Claims Filing Instructions

Claim Filing .................................................................................................................................... 4

Claims filed with the Plan are subject to the following procedures: .......................................... 4
Claim Mailing Instructions ......................................................................................................... 5
Claim Filing Deadlines ............................................................................................................... 5
Exceptions ................................................................................................................................... 5
Refunds for Claims Overpayments or Errors.............................................................................. 6
Claim Form Field Requirements ..................................................................................................... 8
Required Fields (CMS 1500 Claim Form): ................................................................................ 8
Required Fields (UB-04 Claim Form): ..................................................................................... 25
Special Instructions and Examples for CMS 1500, UB-04 and EDI Claims Submissions .......... 59
I. Supplemental Information .................................................................................................... 59
Common Causes of Claim Processing Delays, Rejections or Denials ......................................... 63
ELECTRONIC CLAIMS SUBMISSION (EDI) .......................................................................... 67
Hardware/Software Requirements ............................................................................................ 67
Contracting with Change Healthcare and Other Electronic Vendors ........................................ 67
Contacting the EDI Technical Support Group .......................................................................... 67
Specific Data Record Requirements ......................................................................................... 69
Electronic Claim Flow Description .......................................................................................... 69
Invalid Electronic Claim Record Rejections/Denials ............................................................... 70
Plan Specific Electronic Edit Requirements ............................................................................. 70
Exclusions ..................................................................................................................................... 70
Common Rejections ...................................................................................................................... 71
Resubmitted Professional Corrected Claims ................................................................................ 72
Electronic Billing Inquiries ........................................................................................................... 74
Tips for Accurate Diagnosis Coding: How to Minimize Retrospective Chart Review ................ 75
What is the Risk Score Adjustment Model? ......................................................................... 75
Why are retrospective chart reviews necessary? .................................................................. 75
What is the significance of the ICD-10-CM Diagnosis code? .............................................. 75
Have you coded for all chronic conditions for the member? ................................................ 75
Physician Communication Tips ............................................................................................ 76
Ambulance ................................................................................................................................ 77
Anesthesia ................................................................................................................................. 78
Audiology ................................................................................................................................. 78

2
Chemotherapy ........................................................................................................................... 78
Chiropractic Care ...................................................................................................................... 78
Dialysis ..................................................................................................................................... 78
Durable Medical Equipment ..................................................................................................... 78
EPSDT Supplemental Billing Information ............................................................................... 78
Newborn Care: ...................................................................................................................... 79
New Patient: Established Patient: ................................................................................... 79
Completing the CMS 1500 or UB-04 Claim Form ............................................................... 79
Factor Drug Carve-Out ................................................................................................................. 81
Family Planning ............................................................................................................................ 81
Sterilization ............................................................................................................................... 81
Home Health Care (HHC) ............................................................................................................ 82
Infusion Therapy ........................................................................................................................... 82
Injectable Drugs ............................................................................................................................ 82
Maternity ....................................................................................................................................... 82
Multiple Surgical Reduction Payment Policy ............................................................................... 82
Physical/Occupational and Speech Therapies .............................................................................. 82
Termination of Pregnancy............................................................................................................. 83
Most Common Claims Errors ....................................................................................................... 84
NOTES .......................................................................................................................................... 86

3
Claim Filing
Blue Cross Complete, hereafter referred to as the Plan (where appropriate), is required by state and
federal regulations to capture specific data regarding services rendered to its members. All billing
requirements must be adhered to by the provider in order to ensure timely processing of claims.

When required data elements are missing or are invalid, claims will be rejected by the Plan for
correction and re-submission.

Claims for billable and capitated services provided to Plan members must be submitted by the
provider who performed the services.

Claims filed with the Plan are subject to the following procedures:
 Verification that all required fields are completed on the CMS 1500 or UB-04 forms.
 Verification that all Diagnosis and Procedure Codes are valid for the date of service.
 Verification for electronic claims against 837 edits at Change Healthcare™ (formerly Emdeon,
and heretofore referred to as Change Healthcare).
 Verification of member eligibility for services under the Plan during the time period in which
services were provided.
 Verification that the services were provided by a participating provider or that the “out of plan”
provider has received authorization to provide services to the eligible member.
 Verification that the provider participated with the Medical Assistance program at the time of
service.
 Verification that an authorization has been given for services that require prior authorization
by the Plan.
 Verification of whether there is Medicare coverage or any other third party resources and, if so,
verification that the Plan is the “payer of last resort” on all claims submitted to the Plan.

Important: Rejected claims are defined as claims with invalid or required missing data elements,
such as the provider tax identification number, member ID number, that are returned to the
provider or EDI* source without registration in the claim processing system.

 Rejected claims are not registered in the claim processing system and can be resubmitted as
anew claim.

Important: Denied claims are registered in the claim processing system but do not meet
requirements for payment under Plan guidelines. They should be resubmitted as a corrected claim.

 Denied claims must be re-submitted as corrected claims within 365 calendar days from the
date of service.
 Set claim frequency code correctly and send the original claim number. These are required
elements and the claim will be rejected if not coded correctly.

Note: These requirements apply to claims submitted on paper or electronically.

* For more information on EDI, review the section titled Electronic Data Interchange (EDI) for
Medical and Hospital claims in this booklet.

4
Claim Mailing Instructions
Submit claims to the Plan at the following address:

Claim Processing Department

Blue Cross Complete
P.O. Box 7115
London, KY 40742

The Plan encourages all providers to submit claims electronically. For those interested in electronic
claim filing, contact your EDI software vendor or Change Healthcare’s Provider Support Line at
1-800-845-6592 to arrange transmission.

Any additional questions may be directed to the EDI Technical Support Hotline at 1-800-542-0945
1-800-542-0945 or by email at: [email protected]

Claim Filing Deadlines

All claims must be resolved with 365 calendar days from the date of service or discharge date.

This applies to capitated and fee-for-service claims.

Please allow for normal processing time before re-submitting a claim either through the EDI or
paper process. This will reduce the possibility of your claim being rejected as a duplicate claim.
Claims are not considered as received under timely filing guidelines if rejected for missing or
invalid provider or member data.

Note: Claims must be received by the EDI vendor by 9:00 p.m. in order to be transmitted to the Plan
the next business day.

Exceptions
Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 120
days of the date of the primary insurer’s EOB (claim adjudication).

Important: Requests for adjustments may be submitted by telephone to Provider Claims Services
at 1-800-521-6007.

(Select the prompts for the correct Plan, and then, select the prompt for claim issues.) If submitting
via paper or EDI, please include the original claim number.

If you are submitting a corrected claim, please be sure to enter a “7” along with the original claim
number in box 22 of the 1500. Or use the bill type ending in 7 for a UB.

Claim Processing Department

Blue Cross Complete
P.O. Box 7115
London, KY 40742

Electronically:

Mark claim frequency code “7” and use CLM05-3 to report claims adjustments electronically.
Include the original claim number.

5
Outpatient medical appeals must be submitted in writing to:

Provider Appeals Department

Blue Cross Complete
P.O. Box 7316
London, KY 40742

Inpatient medical appeals must be submitted in writing to:

Provider Appeals Department

Blue Cross Complete
P.O. Box 7307
London, KY 40742

Written Disputes should be mailed to:

Informal Practitioner Dispute

Provider Network Management
Blue Cross Complete
200 Stevens Drive
Philadelphia, PA 19113

Refer to the Provider Manual for complete instructions on submitting appeals.

Note:
The Blue Cross Complete facility payer ID is 00210; the Blue Cross Complete professional
payer ID is 00710. Facility payer ID is 00210; the Blue Cross Complete professional payer ID is
00710

Refunds for Claims Overpayments or Errors

The Plan and the Michigan Department of Health and Human Services encourage providers to
conduct regular self-audits to ensure accurate payment.

Medicaid program funds that were improperly paid or overpaid must be returned. If the provider’s
practice determines that it has received overpayments or improper payments, the provider is
required to make immediate arrangements to return the funds to the Plan or follow the DHS
protocols for returning improper payments or overpayment.

A. Contact Provider Claim Services at 1-800-521-6007 to arrange the repayment.

There are two ways to return overpayments to the Plan:

1. Have the Plan deduct the overpayment/improper payment amount from future claims
payments.

2. Submit a check for the overpayment/improper amount directly to:

Claim Processing Department

Blue Cross Complete
P.O. Box 7115
London, KY 40742

Note: Please include the member’s name and ID, date of service, and Claim ID.

6
7
Claim Form Field Requirements
The following charts describe the required fields that must be completed for the standard Centers
for Medicare & Medicaid Services (CMS) CMS 1500 or UB-04 claim forms. If the field is required
without exception, an “R” (Required) is noted in the “Required or Conditional” box. If completing
the field is dependent upon certain circumstances, the requirement is listed as “C” (Conditional)
and the relevant conditions are explained in the “Instructions and Comments” box.

The CMS 1500 claim form must be completed for all professional medical services, and the UB-04
claim form must be completed for all facility claims. All claims must be submitted within the
required filing deadline of 365 days from the date of service.

Although the following examples of claim filing requirements refer to paper claim forms, claim data
requirements apply to all claim submissions, regardless of the method of submission (electronic or
paper).

Required Fields (CMS 1500 Claim Form):

*Required [R] fields must be completed on all claims. Conditional [C] fields must be completed if the
information applies to the situation or the service provided. Refer to the NUCC or NUBC Reference
Manuals for additional information.

CMS-1500 Claim Form

Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

N/A Carrier Block 2010BB NM103

N301
N302
N401
N402
N403
1 Insurance Check only the type of health coverage R 2000B SBR09 Titled Claim
Program applicable to the claim. This field Filing
Identification indicates the payer to whom the claim is Indicator
being filed. code in
837P.

1a Insured I.D. Health Plan’s member identification R 2010BA NM109 Titled

Number number. If the member is a newborn, Subscriber
the provider must wait until the Primary
newborn’s member ID is issued before Identifier in
submitting a claim. Enter the member’s 837P.
ID number exactly the way it appears on
their Plan-issued ID card. Or the
member’s MDHHS Medicaid ID can be
used in place of the plan ID number.

8
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

2 Patient’s Enter the patient’s name as it appears on R 2010CA or NM103

Name (Last, the member’s Health Plan I.D. card. 2010BA NM104
First, Middle NM105
Initial) NM107

3 Patient’s Birth MMDDYY / M or F R 2010CA or DMG02 Titled

Date / Sex 2010BA Gender in
DMG03 837P.

4 Insured’s Enter the patient’s name as it appears on R 2010BA NM103 Titled

Name (Last, the member’s Health Plan I.D. card.. Subscriber in
First, Middle NM104 837P.
Initial)
NM105

NM107

5 Patient’s Enter the patient’s complete address and R 2010CA N301

Address telephone number. (Do not punctuate
(Number, the address or phone number.) N401
Street, City,
N402
State, Zip+4)
Telephone N403
(include area
code) N404

6 Patient Always indicate self . R 2000B SBR02 Titled

Relationship Individual
To Insured 2000C PAT01 Relationship
code in
837P.

7 Insured’s Always indicate “Same”. C 2010BA N301 Titled

Address Subscriber
(Number, N302 Address in
Street, City, 837P.
N401
State, Zip+4
Code) N402
Telephone
(Include Area N403
Code)

8 Patient Status Not Required Patient

Status does
not exist in

9
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

837P.

9 Other Refers to someone other than the C 2330A NM103 If patient can
Insured's patient. Completion of fields 9a through be uniquely
Name (Last, 9d is Required if patient is covered by NM104 identified to
First, Middle another insurance plan. Enter the the other
NM105
Initial) complete name of the insured. Note: provider in
"COB claims that require attached EOBs NM107 this loop by
must be submitted on paper.” the unique
member ID
then the
patient is the
subscriber
and
identified in
this loop.

Titled Other
Subscriber
Name in
837P.

9a Other Required if # 9 is completed. C 2320 SBR03 Titled Group

Insured's or Policy
Policy Or Number in
Group # 837P.

9b Reserved for Not Required N/A N/A Does not

NUCC use exist in 837P.

9c Reserved for Not Required N/A N/A Does not

NUCC use exist in 837P.

9d Insurance Plan Required if # 9 is completed. List name of C 2320 SBR04 Titled other
Name Or other health plan, if applicable. Required insurance
Program Name when other insurance is available. group in
Complete if more than one other Medical 837P.
insurance is available, or if 9a completed.

10a, Is Patient's Indicate Yes or No for each category. Is R 2300 CLM11 Titled related
b,c Condition condition related to: causes code
Related To: in 873P.
a) Employment
b) Auto Accident

10
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

c) Other Accident

10d Claim Codes C 2300 K3 Use K3 with

(Designated by HIPAA
NUCC) Compliant
codes.

