medicare Assign (Medicare Assignment Code)	If needed, change the default A (Assigned) code to C (Not Assigned) in the Medicare Assign field in Patient>General>Payers>HIPAA.
Provider Taxonomy Code	Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>Generalor in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
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 assigned by the clearing house 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.
Receiver ID (File Recipient)	Enter the United Health Care Receiver ID of 87726 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC or in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
Receiver ID (Payer)	Enter the United HealthCare Receiver ID of 87726 in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC or in Administration>Financial>Insurance Companies>Company. Where you enter this value depends on your commercial insurance setup.
Provider ID	Enter the 11-digit ID (Tax ID followed by 2 characters) assigned to the Agency by United Health Care (West) in the Provider ID field in Administration>Financial>Insurance Companies>Company.