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Provider Notice Issued 03/10/2017

Institutional Paper Claims Technical Guidelines
Date:   March 10, 2017
To:       Enrolled Hospitals:  Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; Ambulatory Surgical Treatment Centers (ASTCs); Hospices; Renal Dialysis Facilities, and Birth Centers
Re:      HFS Technical Guidelines for UB-04 Paper Claim Preparation
The purpose of this notice is to address claim preparation issues regarding the UB-04 claim form for claims received on and after April 1, 2017.
The Department uses a claim imaging system for scanning paper claims, including the
UB-04. If certain claim preparation specifications are not met, claims may be rejected or returned to the provider as unprocessable. 
Attached are Technical Guidelines that, if followed, will minimize processing delays. Many of the guidelines are standard claim submission instructions, while others are specific to the Department’s imaging system. Please review your claim preparation procedures and make any necessary changes. It is extremely important for all providers to share the information in this notice with those who prepare their Medical Programs claims, including billing agencies. 
Special attention should be directed to the following items:
·       Providers billing on the UB-04 cannot leave blank revenue lines within the body of the claim. Revenue lines are not to be skipped.  
·       Correction fluid or correction tape on paper claims may no longer be used. If corrections need to be made, the claim should be reprinted.
·       Claims containing hand-written entries will no longer be accepted.
There are certain circumstances that require the use of a paper claim, such as when a claim requires an attachment or some type of override for processing. The Department, however, strongly encourages the use of electronic claim submittal via an 837I or the Medical Electronic Data Interchange, Internet Electronic Claims (MEDI IEC) System for routine claim submittal. Electronic claim submission allows providers to receive immediate feedback on many of the required field entries. In addition, a confirmation page is available to print on each successful submission of a claim. The confirmation page displays all of the fields that were entered on the claim submission, including date of submission, time of submission and confirmation number, which can be used for tracking purposes.

Electronic claim submission via the Internet is available by registering on the MEDI IEC webpage. The MEDI IEC System is available to enrolled providers and their authorized staff, claim submitting agents and payees. During the registration process, you will be given access to specific claim formats based upon your enrollment status with the Department.
Questions regarding this notice may be directed to a billing consultant in the Bureau of Hospital and Provider Services at 1-877-782-5565.
Felicia F. Norwood

HFS Technical Guidelines for Paper Claim Preparation
Please follow these guidelines in the preparation of paper claims for imaging processing to assure the most efficient processing by the Department:
·        Use original UB-04 claim forms. The Department will not accept downloaded, created, reproduced or faxed forms.
·        Handwritten claims will not be accepted. Claims should be computer-printed or typed in capital letters. The character pitch/font size must be 10-12 printed characters per inch.
·        Do not leave blank revenue lines within the body of the claim. Revenue lines are not to be skipped.
·        If corrections need to be made, reprint the claim. Correction fluid or tape should not be used on the UB-04.
·        Claims that are illegible will be returned to the provider.
·        Claims with extreme print qualities, either light or dark, will not image.
·        Use only one font style on a claim. Do not use bold print, italics, script or any font that has connecting characters.
·        Do not use punctuation marks, slashes, dashes or any special characters anywhere on the claim form.
·        All entries must be within the specified boxes. Do not write outside the box.
·        Red ink does not image. Use only black ink for entries on the billing form and attachments. Stamped signatures are not acceptable.
·        Remove the pin-feed strips on claims at the perforations only. Do not cut the strips, as it may alter the document size.
·        Attachments containing a black border as a result of photocopying with the copier cover open cannot be imaged. Attachments must have a minimum one-half inch white border at the top and on the sides to ensure proper imaging of the document.
·        For attachments containing gray areas, either as part of the original or as a result of photocopying a colored background, print in the gray area is likely to be unreadable. If information in this area is important, the document should be recopied to eliminate the graying effect as much as possible without making the print too light.
·        Attachments should be paper-clipped or rubber-banded to claims. Do not fold invoices or fasten attachment with staples.


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