Introduction

Many clinics, these days are moving from regular professional practice to Rural Heath practice. These practices sign up with Government Insurances like Medicaid and Medicare to be approved for seeing Rural Health patients. Government gives such practices some additional incentives against each Rural Heath Claim, for which clinics have to send UB04 i.e Institutional claim.

This feature is intended to support various Rural Health Billing scenarios by creating appropriate claims and appropriate procedure codes, their amounts depending on value set in the property and for appropriate Insurances provided the Bill Type on Enc Type is selected as ‘Rural Health’. The pre-requisite to create claims for Rural Health are:

• Property ‘billing.ub04.rural.health.support’ is set to ‘Y’. When this property is set to ‘Y’ then only ‘Bill To’ drop down is populated with ‘Rural Health’ option.
• Field ‘Bill To’ on Enc Type must be set to ‘Rural Health’.
• Insurance selected on Patient Insurance must have checkbox ‘Rural Health’ as marked.

Note: For UB04 Rural Health Claims, Place of Service is set as '71' on Claims >> Edit screen.

The ‘Rural Health’ Claims are necessarily created from ‘Encounter Close’ of the patient with above conditions fulfilled.
There are four scenarios for which UB04 Rural Health claims would be created by the system.

Scenario1: Patient having only Primary Insurance
Create an Encounter of patient who has single primary insurance with no ‘Main Ins.’ on Insurance master associated on patient insurance screen and where all the three criteria defined above are satisfied. On Encounter Assessment screen, charge codes can be associated but are not included in the UB04 Rural Health claims. When patient Encounter is closed, claim is created. 
UB04 Rural Health claim is created with Revenue Code, Procedure Code and Amount as set in property ‘ub04.rh1.revprocamts’. The value of Revenue Code, Procedure Code and Amount is property driven. Therefore, it is important to set the values in the property stated above. For example if property ‘ub04.rh1.revprocamts = 451:01$100’ then Revenue Code = 451, Procedure Code = 01 and Amount = $100 for charge row on Rural Health Claim.
UB04 Form >> Box 50 will print name of Primary Insurance.

Scenario2: Patient having Non Rural Health Primary Insurance and Rural Health Secondary Insurance.

Create an Encounter of patient with two insurances having Primary Insurance as Non Rural Health Primary Insurance and Rural Health Secondary Insurance. User can added CPT/HCPC codes on Assessment. On Encounter Close, two claims are created. These are:

• Professional Claim for Primary Insurance – This claim will include CPT/HCPC charge codes included in Encounter Assessment and CMS 1500 will print the name of Primary Insurance only.
• UB04 Rural Health for Secondary Insurance – This claim ignore CPT/HCPC charge codes included in Encounter Assessment and charge rows on this claim would be populated appropriately with values set in property ‘ub04.rh2.revprocamts’. UB04 Form >> Box 50 will print name of both Primary and Secondary Insurance.

Scenario3: Managed Care Workflow
Managed Care Program is for Low Income group individuals with multiple family members.
A Managed Care qualifying patient will have two Insurances defined:

• Primary Insurance- Checkbox ‘Rural Health’ is checked and  ‘Main Ins.’ is selected for this Primary Insurance. It is treated as subsidiary insurance.
• Secondary Insurance- Rural Health Insurance with checkbox ‘Rural Health’ as checked.

Patient having such combination of Insurances on Patient Insurance is considered as ‘Managed Care’ workflow. On encounter close, two claims are created. These claims are:

1. Professional Claim for Primary Insurance – This claim will include CPT/HCPC charge codes included in Encounter Assessment and CMS 1500 will print the name of Primary Insurance only.

2. UB04 Rural Health for Secondary Insurance – This claim ignore CPT/HCPC charge codes included in Encounter Assessment and charge rows on this claim would be populated appropriately with values set in property ‘ub04.managedcare.revprocamts’. UB04 Form >> Box 50 will print name of only Secondary Insurance.