11 Insured's Required when other insurance is C 2000B SBR03 Titled

Policy Group available. Complete if more than one Subscriber
Or FECA # other Medical insurance is available, or if Group or
“yes” to 10a, b, and c. Enter the policy Policy # in
group or FECA number. 837P.

11a Insured's Birth Same as # 3. Required if 11 is completed. C 2010BA DMG02 Titled

Date / Sex Subscriber
DMG03 DOB and
Gender on
837P.

11b Other Claim ID Enter the following qualifier and C 2010BA REF01 Titled Other
accompanying identifier to report the Claim ID in
claim number assigned by the payer for REF02 837P.
worker’s compensation or property and
casualty:

 Y4 – Property Casualty Claim

Number

Enter qualifier to the left of the vertical,

dotted line; identifier to the right of the
vertical, dotted line.

11c Insurance Plan Enter name of Health Plan. Required if 11 C 2000B SBR04 Titled
Name Or is completed. Subscriber
Program Name Group Name
in 837P.

11d Is There Y or N by check box. R 2320 If yes,

Another indicates Y
Health Benefit If yes, complete # 9 a-d. for yes.
Plan?

11
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

12 Patient's Or Enter “Signature on File,” “SOF,” or R 2300 CLM09 Titled

Authorized legal signature. When legal signature, Release of
Person's enter date signed in 6-digit Information
Signature (MM|DD|YY) or 8-digit format code in
(MM|DD|YYYY) format. If there is no 837P.
signature on file, leave blank or enter
“No Signature on File.”

13 Insured's Or Enter “Signature on File,” “SOF,” or C 2300 CLM08 Titled

Authorized legal signature. If there is no signature Benefit
Person's on file, leave blank or enter “No Assignment
Signature Signature on File.” Indicator in
837P.

14 Date Of MMDDYY or MMDDYYYY C 2300 DTP01

Current Illness
Injury, Enter applicable 3-digit qualifier to right DTP03
Pregnancy of vertical dotted line. Qualifiers include:
(LMP)
 431 – Onset of Current
Symptoms or Illness

 484 – Last Menstrual Period
(LMP)

Use the LMP for pregnancy.

Example:

15 Other Date MMDDYY or MMDDYYYY C 2300 DTP01

Enter applicable 3-digit qualifier between DTP03

the left-hand set of vertical dotted lines.
Qualifiers include:

 454 – Initial Treatment

 304 – Latest Visit or Consultation
 453 – Acute Manifestation of a
Chronic Condition
 439 – Accident
 455 – Last X-Ray
 471 – Prescription
 090 – Report Start (Assumed

12
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

Care Date)
 091 – Report End (Relinquished
Care Date)
 444 – First Visit or Consultation

Example:

16 Dates Patient If the patient is employed and is unable C 2300 DTP03 Titled
Unable To to work in current occupation, a 6-digit Disability
Work In (MM│DD│YY) or 8-digit from Date
Current (MM│DD│YYYY) date must be shown and Work
Occupation for the “from–to” dates that the patient Return Date
is unable to work. An entry in this field in 837P.
may indicate employment-related
insurance coverage.

17 Name Of Enter the name (First Name, Middle C 2310A NM 101

Referring Initial, Last Name) followed by the (Refer-ring)
Physician Or credentials of the professional who NM103
Other Source referred or ordered the service(s) or 2310D
(Super- NM104
supply(ies) on the claim.
If multiple providers are involved, enter vising)
NM105
one provider using the following priority
2420
order: NM107
(Ordering)
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen
can be used for hyphenated names.
Enter the applicable qualifier to identify
which provider is being reported.
DN Referring Provider
DK Ordering Provider
DQ Supervising Provider
Enter the qualifier to the left of the

vertical, dotted line. Example:

13
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

17a Other I.D. The Other ID number of the referring, C 2310A REF01 Titled
Number Of ordering, or supervising provider is Referring
Referring reported in 17a in the shaded area. (Referring) REF02 Provider
Physician Secondary
2010D (
The qualifier indicating what the number Identifier,
Supervising
represents is reported in the qualifier Supervising
)
field to the immediate right of 17a. Provider
2420E Secondary
The NUCC defines the following qualifiers (Ordering) Identifier,
used in 5010A1: and Ordering
Provider
0B State License Number Secondary
Identifier in
1G Provider UPIN Number 837P.

G2 Provider Commercial Number

LU Location Number (This qualifier is

used for Supervising Provider only.)

17b National Enter the NPI number of the referring, R 2310D NM109 Titled
Provider ordering, or supervising provider in Referring
Identifier (NPI) Item Number 17b. Provider
Identifier,
Supervising
Provider
Identifier,
and Ordering
Provider
Identifier in
837P.

18 Hospitalization Enter the inpatient 6-digit C 2300 DTP03 Titled

Dates Related (MM│DD│YY) or 8-digit Related
To Current (MM│DD│YYYY) hospital admission Hospitalizati
Services date followed by the discharge date (if on
discharge has occurred). If not Admission
discharged, leave discharge date blank. and
This date is when a medical service is Discharge
furnished as a result of, or subsequent Dates in
to, a related hospitalization. 837P.

14
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

19 Additional Please refer to the most current Not Required 2300 NTE
Claim instructions from the public or private
Information payer regarding the use of this field. PWK
(Designated by Some payers ask for certain identifiers in
NUCC) this field. If identifiers are reported in
this field, enter the appropriate qualifiers
describing the identifier. Do not enter a
space, hyphen, or other separator
between the qualifier code and the
number.
The NUCC defines the following qualifiers
used in 5010A1:

 0B State License Number

 1G Provider UPIN Number
 G2 Provider Commercial Number
 LU Location Number (This
qualifier is used for Supervising
Provider only.)
 N5 Provider Plan Network
Identification Number
 SY Social Security Number (The
social security number may not
be used for Medicare.)
 X5 State Industrial Accident
Provider Number
 ZZ Provider Taxonomy (The
qualifier in the 5010A1 for
Provider Taxonomy is PXC, but ZZ
will remain the qualifier for the
1500 Claim Form.)

20 Outside Lab C 2400 PS102

21 Diagnosis Or Enter the applicable ICD indicator to R 2300 HIXX-02

Nature Of identify which version of ICD codes is
Illness Or being reported. Where
Injury. (Relate XX =
To 24E) 9 ICD-9-CM 01,02,03,
0 ICD-10-CM 04,05,06,
07,08,09,
10,11,12
Enter the indicator between the vertical,

15
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

dotted lines in the upper right-hand area

of the field.

Enter the codes left justified on each line

to identify the patient’s diagnosis or
condition. Do not include the decimal
point in the diagnosis code, because it is
implied. List no more than 12 ICD-10-CM
or ICD-9-CM diagnosis codes. Relate lines
A - L to the lines of service in 24E by the
letter of the line. Use the greatest level
of specificity. Do not provide narrative
description in this field.

22 Resubmission List the original reference number for C 2300 CLM05-3 Send the
Code and/or resubmitted claims. Please refer to the original claim
Original Ref. most current instructions from the public Required for 2300 REF02 if this field is
No or private payer regarding the use of this resubmitted Where used.
field. or adjusted REF01 =
When resubmitting a claim, enter the claims. F8
appropriate bill frequency code left
justified in the left-hand side of the field.

7 Replacement of prior claim

8 Void/cancel of prior claim

 This Item Number is not

intended for use for original
claim submissions.

23 Prior Enter the referral or authorization C 2300 REF02 Titled Prior

Authorization number. Refer to the Provider Manual to Where Authorizatio
Number determine if services rendered require an 2300 REF01 – n Number in
authorization. G1 837P.

REF02 Titled
Where Referral
REF01 = Number in
9F 837P.

24A Date(s) Of “From” date: MMDDYY. If the service R 2400 DTP03 Titled Service
Service was performed on one day leave “To” Date in 837P.
blank or re-enter “From” Date. See below
for Important Note (instructions) for

16
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

completing the shaded portion of field

24.

24B Place Of In 24B, enter the appropriate two-digit R 2300 CLM05-1 Titled Facility
Service code from the Place of Service Code list Code Value
for each item used or service in 837P.
performed. The Place of Service Codes
are available at: 2400 SV105 Titled Place
www.cms.gov/Medicare/Coding/place of Service
-of-service- Code in
codes/Place_of_Service_Code_Set.html. 837P.

24C EMG Check with payer to determine if this C 2400 SV109 Titled
information (emergency indicator) is Emergency
necessary. If required, enter Y for “YES” Indicator in
or leave blank if “NO” in the bottom, 837P.
unshaded area of the field. The
definition of emergency would be
either defined by federal or state
regulations or programs, payer
contracts, or as defined in 5010A1.

24D Procedures, Enter the CPT or HCPCS code(s) and R 2400 SV101 (2- Titled
Services Or modifier(s) (if applicable) from the 6) Product/Serv
Supplies appropriate code set in effect on the ice ID and
CPT/HCPCS date of service. This field Procedure
Modifier accommodates the entry of up to four Modifier in
2-character modifiers. The specific 837P.
procedure code(s) must be shown
without a narrative description.

24E Diagnosis Diagnosis Pointer - Indicate the R 2400 SV107(1- Titled

Pointer associated diagnosis by referencing the 4) Diagnostic
pointers listed in field 21 (1, 2, 3, or 4). Code Pointer
in 837P.
Diagnosis codes must be valid ICD-10
codes for the date of service, and must
be entered in field 21. Do not enter
diagnosis codes in 24E. Note: The Plan
can accept up to twelve (12) diagnosis
pointers in this field. Diagnosis codes
must be valid ICD codes for the date of
service.

24F Charges Enter charges. A value must be entered. R 2400 SV102 Titled Line

17
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

Enter zero ($0.00) or actual charged Item Charge

amount. (This includes capitated Amount in
services.) 837P.

24G Days Or Units Enter the number of days or units. This R 2400 SV104 Titled Service
field is most commonly used for multiple Unit Count in
visits, units of supplies, anesthesia units 837P.
or minutes, or oxygen volume. If only one
service is performed, the numeral 1 must
be entered.

Enter numbers left justified in the field.

No leading zeros are required. If
reporting a fraction of a unit, use the
decimal point.

Anesthesia services must be reported as

minutes. Units may only be reported for
anesthesia services when the code
description includes a time period (such
as “daily management”).

24H EPSDT Family In Shaded area of field: C 2300 CRC

Plan
AV - Patient refused referral;
S2 - Patient is currently under treatment
for referred diagnostic or corrective 2400 SV111
health problems; SV112
NU - No referral given; or
ST - Referral to another provider for
diagnostic or corrective treatment.

In unshaded area of field:

“Y” for Yes – if service relates to a

pregnancy or family planning

“N” for No – if service does not relate to

pregnancy or family planning

24I ID Qualifier Enter in the shaded area of 24I the R 2310B REF(01) Titled
qualifier identifying if the number is a Reference
non-NPI. The Other ID# of the rendering Identification

18
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

provider should be reported in 24J in the Qualifier in

shaded area. 837P.
The NUCC defines the following qualifiers
used in 5010A1:
XX required
0B State License Number
for NPI in
NM109.
1G Provider UPIN Number NM108

G2 Provider Commercial Number

LU Location Number

ZZ Provider Taxonomy (The qualifier in

the 5010A1 for Provider Taxonomy is
PXC, but ZZ will remain the qualifier for
the 1500 Claim Form.)

The above list contains both provider

identifiers, as well as the provider
taxonomy code. The provider identifiers
are assigned to the provider either by a
specific payer or by a third party in order
to uniquely identify the provider. The
taxonomy code is designated by the
provider in order to identify his/her
provider grouping, classification, or area
of specialization. Both, provider
identifiers and provider taxonomy may
be used in this field.

The Rendering Provider is the person or

company (laboratory or other facility)
who rendered or supervised the care. In
the case where a substitute provider
(locum tenens) was used, enter that
provider’s information here. Report the
Identification Number in Items 24I and
24J only when different from data
recorded in items 33a and 33b.

24J Rendering The individual rendering the service is 2310B REF02 Change
Provider ID reported in 24J. Enter the non-NPI ID HealthCare
number in the shaded area of the field. will pass this

19
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

Enter the NPI number in the unshaded R ID on the

area of the field. claim when
The Rendering Provider is the person or present.
company (laboratory or other facility)
who rendered or supervised the care. In
the case where a substitute provider
NPI
(locum tenens) was used, enter that
provider’s information here. Report the NM109
Identification Number in Items 24I and
24J only when different from data
recorded in items 33a and 33b.

25 Federal Tax Enter the “Federal Tax ID Number” R 2010AA REF01 EI Tax
I.D. Number (employer ID number or SSN) of the
SSN/EIN Billing Provider identified in Item Number
33. This is the tax ID number intended to
REF02 /SY SSN
be used for 1099 reporting purposes.
Enter an X in the appropriate box to
indicate which number is being reported.
Only one box can be marked.

