SUBC REQUEST FORM

SUBC REQUEST FORM

(submit one form per item/please print or type)

Submitted by: _____________________________________________ Date: ______________

Date Reviewed by SUBC: ___________ Action Taken: Approved Denied Pending

Effective Date for Change: ___________ Date Communication sent to Provider: ____________

Comments: __________________________________________________________________

Questions to ask when preparing this request. Include answers in your request.

( ) What are other states' policies and reporting requirements?

( ) Is this request uniform with other payers?

( ) How are other payers reporting this information?

( ) Is this unique to your facility?

( ) How will this affect providers? How many providers are/will be affected?

( ) Are there other methods available to meet this request?

( ) Can this request be accommodated with HCPCS, ICD-9, or CPT-4 codes?

THIS IS A REQUEST FOR A:

( ) INFORMATIONAL ITEM/NEWSLETTER INFORMATION

( ) UNIFORMITY ISSUE:

_________________________________________________________________________________________

( ) PAYER UPDATES:

_________________________________________________________________________________________

( ) PROVIDER CONCERN:

_________________________________________________________________________________________

( ) CORRECTION TO MANUAL; Page ____________ (please attach the revised page)

( ) ADDITION TO MANUAL

Description of Addition: ______________________________________________________________________

_________________________________________________________________________________________

( ) REQUEST FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)

In order for a request to be taken to NUBC you must prepare a complete analysis explaining the reason for your request. In the analysis you must explain why the SUBC can not accommodate it, how the change will help other states, and answers to the above questions. The formal request and analysis will be reviewed by SUBC for approval prior to submission to NUBC. Reminder: NUBC meets twice a year, May and November. Requests that are approved at NUBC become effective October 1 and April 1, respectively.

Please mail/fax form to:

State Uniform Billing Commitee,

Michigan Health and Hospital Association

6215 W. St. Joseph Hwy

Lansing, MI 48917 Fax: 517-327-4564

NOTE: ALL REQUESTS MUST BE SUBMITTED WITH SUPPORTING DOCUMENTATION TO MHA AT LEAST TWO WEEKS PRIOR TO THE SUBC MEETING DATE IN ORDER TO BE INCLUDED IN THE MEETING PACKET