Scenario4: Patient having Non Rural Health Primary Insurance ‘Bill To’ set to Rural Health.
In this scenario, single professional claim would be created and CMS 1500 will print Primary Insurance name.

Procedure Code details printed on UB04 Form

UB04 Box No.	Values Displayed
Box 42	Revenue Code as per value set in property.
Box 42 Row 23	It shows the total Revenue Code Billed as per value set in property.
Box 43	Description of Procedure Code.
Box 44	It always prints charge code as ‘18’ for managed care.
Box 47	Total Charges is pulled based on what subsidiary is Primary for the patient. If IMG, pull charges as $x, If Subsidiary is ABC, pull charges as $y, etc.
Box 50	Prints Insurance Name according to scenarios explained above.
Box 56	Prints Clinic NPI on UB04 form.
Box 70	Rendering Doc as Operating Doc and rendering physician’s NPI are populated.

Provider related Information printed UB04 Form

The information related to the provider, which are defined on the provider master for the associated provider on UB04 claims are printed UB04 Form. List of various Qualifier Codes is as follows:

• 0B – State License #. ‘State License #’ is a field on Provider Master.
• 1G – Provider UPIN. ‘Provider UPIN’ is a field on Provider Master.
• G2 – Provider Commercial #. ‘Provider Commercial #’is a field on Provider Master.
• XX–  NPI. ‘NPI’ is a field on Provider Master.
• ZZ – Taxonomy Code. ‘Taxonomy Code’ is a field on Provider Master.

On UB04 Form, Qualifier and ID associated to Provider are printed in box 76, 77, 78, 79 in accordance to defined in properties written below:

• billing.ub04.cell76.qualifier.codes – Accepts comma separated list of qualifiers and priority is set by the sequence of qualifier entered. For example, if ‘ZZ, XX’ is entered in the property. On UB04 form >> Cell76: ‘ZZ- Taxonomy Code’ would be printed if found in associated provider details on Provider Master. In case ‘ZZ’ is not found on Provider Master then Cell76 will print ‘XX-NPI’. Therefore, preference to print qualifier in Cell76 depends on sequence in which qualifiers are entered in the property.
• billing.ub04.cell77.qualifier.codes – Accepts comma separated list of qualifiers and priority is set by the sequence of qualifier entered. For example, if ‘1G, XX’ is entered in the property. On UB04 form >> Cell77: ‘1G – Provider UPIN’ would be printed if found in associated provider details on Provider Master. In case ‘ZZ’ is not found on Provider Master then Cell77 will print ‘XX-NPI’. Therefore, preference to print qualifier in Cell77 depends on sequence in which qualifiers are entered in the property.
• billing.ub04.cell78.qualifier.codes – Accepts comma separated list of qualifiers and priority is set by the sequence of qualifier entered. For example, if ‘1G, ZZ’ is entered in the property. On UB04 form >> Cell78: ‘1G – Provider UPIN’ would be printed if found in associated provider details on Provider Master. In case ‘1G’ is not found on Provider Master then Cell78 will print ‘ZZ- Taxonomy Code’. Therefore, preference to print qualifier in Cell78 depends on sequence in which qualifiers are entered in the property.
• billing.ub04.cell79.qualifier.codes– Accepts comma separated list of qualifiers and priority is set by the sequence of qualifier entered. For example, if ‘1G, OB’ is entered in the property. On UB04 form >> Cell79: ‘1G – Provider UPIN’ would be printed if found in associated provider details on Provider Master. In case ‘1G’ is not found on Provider Master then Cell79 will print ‘OB- State License #’. Therefore, preference of printing qualifier in Cell79 depends on sequence in which qualifiers are entered in the property.

Tag Details used on UB04 Forms

UB04 Tags	Remarks
BLH_INS_COMPANY	Prints the Primary insurance name in Box 50.
BLH_INS2_COMPANY	Prints the Secondary insurance name in Box 50.
BLH_INS3_COMPANY	Prints the Tertiary insurance name in Box 50.
BLH_UB04_50PRINAME	Prints the Parent Insurance name for the Insurance in Box 50.