Do not enter hyphens with numbers.

Enter numbers left justified in the field.

26 Patient's Enter the patient’s account number R 2300 CLM01 Titled Patient
Account No. assigned by the provider of service’s or Control
supplier’s accounting system. Number in
837P.
Do not enter hyphens with numbers.
Enter numbers left justified in the field.

27 Accept Always indicate Yes. Refer to the back of R 2300 CLM07 Titled
Assignment the CMS 1500 (08-05) form for the Assignment
section pertaining to Medicaid Payments. or Plan
Participation
Code in
837P.

28 Total Charge Enter charges. A value must be entered. R 2300 CLM02 May be $0.
Enter zero (0.00) or actual charges (this
includes capitated services. Blank is not
acceptable.

20
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

29 Amount Paid Required when another carrier is the C 2300 AMT02 Patient Paid
primary payer. Enter the payment
received from the primary payer prior to
invoicing the Plan. Medicaid programs
2320 AMT02 Payer Paid
are always the payers of last resort.

30 Reserved for Not Required

NUCC Use

31 Signature Of “Signature of Physician or Supplier R 2300 CLM06 Titled

Physician Or Including Degrees or Credential” does Provider or
Supplier not exist in 5010A1. Supplier
Including Signature
Degrees Or Enter the legal signature of the Indicator on
Credentials / practitioner or supplier, signature of the 837P.
Date practitioner or supplier representative,
“Signature on File,” or “SOF.” Enter
either the 6-digit date (MM|DD|YY), 8-
digit date (MM|DD|YYYY), or
alphanumeric date (e.g., January 1, 2003)
the form was signed.

32 Name and Enter the name, address, city, state, and R 2310C NM103
Address of ZIP code of the location where the
Facility Where services were rendered. Providers of N301
Services Were service (namely physicians) must identify
N401
Rendered (If the supplier’s name, address, ZIP code,
other than and NPI number when billing for N402
Home or purchased diagnostic tests. When more
Office) than one supplier is used, a separate N403
1500 Claim Form should be used to bill
for each supplier.

If the “Service Facility Location” is a

component or subpart of the Billing
Provider and they have their own NPI
that is reported on the claim, then the
subpart is reported as the Billing Provider
and “Service Facility Location” is not
used. When reporting an NPI in the
“Service Facility Location,” the entity
must be an external organization to the
Billing Provider.

21
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

Enter the name and address information

in the following format:

1st Line – Name

2nd Line – Address
3rd Line – City, State and ZIP code

Do not use punctuation (i.e., commas,

periods) or other symbols in the address
(e.g., 123 N Main Street 101 instead of
123 N. Main Street, #101). Enter a space
between town name and state code; do
not include a comma. Report a 9-digit ZIP
code. Enter the 9-digit ZIP code without
the hyphen.

32a. NPI number Required unless Rendering Provider is an R 2310C NM109

Atypical Provider and is not required to
have an NPI number.

32b. Other ID# Enter the Health Plan ID # (strongly C 2310C REF01 Titled
recommended) Reference
Recommende REF02 Identification
Enter the G2 qualifier followed by the d Qualifier and
Health Plan ID # Laboratory
or Facility
The NUCC defines the following qualifiers
secondary
used in 5010A1:
Identifier in
0B State License Number 837P.

G2 Provider Commercial Number

LU Location Number

Required when the Rendering Provider is

an Atypical Provider and does not have
an NPI number. Enter the two-digit
qualifier identifying the non-NPI number
followed by the ID number. Do not enter
a space, hyphen, or other separator
between the qualifier and number.

22
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

33 Billing Enter the provider’s or supplier’s billing R 2010AA NM103

Provider Info name, address, ZIP code, and phone NM104
& Ph. # number. The phone number is to be NM105
entered in the area to the right of the NM107
field title. Enter the name and address N301
information in the following format: N401
N402
1st Line – Name N403
2nd Line – Address PER04
3rd Line – City, State and ZIP code

Item 33 identifies the provider that is

requesting to be paid for the services
rendered and should always be
completed.

Do not use punctuation (i.e., commas,

periods) or other symbols in the address
(e.g., 123 N Main Street 101 instead of
123 N. Main Street, #101). Enter a space
between town name and state code; do
not include a comma. Report a 9-digit ZIP
code. Enter the 9-digit ZIP code without
the hyphen.
33a. NPI number Required unless Rendering Provider is an R 2010AA NM109 Titled Billing
Atypical Provider and is not required to Provider
have an NPI number Identifier in
837P.

33b. Other ID# Enter the Health Plan ID # (strongly C Titled

recommended) Provider
Recommende 2000A PRV03 Taxonomy
Enter the G2 qualifier followed by the d Code in
Health Plan ID # 837P.
The NUCC defines the following
qualifiers:
2010AA REF02
Titled
0B State License Number where
Reference
REF01 =
Identification
G2 Provider Commercial Number G2
Qualifier and
ZZ Provider Taxonomy Billing
Provider
Required when the Rendering Provider is Additional

23
CMS-1500 Claim Form
Field Field Instructions and Comments Required or Loop ID Segment Notes
# Description Conditional*

an Atypical Provider and does not have Identifier in

an NPI number. Enter the two-digit 837P.
qualifier identifying the non-NPI number
followed by the ID number. Do not enter
a space, hyphen, or other separator
between the qualifier and number.

24
Required Fields (UB-04 Claim Form):

25
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

1 Unlabeled Field Service R R 2010 NM1/85

Location, no PO AA
NUBC – Billing Boxes N3
Provider Name,
Address and Left justified N4
Telephone Number
Line a: Enter the
complete
provider name.

Line b: Enter the

complete
address

Line c: City,
State, and Zip
code + 4

Line d: Enter the

area code,
telephone
number.

2 Unlabeled Field Enter Remit R R 2010 NM1/87

Address AB
NUBC – Pay-to N3
Name and Address Enter the Facility
PROMISe N4
Provider I.D.
(PPID) number.
Left justified

3a Patient Control No. Provider's R R 2300 CLM01

patient
account/control

26
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

number

3b Medical/Health The number C C 2300 REF02

Record Number assigned to the where
patient’s REF01 = EA
medical/health
record by the
provider

4 Type Of Bill Enter the R R 2300 CLM05

appropriate
three or four -
digit code.

1st position is a
leading zero –
Do not include
the leading zero
on electronic
claims.

2nd position
indicates type of
facility.

3rd position
indicates type of
care.

4th position
indicates billing
sequence.

5 Fed. Tax No. Enter the R R 2010 REF02 Pay to provider

number AA Where = Billing Prov
assigned by the

27
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

federal REF01 = EI use 2010AA

government for
tax reporting
purposes.

6 Statement Covers Enter dates for R R 2300 DTP03 MMDDCCYY

Period the full ranges of where
From/Through services being DTP01 =
invoiced. 434
MMDDYY

7 Unlabeled Field Not Used. Leave

Blank.

8a Patient Identifier Patient Health R R 2010 NM109 Patient

Plan ID is BA where =Subscriber Use
conditional if NM101 = 2010BA
number is IL
different from
2010 NM109
field 60
CA where
NM101 =
QC

8b Patient Name Patient name is R R 2010 NM103,N Patient

required. BA M104,NM =Subscriber Use
107 where 2010BA
Last name, first NM101=IL
name, and
middle initial. 2010 NM103,N
Enter the CA M104,NM
patient name as 107 where
it appears on NM101 =
the Health Plan QC
ID card.

28
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

Use a comma or
space to
separate the last
and first names.

Titles (Mr., Mrs.,

etc.) should not
be reported in
this field.

Prefix: No space
should be left
after the prefix
of a name e.g.,
McKendrick.

Hyphenated
names: Both
names should be
capitalized and
separated by a
hyphen (no
space).

Suffix: A space
should separate
a last name and
suffix.

Newborns and
Multiple Births:
If submitting a
claim for a
newborn that
does not have
an identification

29
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

number, enter
“Baby Girl” or
“Baby Boy” and
last name. Refer
to page 42 for
additional
newborn billing
information,
including
Multiple Births.

9a-e Patient Address The mailing R R 2010 N301,

address of the BA N302
patient
2010 N401, 02,
9a. Street CA 03, 04
Address
N301,
9b. City N302

9c. State N401, 02,

03, 04
9d. ZIP Code + 4

9e. Country
Code (report if
other than USA)

10 Patient Birth Date The date of birth R R 2010 DMG02

of the patient BA
DMG02
Right-justified; 2010
MMDDYYYY CA

11 Patient Sex The sex of the R R 2010 DMG03

patient recorded BA

30
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

at admission, 2010 DMG03

outpatient CA
service, or start
of care.

12 Admission Date The start date R R 2300 DTP03 Required on

for this episode where inpatient.
of care. For DTP01=43
inpatient 5
services, this is
the date of
admission.
Right-justified

13 Admission Hour The code R R 2300 DTP03 Required on

referring to the where inpatient.
hour during for bill DTP01=43
which the types 5
patient was other than
admitted for 21X.
inpatient or
outpatient care.
Left Justified

14 Admission Type A code R R 2300 CL101

indicating the
priority of this
admission/visit.

15 Point of Origin for A code R R 2300 CL102

Admission or Visit indicating the
source of the
referral for this
admission or

31
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

visit.

16 Discharge Hour Code indicating R R 2300 DTP03

the discharge where
hour of the DTP01=09
patient from 6
inpatient care.

17 Patient Discharge A code R R 2300 CL103

Status indicating the
disposition or
discharge status
of the patient at
the end service
for the period
covered on this
bill, as reported
in Field 6.

18 - Condition Codes When C C 2300 HIXX-2 HIXX-1=BG

28 submitting
claims for
services not
covered by
The following is Medicare and
unique to Medicare the resident is
eligible Nursing eligible for
Facilities. Condition Medicare Part A,
codes should be the following
billed when instructions
Medicare Part A should be
does not cover followed:
Nursing Facility
Condition codes:
Services
Enter condition

32
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

code X2 or X4
when one of the
following criteria
is applicable to
Applicable
the nursing
Condition Codes:
facility service
X2 – Medicare for which you
EOMB on File are billing:

X4 – Medicare  There was

Denial on File no 3-day
prior
hospital stay
 The resident
was not
transferred
within 30
days of a
hospital
discharge
 The
resident’s
100 benefit
days are
exhausted
 There was
no 60-day
break in
daily skilled
care
 Medical
Necessity
Requiremen
ts are not

33
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

met
 Daily skilled
care
requirement
s are not
met

All other fields

must be
completed as
per the
appropriate
billing guide

29 Accident State The accident C C 2300 REF02

state field
contains the
two-digit state
abbreviation
where the
accident
occurred.
Required when
applicable.

30 Unlabeled Field Leave Blank

31a,b Occurrence Codes Enter the C C 2300 HIXX-2 HIXX-1 = BH

– and Dates appropriate
34a,b occurrence code
and date.
Required when
applicable.

35a,b Occurrence Span A code and the C C 2300 HIXX-2 HIXX-1 = BI

34
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

– Codes And Dates related dates

36a,b that identify an
event that
relates to the
payment of the
claim. Required
when applicable.

37a,b EPSDT Referral Required when C C 2300 K3 Use K3 with

Code applicable. HIPAA
Compliant
Enter the codes.
applicable 2-
character EPSDT
Referral Code
for referrals
made or needed
as a result of the
screen.

YD – Dental C
*(Required for
Age 3 and
Above)
YO – Other C C
YV – Vision C C
YH – Hearing C C
YB – Behavioral C C
YM – medical C C
38 Responsible Party The name and C C Not required
Name and Address address of the Not mapped
party 837I
responsible for

35
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

the bill.

39a,b, Value Codes and A code structure C C 2300 HIXX-2 HIXX-1 = BE

c,d – Amounts to relate
41a,b, amounts or HIXX-5
c,d values to
identify data
elements
necessary to
process this
claim as
qualified by the
payer
organization.
Value Codes and
amounts. If
more than one
value code
applies, list in
alphanumeric
order. Required
when applicable.
Note: If value
code is
populated then
value amount
must also be
populated and
vice versa.
Please see NUCC
Specifications
Manual
Instructions for
value codes and

36
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

descriptions.

Documenting
covered and
non-covered
days: Value
Code 81 – non-
covered days; 82
to report co-
insurance days;
83- Lifetime
reserve days.
Code in the code
portion and the
Number of Days
in the “Dollar”
portion of the
“Amount”
section. Enter
“00” in the
“Cents” field.

42 Rev. Cd. Codes that R R 2400 SV201

identify specific
accommodation,
ancillary service
or unique billing
calculations or
arrangements.

43 Revenue The standard R R N/A N/A Not mapped

Description abbreviated 837I
description of
the related
revenue code

37
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

categories
included on this
bill. See NUBC
instructions for
Field 42 for
description of
each revenue
code category.

