Critical Access Hospitals Requirement
Provider Type
- Hospitals
Critical Access Hospitals contracted with Health Net for the Individual and Family Plans (IFP), including Ambetter HMO and Ambetter PPO, and Employer Group HMO, POS and PPO lines of business must use the correct Type of Bill (TOB) when submitting claims, based on the service type.
Claims submitted with an incorrect TOB will be denied.
Denied claims must be corrected and resubmitted with the appropriate TOB to be reconsidered for payment. Follow the steps below for appropriate submission:
- Review your current claim submission processes.
- Verify that claims are submitted with the correct TOB.
- Update billing system configurations, if needed, to support accurate claim submissions.
Use the following TOB designations when submitting claims for Ambetter HMO and Ambetter PPO:
Service Type | Type of Bill |
|---|---|
Inpatient hospital services | 11X |
Outpatient hospital services | 85X |
Laboratory services | 14X |
Swing bed services | 18X |
Other services | As applicable, based on Centers for Medicare & Medicaid Services (CMS) and contractual billing requirements |