Military Treatment Facility (MTF)

Beginning July 6, 2022, hospitals electing to bill the program for emergency services on a calendar year basis may obtain beneficiary eligibility, claim status from the Interactive Voice Response (IVR) or the Noridian Medicare Portal (NMP). Enrollment to the portal is required and you will be prompted upon accessing the site.

Contact the PCC if you need any further information.

The UB04 form needs to be completed in its entirety, codes are available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data Specifications Manual. If required fields are not completed on the UB04 they will not load into our claims processing system correctly.

Here are some examples of items that are required:

Form Locators 39- 41 Value Codes and amounts:

  • Value codes 80 for covered days, 81 for non-covered days, 82 for co-insurance days, 83 for lifetime reserve days (LTR) and the number of days reported for each. Ex: value code 80 with 4 covered days would be listed as 80 4.00 on the UB04
  • Value codes 08 for LTR amount in first calendar year period, value code 10 for LTR amount in second calendar year period
  • Value code 09 for co-insurance amount in the first calendar year period, value code 11 for co-insurance amount in the second calendar year period

Form Locator 46 - Units of Service

  • Number of units or days of accommodation. Total should match totals of value codes 80-83.

Form locator 47 - Total charges

  • This is the FL in which the provider sums the total charges for the billing period for each revenue code (FL 42); or, if the services require, in addition to the revenue center code, a HCPCS procedure code, where the provider sums the total charges for the billing period for each HCPCS code. The last revenue code entered in FL 42 is “0001” which represents the grand total of all charges billed. The amount for this code, as for all others is entered in FL 47.

Form Locator 50 A-C

  • Medicare must also be listed on the appropriate insurance line, not Noridian

Form Locator 60 A-C

  • Appropriate Medicare Beneficiary Identification (MBI) number for the beneficiary

It is your responsibility to ask about any other applicable insurance. If another insurance is primary over Medicare, provide a copy of any payment or denial from the other insurance with the claim.

Submit a completed hardcopy red and white UB04 form. Noridian will not accept electronic or faxed claims for Part A services. If the claims are not submitted on the red and white UB04 form, they will be returned to you.

Please note: any professional revenue codes should not be billed on the UB04, or the claim will be returned to the provider (RTP) as unprocessable.

 

Last Updated Wed, 03 Aug 2022 14:05:42 +0000