44 HCPCS/Accommoda 1. The R R 2400 SV202-2 SV202-1=HC/HP

tion Rates/HIPPS Healthcare
Rate Codes Common
Procedure
Coding
system
(HCPCS)
applicable to
ancillary
service and
outpatient
bills.
2. The
accommoda
tion rate for
inpatient
bills.
3. Health
Insurance
Prospective
Payment
System
(HIPPS) rate
codes
represent

38
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

specific sets
of patient
characteristi
cs (or case-
mix groups)
on which
payment
determinati
ons are
made under
several
prospective
payment
systems.

Enter the
applicable rate,
HCPCS or HIPPS
code and
modifier based
on the Bill Type
of Inpatient or
Outpatient.
HCPCS are
required for all
Outpatient
Claims. (Note:
NDC numbers
are required for
all administered
or supplied
drugs.)

45 Serv. Date Report line item R R 2400 DTP03

dates of service where

39
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

for each DTP01=47

revenue code or 2
HCPCS/HIPPS
code.

46 Serv. Units Report units of R R 2400 SV205

service. A
quantitative
measure of
services
rendered by
revenue
category to or
for the patient
to include items
such as number
of
accommodation
days, miles,
pints of blood,
renal dialysis
treatments, etc.
Note: for drugs,
service units
must be
consistent with
the NDC code
and its unit of
measure. NDC
unit of measure
must be a valid
HIPAA UOM
code or claim
may be rejected.

40
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

47 Total Charges Total charges for R R 2300 SV203

the primary
payer pertaining
to the related
revenue code
for the current
billing period as
entered in the
statement
covers period.
Total Charges
includes both
covered and
non-covered
charges. Report
grand total of
submitted
charges. Enter a
zero ($0.00) or
actual charged
amount.

48 Non-Covered To reflect the C C 2400 SV207

Charges non-covered
charges for the
destination
payer as it
pertains to the
related revenue
code. Required
when Medicare
is Primary.

41
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

49 Unlabeled Field Not Not

required required

50 Payer Enter the name R R 2330 NM103

for each Payer B where
being invoiced. NM101=PR
When the
patient has
other coverage,
list the payers as
indicated below.
Line A refers to
the primary
payer; B,
secondary; and
C, tertiary.

51 Health Plan The number R R 2330 NM109

Identification used by the B where
Number health plan to NM101=PR
identify itself.
The Blue Cross
Complete
facility payer
ID is 00210

52 Rel. Info Release of R R 2300 CLM09

Information
Certification
Indicator. This
field is required
on Paper and
Electronic

42
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

Invoices. Line A
refers to the
primary payer;
B, secondary;
and C, tertiary.
It is expected
that the
provider have all
necessary
release
information on
file. It is
expected that all
released
invoices contain
"Y"

53 Asg. Ben. Valid entries are R R 2300 CLM08

"Y" (yes) and "N"
(no).

The A, B, C
indicators refer
to the
information in
Field 50. Line A
refers to the
primary payer;
Line B refers to
the secondary;
and Line C refers
to the tertiary.

54 Prior Payments The A, B, C C C 2320 AMT02

indicators refer to where

43
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

the information AMT01=D

in Field 50. The
A, B, C indicators
refer to the
information in
Field 50. Line A
refers to the
primary payer;
Line B refers to
the secondary;
and Line C refers
to the tertiary.

55 Est. Amount Due Enter the C C 2300 AMT02

estimated where
amount due (the AMT01
difference =EAF
between “Total
Charges” and
any deductions
such as other
coverage).

56 National Provider The unique R R 2010 NM109

Identifier – Billing identification AA where
Provider number NM101 =
assigned to the 85
provider
submitting the
bill; NPI is the
national
provider
identifier.
Required if the
health care

44
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

provider is a
Covered Entity
as defined in
HIPAA
Regulations.

57 Other (Billing) A unique C C 2010 REF02 Tax ID

A,B,C Provider Identifier identification AA where
number REF01 = EI
assigned to the 2010
BB REF02 Only sent if
provider
where need to
submitting the
REF01 = G2 determine the
bill by the health
Plan ID
plan. Required
REF02
for providers not Legacy ID
where
submitting NPI
REF01 = 2U
in field 56. Use
this field to
report other
provider
identifiers as
assigned by the
health plan
listed in Field 50
A, B and C.

58 Insured's Name Information R R 2010 NM103,N Use 2010BA is

refers to the BA M104,NM insured is
payers listed in 105 where subscriber
field 50. In most NM101 =
cases this will be IL
2330
the patient
A
name. When
other coverage NM103,N
is available, the M104,NM

45
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

insured is 105 where

indicated here. NM101 =
IL

59 P. Rel Enter the R R 2000 SBR02

patient’s B
relationship to
insured. For
Medicaid
programs the
patient is the
insured.

Code 01: Patient

is Insured

Code 18: Self

60 Insured’s Unique Enter the R R 2010 NM109

Identifier patient's Health BA where
Plan ID on the NM101= IL
appropriate line,
exactly as it
appears on the
REF02
patient's ID card
where
on line B or C.
REF01 = SY
Line A refers to
the primary
payer; B,
secondary; and
C, tertiary.

61 Group Name Use this field C C 2000 SBR04

only when a B
patient has

46
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

other insurance
and group
coverage
applies. Do not
use this field for
individual
coverage.

Line A refers to
the primary
payer; B,
secondary; and
C, tertiary.

62 Insurance Group Use this field C C 2000 SBR03

No. only when a B
patient has
other insurance
and group
coverage
applies. Do not
use this field for
individual
coverage. Line A
refers to the
primary payer;
B, secondary;
and C, tertiary.

63 Treatment Enter the Health R R 2300 REF02

Authorization Plan referral or where
Codes authorization REF01 = G1
number. Line A
refers to the
primary payer;

47
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

B, secondary;
and C, tertiary.

64 DCN Document C C 2320 REF02 Original Claim

Control Number. where Number
New field. The REF01 = F8
control number
assigned to the
original bill by
the health plan
or the health
plan’s fiscal
agent as part of
their internal
control.
Previously, field
64 contained the
Employment
Status Code.
The ESC field has
been eliminated.
Note:
Resubmitted
claims must
contain the
original claim ID

65 Employer Name The name of the C C 2320 SBR04

employer that
provides health
care coverage
for the insured
individual
identified in field
58. Required

48
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

when the
employer of the
insured is known
to potentially be
involved in
paying this
claim. Line A
refers to the
primary payer;
B, secondary;
and C, tertiary.

66 Diagnosis and The qualifier that Not Not 2300 Determine

Procedure Code denotes the Required d by the
Qualifier (ICD version of Required qualifier
Version Indicator) International submitted
Classification of on the
Diseases (ICD) claim
reported. Note:
Claims with
invalid codes will
be denied for
payment.

67 Prin. Diag. Cd. and The appropriate R R 2300 HIXX-2 POA

Present on ICD codes
Admission (POA) corresponding HIXX-9
Indicator to all conditions
Where
that coexist at
HI01-1 =
the time of
BK or ABK
service, that
develop
subsequently, or
that affect the
treatment

49
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

received and/or
the length of
stay. Exclude
diagnoses that
relate to an
earlier episode
which have no
bearing on the
current hospital
service.

67 A - Other Diagnosis The appropriate C C 2300 HIXX-2 POA

Q Codes ICD codes
corresponding HIXX-9
to all conditions
Where
that coexist at
HI01-1 =
the time of
BF or ABF
service, that
develop
subsequently, or
that affect the
treatment
received and/or
the length of
stay. Exclude
diagnoses that
relate to an
earlier episode
which have no
bearing on the
current hospital
service.

68 Unlabeled Field

50
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

69 Admitting Diagnosis The appropriate R R 2300 HI02-2 HI01-1=BJ or

Code ICD code ABJ
describing the
patient’s
diagnosis at the
time of
admission as
stated by the
physician.
Required for
inpatient and
outpatient

70 Patient’s Reason for The appropriate C R 2300 HIXX-2 HI01-1=PR or

Visit ICD code(s) APR
describing the
patient’s reason
for visit at the
time of
outpatient
registration.
Required for all
outpatient visits.
Up to three ICD
codes may be
entered in fields
A, B and C.

71 Prospective The PPS code C C 2300 HI01-2

Payment System assigned to the
(PPS) Code claim to identify Where
the DRG based HI01-1 =
on the grouper DR
software called
for under

51
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

contract with
the primary
payer. Required
when the Health
Plan/ Provider
contract
requires this
information. Up
to 4 digits.

72a-c External Cause of The appropriate C C 2300 HIXX-2 HIXX-1=BN or

Injury (ECI) Code ICD code(s) ABN
pertaining to
external cause
of injuries,
poisoning, or
adverse effect.
External Cause
of Injury “E”
diagnosis codes
should not be
billed as primary
and/or
admitting
diagnosis.
Required if
applicable.

73 Unlabeled Field

74 Principal Procedure The appropriate C C 2300 HI01-2

code and Date ICD code that
identifies the HI01-4
principal
Where
procedure

52
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

performed at HI01-1 =
the claim level BR or BBR
during the
period covered
by this bill and
the
corresponding
date.

Inpatient facility
– Surgical
procedure code
is required if the
R
operating room
was used.

Outpatient
facility or
Ambulatory
Surgical Center –
CPT, HCPCS or
ICD code is
required when a
surgical
procedure is
performed.

53
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

74a-e Other Procedure The appropriate C C 2300 HIXX-2

Codes and Dates ICD codes
identifying all Where
significant HI01-1 =
procedures BQ or BBQ
other than the
principal
procedure and
the dates
(identified by
code) on which
the procedures
were
performed.

Inpatient facility
– Surgical
procedure code
is required when C
a surgical
procedure is
performed. C
Outpatient
facility or
Ambulatory
Surgical Center
– CPT, HCPCS or
ICD code is
required when a
surgical
procedure is
performed.

54
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

75 Unlabeled Field

76 Attending Provider Enter the NPI of R R 2310 NM109 REF01/0B/1G/L

Name and the physician A where U/G2
Identifiers who has primary NM101 =
NPI#/Qualifier/Oth responsibility for 71
er ID# the patient’s
(Do not send the
medical care or
Provider’s Plan
treatment in the 2310 REF02 ID)
upper line, and A
their name in
the lower line,
last name first.
If the attending
physician has
another unique
ID#, enter the
appropriate
descriptive two-
digit qualifier
followed by the
other ID#. Enter
the last name
and first name
of the Attending
Physician.
NM103
Note: If a 2310 where
qualifier is A NM101 =
entered, a 71
secondary ID
must be NM104
2301
present, and if a where
A
secondary ID is NM101 =
present, then a

55
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

qualifier must be 71
present.
Otherwise, the
claim will reject.

77 Operating Physician Enter the NPI of C C 2310 NM109

Name and the physician B where
Identifiers – who performed NM101 =
NPI#/Qualifier/Oth surgery on the 72
er ID# patient in the
2310 NM103
upper line, and
B where
their name in
the lower line, NM101 =
last name first. 72
If the operating 2310
NM104
physician has B
where
another unique
NM101 =
ID#, enter the
72
appropriate
2310
descriptive two- REF02
B
digit qualifier
followed by the R R
other ID#. Enter
the last name
and first name
of the Attending
Physician.

Required when a
surgical
procedure code
is listed.

78 – Other Provider Enter the NPI# R R 2310 NM109

(Individual) Names of any physician, where

56
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

79 and Identifiers – other than the C NM101 =

NPI#/Qualifier/Oth attending ZZ
er ID# physician, who
has NM103
2310 where
responsibility for
C NM101 =
the patient’s
medical care or ZZ
treatment in the
NM104
upper line, and 2310
where
their name in C
NM101 =
the lower line,
last name first. 2310 ZZ
If the other C
REF02
physician has
another unique
ID#, enter the
appropriate
descriptive two-
digit qualifier
followed by the
other ID#

80 Remarks Field Area to capture C C 2300 NTE02 NTE01=ADD

additional
information
necessary to
adjudicate the
claim.

81CC, Code-Code Field To report C C 2000 PRV01

a-d additional codes A
related to Form PRV03
Locator
(overflow) or to
report externally

57
UB-04
Claim
Form
Inpatient, Outpatient,
Bill Types Bill Types
11X, 12X, 13X, 23X,
21X, 22X,
32X 33X 83X

Field Field Description Instructions and Required Required or Loop Segment Notes
# Comments or Condi- Conditional
tional* *

maintained
codes approved
by the NUBC for
inclusion in the
institutional
data set.

58
Special Instructions and Examples for CMS 1500, UB-04 and EDI Claims Submissions
I. Supplemental Information
A. CMS 1500 Paper Claims – Field 24:

Important Note: All unspecified Procedure or HCPCS codes require a narrative description be
reported in the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry
of 61 characters from the beginning of 24A to the end of 24G.

