Many clinics these days are moving from regular professional practice to Rural Health practice. These practices sign up with government insurances like Medicaid and Medicare to be approved for seeing Rural Health patients. The government gives such practices some additional incentives against each Rural Health claim, for which clinics have to send a UB04, i.e., an institutional claim.
This feature is intended to support various Rural Health Billing scenarios by creating appropriate claims and appropriate procedure codes, with their amounts depending on the value set in the property, and for the appropriate insurances, provided the Bill Type on Enc Type is selected as 'Rural Health'. The pre-requisites to create claims for Rural Health are:
- Property 'billing.ub04.rural.health.support' is set to 'Y'. When this property is set to 'Y', only then is the 'Bill To' drop-down populated with the 'Rural Health' option.
- The 'Bill To' field on Enc Type must be set to 'Rural Health'.
- The insurance selected on Patient Insurance must have the 'Rural Health' checkbox marked.
Note: For UB04 Rural Health claims, the Place of Service is set as '71' on the Claims >> Edit screen.
The 'Rural Health' claims are necessarily created from the 'Encounter Close' of the patient with the above conditions fulfilled.
There are four scenarios for which UB04 Rural Health claims are created by the system.Scenario 1: Patient having only Primary Insurance
Create an encounter for a patient who has a single primary insurance with no 'Main Ins.' on the Insurance Master associated on the Patient Insurance screen, and where all three criteria defined above are satisfied. On the Encounter Assessment screen, charge codes can be associated but are not included in the UB04 Rural Health claims. When the patient encounter is closed, a claim is created.
The UB04 Rural Health claim is created with the Revenue Code, Procedure Code, and Amount as set in the property 'ub04.rh1.revprocamts'. The values of the Revenue Code, Procedure Code, and Amount are property-driven. Therefore, it is important to set the values in the property stated above. For example, if the property 'ub04.rh1.revprocamts = 451:01$100', then Revenue Code = 451, Procedure Code = 01, and Amount = $100 for the charge row on the Rural Health Claim.
UB04 Form >> Box 50 will print the name of the Primary Insurance.Scenario 2: Patient having Non-Rural Health Primary Insurance and Rural Health Secondary Insurance.
Create an encounter for a patient with two insurances, having a Non-Rural Health Primary Insurance and a Rural Health Secondary Insurance. The user can add CPT/HCPCS codes on the Assessment. On Encounter Close, two claims are created. These are:
- Professional Claim for Primary Insurance – This claim will include the CPT/HCPCS charge codes included in the Encounter Assessment, and CMS 1500 will print the name of the Primary Insurance only.
- UB04 Rural Health for Secondary Insurance – This claim ignores CPT/HCPCS charge codes included in the Encounter Assessment, and the charge rows on this claim are populated appropriately with the values set in the property 'ub04.rh2.revprocamts'. UB04 Form >> Box 50 will print the names of both the Primary and Secondary Insurances.
Scenario 3: Managed Care Workflow
The 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 - The 'Rural Health' checkbox is checked, and 'Main Ins.' is selected for this Primary Insurance. It is treated as the subsidiary insurance.
- Secondary Insurance - Rural Health Insurance with the 'Rural Health' checkbox checked.
A patient having such a combination of insurances on Patient Insurance is considered as a 'Managed Care' workflow. On Encounter Close, two claims are created. These claims are:
Professional Claim for Primary Insurance – This claim will include the CPT/HCPCS charge codes included in the Encounter Assessment, and CMS 1500 will print the name of the Primary Insurance only.
UB04 Rural Health for Secondary Insurance – This claim ignores CPT/HCPCS charge codes included in the Encounter Assessment, and the charge rows on this claim are populated appropriately with the values set in the property 'ub04.managedcare.revprocamts'. UB04 Form >> Box 50 will print the name of only the Secondary Insurance.
Scenario 4: Patient having Non-Rural Health Primary Insurance with 'Bill To' set to 'Rural Health'.
In this scenario, a single professional claim will be created, and CMS 1500 will print the Primary Insurance name.
Procedure Code Details Printed on the UB04 Form
UB04 Box No.
Values Displayed
Box 42
Revenue Code as per the value set in the property.
Box 42 Row 23
It shows the total Revenue Code billed as per the value set in the property.
Box 43
Description of the Procedure Code.
Box 44
It always prints the charge code as '18' for Managed Care.
Box 47
Total charges are pulled based on which subsidiary is Primary for the patient. If IMG, pull charges as $x; if the subsidiary is ABC, pull charges as $y, etc.
Box 50
Prints the insurance name according to the scenarios explained above.
Box 56
Prints the clinic NPI on the UB04 form.
Box 70
The Rendering Doc as Operating Doc and the rendering physician's NPI are populated.
Provider-Related Information Printed on the UB04 Form
The information related to the provider, which is defined on the Provider Master for the associated provider on UB04 claims, is printed on the UB04 Form. The list of various Qualifier Codes is as follows:
On the UB04 Form, the Qualifier and ID associated with the provider are printed in boxes 76, 77, 78, and 79 in accordance with the properties defined below:
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.