We’re offering reminders of correct coding practices to keep in mind when completing a UB-04 claim, as well as when billing for services rendered at an ambulatory surgical center. Because errors are common in these billing scenarios, we want to support our provider partners in billing appropriately to enable claims to be priced and paid properly.
Billing UB-04 claims
It’s important to follow industry standard billing guidance when completing a UB-04 form or its electronic equivalent, the 837 institutional claim transaction. As a reminder, facility providers should not bill both medical and behavioral health services together on the same claim. In addition, to identify members discharged/transferred to a psychiatric hospital or a psychiatric distinct part unit (DPU) of a hospital, it’s mandatory to include discharge status code 65 on the claim.
We’ve updated our Commercial Behavioral Health and Substance Use Disorder Payment Policy for additional clarity around this requirement. For general billing guidance pertaining to the UB-04 form or the electronic 837 institutional claim transaction, you can refer to the Billing & Reimbursement section of our Harvard Pilgrim Health Care Commercial Provider Manual, as well as the Claim Requirements, Coordination of Benefits and Payment Disputes sections of our Tufts Health Plan Commercial, Senior Products, and Public Plans Provider Manuals.
Billing for ambulatory surgical center services
When billing for services rendered at an ambulatory surgical center on a CMS-1500 form or an 837 professional claim transaction, please remember to include the modifier SG in order to apply the correct benefit configuration (e.g., cost sharing, deductible). When applicable, always submit a modifier that reduces the fee schedule/allowable amount in the primary modifier position, and modifier SG in the secondary position.