The following are types of supplemental information that can be entered in the shaded lines of Item
Number 24 (or 2410/LIN and CTP segments when submitting via 837):

 Narrative description of unspecified codes

 National Drug Codes (NDC) for drugs
 Vendor Product Number – Health Industry Business Communications Council (HIBCC)
 Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN) formerly
Universal Product Code (UPC) for products
 Contract rate
The following qualifiers are to be used when reporting these services.

Qualifiers Service
ZZ Narrative description of unspecified code (all miscellaneous fields require this
section be reported)

N4 National Drug Codes

VP Vendor Product Number Health Industry Business Communications Council
(HIBCC)
OZ Product Number Health Care Uniform Code Council – Global Trade Item Number
(GTIN)
CTR Contract rate

To enter supplemental information, begin at 24A by entering the qualifier and then the information.
Do not enter a space between the qualifier and the number/code/information. Do not enter
hyphens or spaces within the number/code.

More than one supplemental item can be reported in the shaded lines of Item Number 24. Enter the
first qualifier and number/code/information at 24A. After the first item, enter three blank spaces
and then the next qualifier and number/code/information.

B. EDI – Field 24D (Professional)

C. EDI – Field 33b (Professional)

Field 33b – Other ID# - Professional: 2310B loop, REF01=G2, REF02+ Plan’s Provider Network
Number. Less than 13 Digits Alphanumeric. Field is required. Note: do not send the provider on
the 2400 loop. This loop is not used in determining the provider ID on the claims D. EDI – Field 45
and 51 (Institutional)

Field 45 – Service Date must not be earlier than the claim statement date.

59
Service Line Loop 2400, DTP*472

Claim statement date Loop 2300, DTP*434

Field 51 – Health Plan ID – the number used by the health plan to identify itself. Blue Cross
Complete’s facility payer ID is 00210; the Blue Cross Complete professional payer ID is 00710.

E. Reporting NDC on CMS-1500 and UB-04 and EDI

1. NDC on CMS 1500

 NDC must be entered in the shaded sections of item 24A through 24G.
 Do not submit any other information on the line with the NDC; drug name and drug strength
should not be included on the line with the NDC.
 To enter NDC information, begin at 24A by entering the qualifier N4 and then the 11 digit NDC
information.
o Do not enter a space between the qualifier and the 11 digit NDC number.
o Enter the 11 digit NDC number in the 5-4-2 format (no hyphens).
o Do not use 99999999999 for a compound medication, bill each drug as a separate
line item with its appropriate NDC
 Enter the NDC quantity unit qualifier
o F2 – International Unit
o GR – Gram
o ML – Milliliter
o UN – Unit
 Enter the NDC quantity
o Do not use a space between the NDC quantity unit qualifier and the NDC quantity
o Note: The NDC quantity is frequently different than the HCPC code quantity

Example of entering the identifier N4 and the NDC number on the CMS 1500 claim form:

N4 qualifier NDC Quantity

11 digit NDC NDC Unit Qualifier

2. NDC on UB-04

 NDC must be entered in Form Locator 43 in the Revenue Description Field.

 Do not submit any other information on the line with the NDC; drug name and drug strength
should not be included on the line with the NDC.
 Report the N4 qualifier in the first two (2) positions, left-justified.
o Do not enter spaces
o Enter the 11 character NDC number in the 5-4-2 format (no hyphens).

60
o Do not use 99999999999 for a compound medication, bill each drug as a separate
line item with its appropriate NDC

Immediately following the last digit of the NDC (no delimiter), enter the Unit of Measurement
Qualifier.

o F2 – International Unit
o GR – Gram
o ML – Milliliter
o UN – Unit
 Immediately following the Unit of Measure Qualifier, enter the unit quantity with a floating
decimal for fractional units limited to 3 digits (to the right of the decimal).
o Any unused spaces for the quantity are left blank.

Note that the decision to make all data elements left-justified was made to accommodate the largest
quantity possible. The description field on the UB-04 is 24 characters in length. An example of the
methodology is illustrated below.

N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 4 5 . 5 6 7

3. NDC via EDI

The NDC is used to report prescribed drugs and biologics as required by government regulation.

EDI claims with NDC info must be reported in the LIN segment of Loop ID-2410. This segment is
used to specify billing/reporting for drugs provided that may be part of the service(s) described in
SV1. Please consult your EDI vendor if not submitting in X12 format for details on where to submit
the NDC number to meet this specification.

When LIN02 equals N4, LIN03 contains the NDC number. This number should be 11 digits sent in
the 5-4-2 format with no hyphens. Submit one occurrence of the LIN segment per claim line.
Claims requiring multiple NDC’s sent at claim line level should be submitted using CMS-1500 or UB-
04 paper claim.

When submitting NDC in the LIN segment, the CTP segment is required. This segment is to be
submitted with the Unit of Measure and the Quantity.

When submitting this segment, CTP03, Pricing; CTP04, Quantity; and CTP05, Unit of Measure are
required.

II. Provider Preventable Conditions Payment Policy and Instructions for Submission of POA
Indicators for Primary and Secondary Diagnoses

Which events must be reported?

Never events and other preventable serious adverse events must be reported on claims for all Blue
Cross Complete products.

What are these events?

A never event is a serious, preventable condition that results from health care management and
that should never have occurred. A never event is defined as follows:

61
 A surgical or other invasive procedure performed on the wrong body part or the wrong site
 A surgical or other invasive procedure performed on the wrong member
 The wrong surgical or other invasive procedure performed on a member

A preventable serious adverse event other than a never event is one that meets all of the following
criteria:
 It is reasonably preventable through the use of evidence-based guidelines or criteria.
 It is within the control of the facility or the providers practicing within the facility.
 It is the result of an error made in the facility. (That is, the condition was not present when
the member entered the facility.)
 It results in serious or significant harm.
 It is clearly, unambiguously and precisely identified, reportable and measurable.

Note: In the terminology of government programs, never events and other preventable serious
adverse events are known as provider-preventable conditions. Those PPCs that occur in an
inpatient hospital setting are called health care-acquired conditions. Those that occur elsewhere
are called other provider-preventable conditions. The list of hospital-acquired conditions published
by CMS is available at cms.gov > Medicare > Hospital-Acquired Conditions (Present on Admission
Indicator) > Hospital-Acquired Conditions (on the left navigation bar) > FY 2013, FY 2014, and FY
2015 Final Hac List (no changes have been made during the past 3 years). This document is a
list of hospital-acquired conditions with ICD-9 codes.

Information on hospital-acquired conditions with ICD-10 codes is available at cms.gov .

How to report never events

Providers must comply with the following guidelines when reporting never events:
 Facility services. Hospitals are required to submit a no-pay claim (TOB 110) when an
erroneous surgery related to a never event is reported. If there are covered services or
procedures provided during the same stay as the erroneous surgery, hospitals are required
to submit two claims:
 One claim with covered services or procedures unrelated to the erroneous surgery(s) on a
TOB 11X (with the exception of 110)
 The other claim with the noncovered services or procedures related to the erroneous
surgery or surgeries on a TOB 110 (no-pay claim). Within the first five diagnosis codes
listed on the claim, the TOB 110 claim should also contain one of the diagnosis codes to
indicate the type of preventable serious adverse event: E876.5 (wrong surgery), E876.6
(wrong patient) or E876.7 (wrong body part).

Note: Both the covered and the noncovered claim must have Statement Covers Periods that match.
 Professional services. Any claim for an erroneous surgery or procedure rendered by a
practitioner should be submitted using the CMS-1500 claim form or an 837P claim
transaction. The claim must include the appropriate modifier appended to all lines that
relate to the erroneous surgery or procedure using one of the following applicable National
Coverage Determination modifiers:
o PA – surgery wrong body part
o PB – surgery wrong patient
o PC – wrong surgery on patient

Note: Physician claims associated with these events should be submitted with a charge of 1 cent.

62
Never events are not reimbursed
Blue Cross Complete will not reimburse a hospital or physician in the hospital setting for costs
associated with direct actions that result in a never event.
In addition, all services provided in the operating room when an error occurs are considered
related and are therefore not covered. No providers who are in the operating room when the
preventable serious adverse event occurs and who could bill individually for their services are
eligible for payment. All related services provided during the same hospitalization in which the
error occurred are noncovered.
Note: Related services do not include performance of the correct procedure.

Policy is administered using APR-DRG Grouper

For DRG-reimbursed hospitals, Blue Cross Complete uses the most current version of the All Patient
Refined Diagnosis-Related Groups (APR-DRG) Grouper to administer the policy, incorporating the
POA indicator into the DRG assignment.

Note: Blue Cross Complete continues to require authorization for all inpatient services. Authorizations do not change
any of the payment guidelines stated here.

Common Causes of Claim Processing Delays, Rejections or Denials

Authorization Invalid or Missing - A valid authorization number must be included on the claim
form for all services requiring prior authorization.

Attending Physician ID Missing or Invalid – Inpatient claims must include the name of the
physician who has primary responsibility for the patient's medical care or treatment, and the
medical license number on the appropriate lines in field number 82 (Attending Physician ID) of the
UB-04 (CMS 1450) claim form. A valid medical license number is formatted as 2 alpha, 6 numeric,
and 1 alpha character (AANNNNNNA) OR 2 alpha and 6 numeric characters (AANNNNNN).

Billed Charges Missing or Incomplete – A billed charge amount must be included for each
service/procedure/supply on the claim form.

Diagnosis Code Missing Required Digits – Precise coding sequences must be used in order to
accurately complete processing. Review the ICD-10-CM or ICD-10 manual for the appropriate
categories, subcategories, and extensions. After October 1, 2015, three-digit category codes are
required at a minimum. Refer to the coding manuals to determine when additional alpha or
numeric digits are required. Use “X” as a place holder where fewer than seven digits are required.
Submit the correct ICD qualifier to match the ICD code being submitted.

Diagnosis, Procedure or Modifier Codes Invalid or Missing Coding from the most current coding
manuals (ICD-10-CM, CPT or HCPCS) is required in order to accurately complete processing. All
applicable diagnosis, procedure and modifier fields must be completed.

DRG Codes Missing or Invalid – Hospitals contracted for payment based on DRG codes must
include this information on the claim form.

EOBs (Explanation of Benefits) from Primary Insurers Missing or Incomplete – A copy of the
EOB from all third party insurers must be submitted with the original claim form. Include pages
with run dates, coding explanations and messages. Payment from the previous payer may be submitted
on the 837I or 837P. Besides the information supplied in this document, the line item details may be sent in

63
the SVD segment. Include the adjudication date at the other payer in the DTP, qualifier 573. COB pertains to
the other payer found in 2330B. For COB, the plan is consider the payer of last resort.

External Cause of Injury Codes – External Cause of Injury “E” diagnosis codes should not be billed
as primary and/or admitting diagnosis. Include applicable POA Indicators with ECI codes.

Future Claim Dates – Claims submitted for Medical Supplies or Services with future claim dates
will be denied, for example, a claim submitted on October 1 for bandages that are delivered for
October 1 through October 31 will deny for all days except October 1.

Handwritten Claims – Handwritten claims are no longer accepted. Handwritten information often
causes delays in processing or inaccurate payments due to reduced clarity, therefore handwritten
claims will be rejected.

Highlighted Claim Fields (See Illegible Claim Information)

Illegible Claim Information – Information on the claim form must be legible in order to avoid
delays or inaccuracies in processing. Review billing processes to ensure that forms are typed or
printed in black ink, that no fields are highlighted (this causes information to darken when scanned
or filmed), and that spacing and alignment are appropriate.

Incomplete Forms – All required information must be included on the claim forms in order to
ensure prompt and accurate processing.

Member Name Missing – The name of the member must be present on the claim form and must
match the information on file with the Plan.

Member Plan Identification Number Missing or Invalid – The Plan’s assigned identification
number must be included on the claim form or electronic claim submitted for payment.

Member Date of Birth does not match Member ID Submitted – a newborn claim submitted with
the mother’s ID number will be pended for manual processing causing delay in prompt payment.

Payer or Other Insurer Information Missing or Incomplete – Include the name, address and
policy number for all insurers covering the Plan member.

Place of Service Code Missing or Invalid – A valid and appropriate two digit numeric code must
be included on the claim form. Refer to CMS 1500 coding manuals for a complete list of place of
service codes.

Provider Name Missing – The name of the provider of service must be present on the claim form
and must match the service provider name and TIN on file with the Plan.

Provider NPI Number Missing or Invalid – The individual NPI and group NPI numbers for the
service provider must be included on the claim form.

Revenue Codes Missing or Invalid – Facility claims must include a valid four-digit numeric
revenue code. Refer to UB-04 coding manuals for a complete list of revenue codes.

Spanning Dates of Service Do Not Match the Listed Days/Units – Span-dating is only allowed for
identical services provided on consecutive dates of service. Always enter the corresponding
number of consecutive days in the days/unit field.

