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SHPBN-2016-086 OB Deliveries & Newborn Claims Billing Clarification

Fecha: 02/12/16

When the Mother is Assigned to Sunflower Health Plan:

Delivery and Newborn Claims

  • Maternity admissions without delivery complications require notification and information on the delivery outcome within one business day of delivery and must include birth outcomes, including Ballard score or equivalent.
  • NICU admissions require notification within one business day (by 5 p.m. CT) of admission. All NICU admissions are subject to concurrent review for continued stay.

For the Mom's Claim:

Medicaid ID: Use the beneficiary's (the mom's) Medicaid ID
Patient Name: Use the the mom's first and last name
Date of Birth: Use the the mom's date of birth
Diagnosis Code: Use the appropriate ICD10 diagnosis code, for example, Z37 - Outcome of Delivery*
Room & Board Revenue Code: Use the appropriate Med/Surg/Gyn/OB revenue code

*Note: Z37 ICD10 codes are not for use on the newborn claim

When billing for a newborn who does not have a Medicaid ID number:

For the Baby's Claim:

Medicaid ID: Use the mom’s Medicaid ID
Patient Name: "Newborn," "BabyGirl," or "Baby Boy" and the mom's last name
Date of Birth: Use the newborn’s date or birth
Diagnosis Code: Use the appropriate ICD10 diagnosis code, for example, Z38 - Liveborn Infants according to place of birth and type of delivery**
Room & Board Revenue Code: must be a nursery room and board revenue code 170-179

**Note: Z38 ICD10 codes are not for use on the mother's claim

  • Effective with dates of service beginning January 1, 2015 claims for newborn services billed under the mother’s beneficiary ID will be pended for 45 days pending receipt of the newborn’s beneficiary ID number.
  • If a newborn ID is received, the claim will be denied "EXnB – Deny: Rebill with Newborn Medicaid ID#, Name and DOB" notifying the provider they must submit a corrected claim using the newborn’s ID number, name, and DOB.
  • If no newborn ID is received and the date of service is within 45 days of the newborn’s date of birth, the claim may be paid using the mother’s ID number.  If the date of service is not within 45 days of the newborn’s date of birth, the claim will be denied.

When billing for a newborn who has their own Medicaid ID number:

For the Baby's Claim:

Medicaid ID: Use the newborn's Medicaid ID
Patient Name: Use the newborn's first and last name as shown in KMAP or on the ID card
Date of Birth: Use the newborn’s date or birth|
Diagnosis Code: Use the appropriate ICD10 diagnosis code, for example, Z38 - Liveborn Infants according to place of birth and type of delivery**
Room & Board Revenue Code: must be a nursery room and board revenue code 170-179

**Note: Z38 ICD10 codes are not for use on the mother's claim

Billing Reminders When Using the Mother’s Beneficiary ID Number

Newborn services are considered procedure codes which specifically state “newborn” in the code description according to the CPT® manual or revenue codes 170-179. These services must be billed with a newborn diagnosis code in order to receive payment.

When billing newborn services for a newborn that does not have a beneficiary ID number, use “Newborn,” “Baby Girl,” or “Baby Boy” in the first name field and enter the last name. Use the newborn’s date of birth and the mother’s beneficiary ID number.

When the Mother is SOBRA or not assigned to Sunflower Health Plan: Newborn Claims

When a newborn delivery occurs and the mother is not assigned to an MCO or the mother is SOBRA, hospitals should refer to the Kansas Medical Assistance Program Fee-for-Service Hospital Provider Manual for guidance on billing for Emergency Medical Services for Aliens (SOBRA). Claims for normal newborn births born to SOBRA mothers would be considered to be retro-eligible and do not require notification, unless the newborn is in a NICU level of care. When the newborn is retro-eligible, they would be assigned their own Medicaid ID, and should be billed as follows:

For the Newborn Claim born to a SOBRA Mother:

Medicaid ID: Use the newborn's Medicaid ID
Patient Name: Use the newborn's first and last name as shown in KMAP or on the ID card
Date of Birth: Use the newborn’s date or birth
Diagnosis Code: Use the appropriate ICD10 diagnosis code, for example, Z38 - Liveborn Infants according to place of birth and type of delivery**
Room & Board Revenue Code: must be a nursery room and board revenue code 170-179

**Note: Z38 ICD10 codes are not for use on the mother's claim

 

If you have questions about this bulletin or other provider resources, please contact Customer Service at 1-877-644-4623.