EOB Data elements align with claims submission standards

EOB| Data elements align with claims submission standards adopted by the Department of Health and Human Services Inpatient Facility The result is multiple EOB Profiles: Header Line Item Outpatient Facility (CMS-1450 / UB-04 or 835 / 837) - (CMS-1450 / UB-04 or 835 / 837) ICD Diagnosis Codes (NCHS-CDC) ICD Procedure codes (CMS) DRGs (CMS) Admission – Discharge Dates Type of Bill Code (NUBC)* [Diagnosis is ] Present on Admission Code (NUBC)* Point of Origin for Admission or Visit (NUBC)* Priority (Type) of Admission or Visit (NUBC)* Discharge Status Code (NUBC)* Patient account number Attending Physician NPI Operating Physician NPI Claim Amounts are required Benefit Payment Status - Revenue Codes (NUBC)* - CPT (AMA)* / HCPCS (CMS) Procedure codes (Drugs and biologics) - CPT (AMA)*/ HCPCS Modifiers (CMS) - Line Amounts are optional - NDC codes (FDA) ICD Diagnosis Codes (NCHS-CDC) Type of Bill Code (NUBC)* Point of Origin for Admission or Visit (NUBC)* Priority (Type) of Admission or Visit (NUBC)* Discharge Status Code (NUBC)* Patient account number Operating Physician NPI Claim Amounts are required Benefit Payment Status - CPT (AMA)* / HCPCS (CMS) Procedure codes - CPT AMA* / HCPCS Modifiers (CMS) - Revenue Codes (NUBC)* - Service Date - Line Amounts are optional - NDC codes (FDA) Professional / Non-Clinician Pharmacy (CMS-1500 or 835 / 837) - ICD Diagnosis Codes (NCHS-CDC) - Patient account number - Claim Amounts are optional (NCPDP) - - ICD Diagnosis Code Pointers - CPT (AMA)* / HCPCS (CMS) Procedure codes - CPT (AMA)* / HCPCS (CMS) Modifiers - Service From / Through Dates - Place of service (CMS) - Type of service (CMS) - Line Amounts are required - Benefit Payment Status - NDC codes (FDA) - One line per claim NDC codes (FDA) Service Date Days Supply Compound Code (NCPDP)* Dispensed As Written Code (NCPDP)* Average Wholesale Price (AWP) Submitted Prescribing Physician NPI Claim Amounts optional Line Amounts are required Benefit Payment Status *Required Profiles include: Person | Patient | Related Person | Organization | Practioner Role | Practioner | Coverage | 4 Explanation of Benefits (EOB) and 2 future EOB for vision and dental * License required © 2019 LEAVITT PARTNERS 1