64
Signature Missing – The signature of the practitioner or provider of service must be present on the
claim form and must match the service provider name, NPI and TIN on file with the Plan.

Tax Identification Number (TIN) Missing or Invalid - The Tax I. D. number must be present and
must match the service provider name and payment entity (vendor) on file with the Plan.

Taxonomy –The provider’s taxonomy number is required wherever requested in claim

submissions.

Third Party Liability (TPL) Information Missing or Incomplete – Any information indicating a
work related illness/injury, no fault, or other liability condition must be included on the claim form.
Additionally, a copy of the primary insurer’s explanation of benefits (EOB) or applicable
documentation must be forwarded along with the claim form.

Type of Bill – A code indicating the specific type of bill (e.g., hospital inpatient, outpatient,
replacements, voids, etc.). The first digit is a leading zero. Do not include the leading zero on
electronic claims. Adjusted claims may be sent via paper or EDI.

IMPORTANT BILLING REMINDERS:

 Include all primary and secondary diagnosis codes on the claim. All primary and secondary
diagnosis codes must have a corresponding POA indicator.
 Missing or invalid data elements or incomplete claim forms will cause claim processing
delays, inaccurate payments, rejections or denials.
 Regardless of whether reimbursement is expected, the billed amount of the service must be
documented on the claim. Missing charges will result in rejections or denials.
 All billed codes must be complete and valid for the time period in which the service is
rendered. Incomplete, discontinued, or invalid codes will result in claim rejections or
denials.
 State level HCPCS coding takes precedence over national level codes unless otherwise
specified in individual provider contracts.
 The services billed on the claim form should exactly match the services and charges detailed
on the accompanying EOB. If the EOB charges appear different due to global coding
requirements of the primary insurer, submit claim with the appropriate coding which
matches the total charges on the EOB.
 EPSDT services may be submitted electronically or on paper.
 Submitting the original copy of the claim form will assist in assuring claim information is
legible.
 The individual provider name and NPI number as opposed to the group NPI number must be
indicated on the claim form.
 Do not highlight any information on the claim form or accompanying documentation.
Highlighted information will become illegible when scanned or filmed.
 Do not attach notes to the face of the claim. This will obscure information on the claim form
or may become separated from the claim prior to scanning.

65
 Although the newborn claim is submitted under the mother’s ID, the claim must be
processed under the baby’s ID. The claim will not be paid until the state confirms eligibility
and enrollment in the plan.
 The claim for baby must include the baby’s date of birth as opposed to the mother’s date of
birth. Claim must also include baby’s birth weight (value code 54).
 Date of service and billed charges should exactly match the services and charges detailed on
the accompanying EOB. If the EOB charges appear different due to global coding
requirements of the primary insurer, submit claim with the appropriate coding which
matches the total charges on the EOB.
 The individual service provider name and NPI number must be indicated on all claims,
including claims from outpatient clinics. Using only the group NPI or billing entity name and
number will result in rejections, denials, or inaccurate payments.
 When the provider or facility has more than one NPI number, use the NPI number that
matches the services submitted on the claim form. Imprecise use of NPI number’s results in
inaccurate payments or denials.
 When submitting electronically, the provider NPI number must be entered at the claim level
as opposed to the claim line level. Failure to enter the provider NPI number at the claim
level will result in rejection. Please review the rejection report from the EDI software
vendor each day.
 Claims without the provider signature will be rejected. The provider is responsible for re-
submitting these claims within 365 calendar days from the date of service.
 Claims without a tax identification number (TIN) will be rejected. The provider is
responsible for re-submitting these claims within 365 calendar days from the date of
service.
 Any changes in a participating provider’s name, address, NPI number, or tax identification
number(s) must be reported to the Plan immediately. Contact your Provider Account
Executive to assist in updating the Plan’s records.

Electronic Data Interchange (EDI) for Medical and Hospital Claims

Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission
for providers. EDI, performed in accordance with nationally recognized standards, supports the
health care industry’s efforts to reduce administrative costs.

The benefits of billing electronically include:

 Reduction of overhead and administrative costs. EDI eliminates the need for paper claim
submission. It has also been proven to reduce claim re-work (adjustments).
 Receipt of clearinghouse reports makes it easier to track the status of claims.
 Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to
48 hours from the time it is sent to the time it is received. This enables providers to easily track
their claims.
 Validation of data elements on the claim form. By the time a claim is successfully received
electronically, information needed for processing is present. This reduces the chance of data
entry errors that occur when completing paper claim forms.
 Quicker claim completion. Claims that do not need additional investigation are generally
processed quicker. Reports have shown that a large percentage of EDI claims are processed
within 10 to 15 days of their receipt.

All the same requirements for paper claim filing apply to electronic claim filing.

66
Important: Please allow for normal processing time before resubmitting the claim either through
EDI or paper claim. This will reduce the possibility of your claim being rejected as a duplicate
claim.

Important: In order to verify satisfactory receipt and acceptance of submitted records, please
review both the Change Healthcare (formerly Change Healthcare) Acceptance report, and the R059
Plan Claim Status Report.

Refer to the Claim Filing section for general claim submission guidelines.

ELECTRONIC CLAIMS SUBMISSION (EDI)

The following sections describe the procedures for electronic submission for hospital and medical
claims. Included are a high level description of claims and report process flows, information on
unique electronic billing requirements, and various electronic submission exclusions.

Hardware/Software Requirements
There are many different products that can be used to bill electronically. As long as you have the
capability to send EDI claims to Change Healthcare, whether through direct submission or through
another clearinghouse/vendor, you can submit claims electronically.

Contracting with Change Healthcare and Other Electronic Vendors

If you are a provider interested in submitting claims electronically to the Plan but do not currently
have Change Healthcare EDI capabilities, you can contact the Change Healthcare Provider Support
Line at 1-800-845-6592. You may also choose to contract with another EDI clearinghouse or
vendor who already has Change Healthcare capabilities.

Contacting the EDI Technical Support Group

Providers interested in sending claims electronically may contact the EDI Technical Support Group
for information and assistance in beginning electronic submissions.

When ready to proceed:

 Read over the instructions within this booklet carefully, with special attention to the
information on exclusions, limitations, and especially, the rejection notification reports.
 Contact your EDI software vendor and/or Change Healthcare to inform them you wish to
initiate electronic submissions to the Plan.
 Be prepared to inform the vendor of the Plan’s electronic payer identification number.

Important: Change Healthcare is the largest clearinghouse for EDI Healthcare transactions in the
world. It has the capability to accept electronic data from numerous providers in several
standardized EDI formats and then forwards accepted information to carriers in an agreed upon
format.

Important: Contact EDI Technical Support at:

1-800-542-0945

Or by email at: [email protected]

67
Important: Providers using Change Healthcare or other clearinghouses and vendors are
responsible for arranging to have rejection reports forwarded to the appropriate billing or open
receivable departments.

68
Important: the Payer ID for Blue Cross Complete facility payer ID is 00210; the Blue Cross
Complete professional payer ID is 00710

NOTE: Plan payer specific edits are described in Exhibit 99 at Change Healthcare.

Specific Data Record Requirements

Claims transmitted electronically must contain all the same data elements identified within the
Claim Filing section of this booklet. Change Healthcare or any other EDI clearinghouse or vendor
may require additional data record requirements.

Electronic Claim Flow Description

In order to send claims electronically to the Plan, all EDI claims must first be forwarded to Change
Healthcare. This can be completed via a direct submission or through another EDI clearinghouse or
vendor.

Once Change Healthcare receives the transmitted claims, the claim is validated for HIPAA
compliance and the Plan’s Payer Edits as described in Exhibit 99 at Change Healthcare. Claims not
meeting the requirements are immediately rejected and sent back to the sender via a Change
Healthcare error report. The name of this report can vary based upon the provider’s contract with
their intermediate EDI vendor or Change Healthcare.

Accepted claims are passed to the Plan, and Change Healthcare returns an acceptance report to the
sender immediately.

Claims forwarded to the Plan by Change Healthcare are immediately validated against provider and
member eligibility records. Claims that do not meet this requirement are rejected and sent back to
Change Healthcare, which also forwards this rejection to its trading partner – the intermediate EDI
vendor or provider. Claims passing eligibility requirements are then passed to the claim processing
queues. Claims are not considered as received under timely filing guidelines if rejected for
missing or invalid provider or member data.

Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted
or rejected claims received from Change Healthcare or other contracted EDI software vendors,
must be reviewed and validated against transmittal records daily.

Since Change Healthcare returns acceptance reports directly to the sender, submitted claims not
accepted by Change Healthcare are not transmitted to the Plan.

 If you would like assistance in resolving submission issues reflected on either the
Acceptance or R059 Plan Claim Status reports, contact the Change Healthcare Provider
Support Line at 1-800-845-6592.
 If you need assistance in resolving submission issues identified on the R059 Plan Claim
Status report, contact the EDI Technical Support Hotline at 1-800-542-0945 or by email at:
[email protected]

Important: Rejected electronic claims may be resubmitted electronically once the error has been
corrected.

Important: Change Healthcare will produce an Acceptance report * and a R059 Plan Claim Status
Report** for its trading partner whether that is the EDI vendor or provider. Providers using Change

69
Healthcare or other clearinghouses and vendors are responsible for arranging to have these reports
forwarded to the appropriate billing or open receivable departments.

* An Acceptance report verifies acceptance of each claim at Change Healthcare.

** A R059 Plan Claim Status Report is a list of claims that passed Change Healthcare‘s validation
edits. However, when the claims were submitted to the Plan, they encountered provider or member
eligibility edits.

Important: Claims are not considered as received under timely filing guidelines if rejected for
missing or invalid provider or member data.

Timely Filing Note: Your claims must be received by the EDI vendor by 9 p.m. in order to be
transmitted to the Plan the next business day.

Important: Contact Change Healthcare Provider Support Line at 1-800-845-6592.

Important: Claims submitted can only be verified using the Accept and/or Reject Reports. Contact
your EDI software vendor or Change Healthcare to verify you receive the reports necessary to
obtain this information.

Important: When you receive the Rejection report from Change Healthcare or your EDI vendor, the
plan does not receive a record of the rejected claim.

Invalid Electronic Claim Record Rejections/Denials

All claim records sent to the Plan must first pass Change Healthcare HIPAA edits and Plan specific
edits prior to acceptance. Claim records that do not pass these edits are invalid and will be rejected
without being recognized as received at the Plan. In these cases, the claim must be corrected and
re-submitted within the required filing deadline of 365 calendar days from the date of service. It is
important that you review the Acceptance or R059 Plan Claim Status reports received from Change
Healthcare or your EDI software vendor in order to identify and re-submit these claims accurately.

Plan Specific Electronic Edit Requirements

The Plan currently has two specific edits for professional and institutional claims sent
electronically.

837P –005010X222A1– Provider ID Payer Edit states the ID must be less than 13 alphanumeric
digits.

837I – 005010X223A2 – Provider ID Payer Edit states the ID must be less than 13 alphanumeric
digits.

Exclusions
Certain claims are excluded from electronic billing. These exclusions fall into two groups and apply
to inpatient and outpatient claim types.

Excluded Claim Categories. At this time, these claim records must be submitted on paper.

Claim records for medical, administrative or claim appeals

70
Excluded Provider Categories. Claims issued on behalf of the following providers must be
submitted on paper.

Providers not transmitting through Change Healthcare or providers sending to Vendors that are
not transmitting (through Change Healthcare) NCPDP Claims

Pharmacy (through Change Healthcare)

Important: Requests for adjustments may be submitted by telephone to:

Provider Claim Services: 1-800-521-6007

If you prefer to write, please be sure to stamp each claim submitted “corrected” or “resubmission”
and address the letter to:

Claim Processing Department

Blue Cross Complete
P.O. Box 7115
London, KY 40742

Outpatient medical appeals must be submitted in writing to:

Provider Appeals Department

Blue Cross Complete
P.O. Box 7316
London, KY 40742

Inpatient medical appeals must be submitted in writing to:

Provider Appeals Department

Blue Cross Complete
P.O. Box 7307
London, KY 40742

Refer to the Provider Manual on the Blue Cross Complete provider website online at:
mibluecrosscomplete.com/providers for complete instructions on submitting administrative or
medical appeals.

Submit written disputes to:

Informal Practitioner Dispute

P.O. Box 7329
London, KY 40742

Common Rejections
Invalid Electronic Claim Records – Common Rejections from Change Healthcare

Claims with missing or invalid batch level records

Claim records with missing or invalid required fields

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Claim records with invalid (unlisted, discontinued, etc.) codes (CPT-4, HCPCS, ICD-10, etc.)

Claims without provider numbers

Claims without member numbers

Claims in which the date of birth submitted does not match the member ID.

Invalid Electronic Claim Records – Common Rejections from the Plan (EDI Edits within the Claim
System)

Claims received with invalid provider numbers

Claims received with invalid member numbers

Claims received with invalid member date of birth

Resubmitted Professional Corrected Claims

Providers using electronic data interchange (EDI) can submit “professional” corrected claims*
electronically rather than via paper to the Plan.

* A corrected claim is defined as a resubmission of a claim with a specific change that you have
made, such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review
the processing of a claim.

Your EDI clearinghouse or vendor needs to:

 Use “7” for replacement of a prior claim utilizing bill type in loop 2300, CLM05-03 (837P)
 Include the original claim number in segment REF01=F8 and REF02=the original claim
number; no dashes or spaces
 Do include the plan’s claim number in order to submit your claim with the 7
 Do use this indicator for claims that were previously processed (approved or denied)
 Do not use this indicator for claims that contained errors and were not processed (rejected
upfront)
 Do not submit corrected claims electronically and via paper at the same time
o For more information, please contact the EDI Hotline at 1-800-542-0945 or:
[email protected]
o Providers using our NaviNet portal, (www.navinet.net) can view their corrected
claims faster than available with paper submission processing.

Important: Claims originally rejected for missing or invalid data elements must be corrected and re-
submitted within 365 calendar days from the date of service. Rejected claims are not registered as
received in the claim processing system. (Refer to the definitions of rejected and denied claims on
page 1.)

Important: Before resubmitting claims, check the status of your submitted claims online at
www.navinet.net

72
Important: Corrected Professional Claims may be sent in on paper via CMS 1500 or via EDI.

If sending paper, please stamp each claim submitted “corrected” or “resubmission” and send all
corrected or resubmitted claims to:

Claim Processing Department

Blue Cross Complete

P.O. Box 7115
London, KY 40742

Important: Corrected Institutional and Professional claims can be resubmitted electronically using
the appropriate bill type to indicate that it is a corrected claim.

Contact Change Healthcare Provider Support Line at: 1-800-845-6592

Contact EDI Technical Support at: 1-800-542-0945

Important: Provider NPI number validation is not performed at Change Healthcare. Change
Healthcare will reject claims for provider NPI only if the provider number fields are empty.

Important: The Plan’s Provider ID is recommended as follows:

837P – Loop 2310B, REF*G2[PIN]

837I – Loop 2310A, REF*G2 [PIN]

NPI Processing – The Plan’s Provider Number is determined from the NPI number using the
following criteria:

1. Plan ID, Tax ID and NPI number

2. If no single match is found, the Service Location’s full 9 character ZIP code + 4
3. is used
4. If no service location is include, the billing address full 9 character ZIP code + 4 will be
used
5. If no single match is found, the required Taxonomy is used
6. If no single match is found, the claim is sent to the Invalid Provider queue (IPQ) for
processing
7. If a plan provider ID is sent using the G2 qualifier, it is used as provider on the
claim The legacy Plan ID is used as the primary ID on the claim
8. If you have submitted a claim, and you have not received a rejection report, but are
unable to locate your claim via NaviNet, it is possible that your claim is in review by the
Plan. Please check with provider services and update you NPI data as needed. It is
essential that the service location of the claim match the NPI information sent on the
claim in order to have your claim processed effectively.

73
Electronic Billing Inquiries

Action Contact

If you would like to transmit claims Contact Change Healthcare Provider Support Line at:
electronically…
1-800-845-6592

If you have general EDI questions … Contact EDI Technical Support at: 1-800-542-0945

Or via email: [email protected]

If you have questions about specific claims Contact your EDI Software Vendor or call the Change
transmissions or acceptance and R059 - Healthcare Provider Support Line at 1-800-845-6592
Claim Status reports…

If you have questions about your R059 – Contact Provider Claim Services at-1-800-521-6007
Plan Claim Status (receipt or completion
dates)…

If you have questions about claims that are Contact Provider Claim Services at 1-800-521-6007
reported on the Remittance Advice….

If you need to know your provider NPI Contact Provider Claim Services at 1-800-521-6007
number…

If you would like to update provider, Notify Provider Network Management in writing at:
payee, NPI, UPIN, tax ID number or
payment address information… Blue Cross Complete
200 Stevens Drive
For questions about changing or verifying Philadelphia, PA 19113
provider information…
Or by fax at: 215-937-5343
If you would like information on the 835 Contact your EDI Vendor
Remittance Advice:

Check the status of your claim: Review the status of your submitted claims on NaviNet at
www.navinet.net

Sign up for NaviNet www.navinet.net

NaviNet Customer Service: 1-888-482-8057

74
Tips for Accurate Diagnosis Coding: How to Minimize Retrospective Chart Review

What is the Risk Score Adjustment Model?

Michigan Department of Health and Human Services (MDHHS) utilizes medical encounter data
supplied by the Plan to evaluate disease severity and risk of increased medical expenditures.
MDHHS employs the Chronic Illness and Disability Payment System (CDPS), a diagnostic
classification system, to support health-based capitation payments to the Plan. Accurate payments
from MDHHS help us ensure that providers are reimbursed appropriately for services provided to
our members.

 We must obtain health status documentation from the diagnoses contained in claims data.

Why are retrospective chart reviews necessary?

Although the Plan captures information through claims data, certain diagnosis information is
commonly contained in medical records but is not reported via claim submission. Complete and
accurate diagnosis coding will minimize the need for retrospective chart reviews.

What is the significance of the ICD-10-CM Diagnosis code?

International Classification of Diseases-10th Edition-Clinical Modification (ICD-10-CM) codes are

identified as 3 to 7 alpha-numeric codes used to describe the clinical reason for a patient’s
treatment and a description of the patient’s medical condition or diagnosis (rather than the service
performed).

 Chronic diseases treated on an ongoing basis may be coded and reported as many times as
the patient receives treatment and care for the condition(s).
 Do not code conditions that were previously treated and no longer exist. However, history
codes may be used as secondary codes if the historical condition or family history has an
impact on current care or influences treatment.
 Per the ICD-10-CM Official Guidelines for Coding and Reporting (October, 1, 2015),
providers must code all documented conditions that were present at time of the
encounter/visit, and require or affect patient care treatment or management.

Have you coded for all chronic conditions for the member?

Examples of disease conditions that should always be considered and included on the submission of
the claim if they coexist at the time of the visit:

Amputation status Diabetes mellitus Multiple sclerosis

Bipolar disorder Dialysis status Paraplegia
Cerebral vascular disease Drug/alcohol psychosis Quadriplegia
COPD Drug/alcohol dependence Renal failure
Chronic renal failure HIV/AIDS Schizophrenia
Congestive heart failure Hypertension Simple chronic bronchitis
CAD Lung, other severe cancers Tumors and other cancers
Depression Metastatic cancer, acute leukemia (Prostate, breast, etc.)

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What are your responsibilities?

Physicians must accurately report the ICD-10-CM diagnosis codes to the highest level of specificity.

 For example, a diabetic with neuropathy should be reported with the following primary and
secondary codes:
o E11.40 Diabetes with neurological manifestations and E08.40 for diabetic
polyneuropathy

Accurate coding can be easily accomplished by keeping accurate and complete medical record
documentation.

Documentation Guidelines

 Reported diagnoses must be supported with medical record documentation.

 Acceptable documentation is clear; concise, consistent, complete, and legible.

Physician Documentation Tips

 First list the ICD-10CM code for the diagnosis, condition, problem or other reason for the
encounter visit shown in the medical record to be chiefly responsible for the services
provided.
 Adhere to proper methods for appending (late entries) or correcting inaccurate data
entries, such as lab or radiology results.
 Strike through, initial, and date. Do not obliterate.
 Use only standard abbreviations.
 Identify patient and date on each page of the record.
 Ensure physician signature and credentials are on each date of service documented.
 Update physician super bills annually to reflect updated ICD-10CM coding changes, and the
addition of new ICD-10CM codes.

Physician Communication Tips

 When used, the SOAP note format can assist both the physician and record reviewer/coder
in identifying key documentation elements.

SOAP stands for:

Subjective: How the patients describe their problems or illnesses.

Objective: Data obtained from examinations, lab results, vital signs, etc.

Assessment: Listing of the patient’s current condition and status of all chronic conditions.
Reflects how the objective data relate to the patient’s acute problem.

Plan: Next steps in diagnosing problem further, prescriptions, consultation referrals, patient
education, and recommended time to return for follow-up.

76
Supplemental Information:

Ambulance
Ground and Air Ambulance Services are billed on CMS 1500 or UB-04 or 837 Format

When billing for Procedure Codes A0425 – A0429 and A0433 – A0434 for Ambulance
Transportation services, the provider must also enter a valid 2-digit modifier at the end of the
associated 5-digit Procedure Code. Different modifiers may be used for the same Procedure Code.

 Providers must bill the transport codes with the appropriate destination modifier.
 Mileage must also be billed with the ambulance transport code and be billed with the
appropriate transport codes.
 Providers who submit transport codes without a destination modifier will be denied for
invalid/missing modifier.
 Providers who bill mileage alone will be denied for invalid/inappropriate billing.
 Mileage when billed will only be paid when billed in conjunction with a PAID transport code.
 A second trip is reimbursed if the recipient is transferred from first hospital to another hospital
on same day in order to receive appropriate treatment. Second trip must be billed with a (HH)
destination modifier.
 For 837 claims, all ambulance details are required. Ambulance Transport information;
Ambulance Certification; pick-up and drop-off locations.

Procedure Code Modifiers: The following procedure code modifiers are required with all transport
procedure codes. The first place alpha code represents the origin and the second place alpha code
represents the client's destination. Codes may be used in any combination unless otherwise noted.

D - Diagnostic or therapeutic site (other than physician's office or hospital)

E - Residential, domiciliary or custodial facility (other than skilled nursing facility)

G - Hospital-based dialysis facility (hospital or hospital-related)

H - Hospital

I - Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport

J - Non hospital-based dialysis facility

N - Skilled nursing facility

P - Physician's office (includes HMO non-hospital facility, clinic, etc.)

R - Residence

S - Scene of accident or acute event

X - (DESTINATION CODE ONLY) Intermediate stop at physician's office enroute to the hospital
(includes HMO non-hospital facility, clinic, etc.)

77
Anesthesia
Procedure codes in the Anesthesia section of the Current Procedural Terminology manual are to be
used to bill for surgical anesthesia procedures.
 Anesthesia claims must be submitted using anesthesia (ASA) procedure codes only (base plus
time units);
 All services must be billed in minutes;
 15 minute time increments will be used to determine payment.

Audiology
Audiology services must be billed on a CMS 1500 claim form or via 837P.

Chemotherapy
 Services may be billed electronically via 837 electronic format or via paper on a CMS 1500 or
UB-04.
 Providers are to use the appropriate chemotherapy administration procedure code in addition
to the “J-code” for the chemotherapeutic agent.
 If a significant separately identifiable Evaluation and Management service is performed,
the appropriate E/M procedure code may also be reported.

Chiropractic Care
 Claims for chiropractic services are billed on a CMS 1500 or via 837 electronic format.
 .
 Must bill appropriate CPT code and modifiers.

Dialysis
 Reimbursement for dialysis services must be billed using the UB-04 claim form or via 837I
electronic format.
 Epogen must be reported with revenue code 634 and revenue code 635.

Durable Medical Equipment

 Services are billed on a CMS 1500 claim form.
 An “RR” modifier is required for all rentals.
 Repair codes on the DME Fee Schedule require the submission of procedure code K0739.
 Refer to the Provider Manual for DME authorization rules and guidelines.
 .
 Benefit Exceptions – items/services not listed on the Plan’s DME fee schedule will be reviewed
on an individual basis based on coverage, benefit guidelines, and medical necessity.
 Miscellaneous codes will not be used if an appropriate code is on the Plan’s First DME fee
schedule.

EPSDT Supplemental Billing Information

EPSDT Billing Guidelines – CMS 1500, UB-04 or Electronic 837 Format

EPSDT Billing Guidelines for Paper or Electronic 837 Claim Submissions

Providers billing for complete Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
screens may bill using the CMS 1500 or UB-04 paper claim forms or electronically, using the 837
format.

78
Providers choosing to bill for complete EPSDT screens, including immunizations, on the CMS 1500
or UB-04 claim form or the 837 electronic formats must:

 Use Z76.1, Z76.2, Z00.121 or Z00.129 as the primary diagnosis code

 Accurate payment of EPSDT claims will be determined solely by the presence of EPSDT
modifiers to identify an EPSDT Claim. Failure to append EPSDT modifiers will cause claims
to be processed as non-EPSDT related encounters
 Use one of the individual age-appropriate procedure codes outlined on the most current
EPSDT Periodicity Schedule (listed below), as well as any other EPSDT related service, e.g.,
immunizations, etc.
 Use EPSDT Modifiers as appropriate: EP - Complete Screen; 52 - Incomplete Screen; 90 -
Outpatient Lab; U1 - Autism.
o Use U1 modifier in conjunction with CPT code 96110 for Autism screening
o CPT code 96110 without a U1 modifier is to be used for a Developmental screening

Age Appropriate Evaluation and Management Codes

(As listed on the current EPSDT Periodicity Schedule and Coding Matrix)

Newborn Care:

99460 Newborn Care (during the admission) 99463 Newborn (same day discharge)

New Patient: Established Patient:

99381 Age < 1 yr 99391 Age < 1 yr

99382 Age 1-4 yrs 99392 Age 1-4 yrs
99383 Age 5-11 yrs 99393 Age 5-11 yrs
99384 Age 12-17 yrs 99394 Age 12-17 yrs
99385 Age 18-20 yrs 99395 Age 18-20 yrs

Billing example: New Patient EPSDT screening for a 1 month old. The diagnosis and procedure
code for this service would be:

 Z76.2 (Primary Diagnosis)

 99381EP (E&M Code with “Complete” modifier)

* Enter charges. Value entered must be greater than zero ($0.00) including capitated services.

Please consult the EPSDT Program Periodicity Schedule and Coding Matrix, as well as the
Recommended Childhood Immunization Schedule for screening timeframes and the services
required to bill for a complete EPSDT screen. Both are available in a printable PDF format online at
the Provider Center at: www.keystonefirstpa.com

Completing the CMS 1500 or UB-04 Claim Form

The following blocks must be completed when submitting a CMS 1500 or UB-04 claim form for a
complete EPSDT screen:

 EPSDT Referral Codes (when a referral is necessary, use the listed codes in the example
below to indicate the type of referral made)
 Diagnosis or Nature of Illness or Injury

79
 Procedures, Services or Supplies CPT/HCPCS Modifier
 EPSDT/Family Planning

UB- CMS Item Description C/R

04 1500

37 10d Reserved for Local Enter the applicable 2-character EPSDT

Use Referral Code for referrals made or needed
as a result of the screen.

YD – Dental (Required for ages 3 and over) C

EPSDT Referrals YO – Other* C
YV – Vision C
YH – Hearing C
YB – Behavioral C
YM – Medical C
* *Following an EPSDT screen, if the
screening Provider suspects developmental
delay and the child is not receiving services
at the time of screening, he/she is required
to refer the child (ages birth to age 5)
through the CONNECT Helpline at 1-800-
692-7288, document the referral in the
child’s medical record and submit the YO
EPSDT referral code.
18 N/A Condition Codes Enter the Condition Code A1 EPSDT R

67 21 Diagnosis or When billing for EPSDT screening services, R

Nature of Illness diagnosis code Z76.1, Z76.2, Z00.121 or
or Injury Z00.129 (Routine Infant or Child Health
Check) must be used in the primary field
(21.1) of this block. Additional diagnosis
codes should be entered in fields 21.2, 21.3,
21.4. An appropriate diagnosis code must
be included for each referral.
Immunization V-Codes are not required.

42 N/A Revenue code Enter Revenue Code 510 R

44 24D Procedures, Populate the first claim line with the age R
Services or appropriate E & M codes along with the EP
Supplies modifier when submitting a “complete’
CPT/HCPCS EPSDT visit, as well as any other EPSDT
Modifier related services, e.g., immunizations

N/A 24H EPSDT/Family Enter Visit Code 03 when providing EPSDT R

Planning screening services.

Key:

 Block Code – Provides the block number as it appears on the claim.

80
 C – Conditional must be completed if the information applies to the situation or the service
provided.
 R – Required – must be completed for all EPSDT claims.

Factor Drug Carve-Out

Note: These instructions are only applicable for in-patient facilities for which factor are a carve-out
in their Plan contract.

Submit clinical information for Factor via secure email to [email protected].

The request is reviewed by hemophilia Nurse Case Manager who has thirty (30) days from receipt
of complete information to review the case.

 Questions regarding status should be directed to the Nurse Case Manager at 215-937-5052.
 Upon Nurse Case Manager approval and authorization, an approval notice is sent to the
Attending Physician, Member and Hospital contact.
 Upon Case Manager recommendation of denial, the case is sent to a Medical Director for
review.
o After review of the request and the Medical Director concurs with the denial
recommendation, a denial notice is sent to the Attending Physician, Member and
Hospital Contact.
o Any appeal should follow the instructions and process that are provided on the
denial letter.
o After review, if the Medical Director decides to approve and authorizes the request,
an approval notice is sent to the Attending Physician, Member and Hospital Contact.

Family Planning
Members are covered for Family Planning Services without a referral or Prior Authorization from
the Plan. Members may self-refer for routine Family Planning Services and may go to any physician
or clinic, including physicians and clinics not in the Plan’s Network. Members that have questions or
need help locating a Family Planning Services provider can be referred to Member Services at 1-
800-521-6860.

Sterilization
Sterilization is defined as any medical procedure, treatment or operation for the purpose of
rendering an individual permanently incapable of reproducing.

A Member seeking sterilization must voluntarily give informed consent on the MDHHS form MSA-
1959

The Member must give informed consent not less than thirty (30) full calendar days (or not less
than 72 hours in the case of emergency abdominal surgery) but not more than 180 calendar days
before the date of the sterilization. In the case of premature delivery, informed consent must have
been given at least 30 days before the expected date of delivery. A new consent form is required if
180 days have passed before the sterilization procedure is provided.

MDHHS' Sterilization Consent Form must accompany all claims for reimbursement for sterilization
services. The form must be completed correctly in accordance with the instructions. The claim and
consent forms will be retained by the Plan.

81
Home Health Care (HHC)
 Provider must bill on UB04, 837 electronic format (whichever format is designated in their
Plan contract).
 When billing on a UB04, bill the appropriate revenue code for the homecare service.
 Providers must bill the appropriate modifier in the first position when more than one
modifier is billed.
 Refer to NDC instructions in the manual.

Infusion Therapy
 Drugs administered by physician or outpatient hospital require prior authorization.
 Drugs require the provider to also bill the NDC and related NDC information.
 Failure to bill the NDC required information will result in denial.

Injectable Drugs
All drugs billed are required to be submitted with NDC information and may be submitted via CMS-
1500 or 837 electronic format. Refer to NDC instructions in Supplemental Information section on
pages 36- 37.

The NDC number and a valid HCPCS code for drug products are required on both the 837 electronic
format and the CMS-1500 for reimbursable medications. For 837I claims, submit only one NDC per
line; Change Healthcare only considers the first NDC on a claim line.

Maternity
 Last menstrual period (LMP) is a required field to be submitted on all claim types.
 The completed ONAF form must be faxed to Bright Start (1-866-405-7946) within seven calendar
days of the date of the prenatal visit as indicated on the form.

Postpartum:
 Render the postpartum visit within 21 to 56 days after delivery.
 Fax the ONAF form again to the Bright Start department (1-866-405-7946) at the post-partum
visit with all post-partum information and any additional visit dates as needed.
 appropriate post-partum diagnosis codes and the appropriate post-partum visit code (59430)
must be reported and billed together on the same claim form within 21-56 days after the
delivery date to receive payment.

Multiple Surgical Reduction Payment Policy

The Plan adheres to the following payment procedure:

 When two or more surgical inpatient or outpatient procedures are performed by the same
practitioner on the same day, the practitioner will be reimbursed at 100% for the highest
allowable payment for one procedure and 50% for the second highest paying procedure,
with no payment for additional procedures.

Physical/Occupational and Speech Therapies

Members are entitled to 36 visits of physical, occupational and speech therapy in a 12 month
period.

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After the 12th visit of physical, occupational, and/or speech therapy, an authorization is required to
continue services. All non-par providers must obtain a prior authorization before any services are
rendered.

Therapy services may be billed on a UB-04 or CMS 1500 claim form or via 837 electronic format.

Termination of Pregnancy
Physicians must certify on a completed Certification for Induced Abortion form (MSA-4240) that,
for medical reasons, an abortion was necessary to save the life of the mother or the beneficiary’s
medical history indicates that the terminated pregnancy was the result of rape or incest. The
physician who completes the MSA-4240 must also ensure completion of the Beneficiary Verification
of Coverage form (MSA-1550) and is responsible for providing copies of the forms for billing
purposes to any other provider
(e.g., anesthesiologist, hospital, laboratory) that would submit claims for services related to the
abortion. Copies of the MSA-4240 and the MSA-1550 are not required for claims for ectopic
pregnancies or spontaneous, incomplete, or threatened abortions. Providers may attach copies of
the MSA-4240 and the MSA-1550 to the claim or submit them via fax.

Federal regulations require that these forms be submitted to Medicaid before reimbursement can
be made for any abortion procedure. This process can eliminate submitting paper attachments for
abortion claims and pre-confirms the acceptability of the completed forms, as well as reduces costly
claim rejections.

Prior to rendering these services, the provider must contact the Utilization Management
department to receive a prior authorization and to also provide copies of the MSA-4240 and/or
MSA-1550.

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Most Common Claims Errors

Field CMS-1500 (02/12) "Reject Statement" (Reject Criteria)

# Field/Data Element

"Member name is missing or illegible." (If first and/or last

2 Patient’s Name
name are missing or illegible, the claim will be rejected.)

"Member date of birth (DOB) is missing." (If missing month

3 Patient’s Birth Date
and/or day and/or year, the claim will be rejected.)

"Member's sex is required." (If no box is checked, the claim

3 Patient’s Birth Sex
will be rejected.)

"Insured’s name missing or illegible." (If first and/or last

4 Insured’s Name
name is missing or illegible, the claim will be rejected.)

"Patient address is missing." (If street number and/or

Patient’s Address( number,
5 street name and/or city and/or state and/or zip+4 are
street, city, state, zip+4) phone
missing, the claim will be rejected.)

"Patient relationship to insured is required." (If none of

6 Patient Relationship to Insured
the four boxes are selected, the claim will be rejected.)

"Insured’s address is missing." (If street number and/or

Insured's Address( number,
7 street name and/or city and/or state and/or zip+4 are
street, city, state, zip+4) phone
missing, the claim will be rejected.)

Information related to
"Diagnosis code is missing or illegible." (The claim will be
21 Diagnosis/Nature of
rejected.)
Illness/Injury

"National Drug Code (NDC) data is

missing/incomplete/invalid." (The claim will be rejected if
24 Supplemental Information
NDC data is missing incomplete, or has an invalid unit/basis
of measurement.)

“Date of service (DOS) is missing or illegible." (The claim

will be rejected if both the” From” and “To” DOS are missing.
24A Date of Service If both “From” and “To” DOS are illegible, the claim will be
rejected. If only the “From” or “To” DOS is billed, the other
DOS will be populated with the DOS that is present.)

"Place of service is missing or illegible." (Claim will be

24B Place of Service
rejected.)

"Procedure code is missing or illegible." (Claim will be

24D Procedure, Services or Supplies
rejected.)

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Field CMS-1500 (02/12) "Reject Statement" (Reject Criteria)
# Field/Data Element

"Diagnosis (DX) pointer is required on line ___” [lines 1-

6]. (For each service line with a “From” DOS, at least one
24E Diagnosis Pointer
diagnosis pointer is required. If the DX pointer is missing, the
claim will be rejected.)

"Line item charge amount is missing on line ___” [lines 1-

24F Line item charge amount 6]. (If a value greater than or equal to zero is not present on
each valid service line, claim will be rejected.)

"Days/units are required on line ___” [lines 1-6]. (For each

line with a “From” DOS, days/units are required. If a numeric
24G Days/Units
value is not present on each valid service line, claim will be
rejected.)

"National provider identifier (NPI) of the servicing/rendering

Rendering Provider
24J provider is missing, or illegible." (If NPI is missing or illegible,
identification
claim will be rejected.)

Patient Account/Control "Patient Account/Control number is missing or illegible" (If

26
Number missing or illegible, claim will reject)

"Assignment acceptance must be indicated on the claim."

27 Assignment Number
(If "Yes" or "No" is not checked, the claim will be rejected.)

"Total charge amount is required." (If a value greater than

28 Total Claim Charge Amount
or equal to zero is not present, the claim will be rejected.)

Signature of physician or "Provider name is missing or illegible." (If the provider

31 supplier including degrees or name, including degrees or credentials, and date is missing or
credentials illegible, the claim will be rejected.)

"Billing provider name and/or address is missing or

Billing Provider Information incomplete." (If the name and/or street number and/or
33
and Phone number street name and/or city and/or state and/or zip+4 are
missing, the claim will be rejected.)

"Field 33 of the CMS1500 claim form requires the provider’s

Billing Provider Information
33 physical service address including the full 9 character ZIP
and Phone number
code + 4." (If a PO Box is present, the claim will be rejected.)

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NOTES

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