| (a) Filing a Clean Claim. A physician or provider submits a clean claim by providing to an HMO, preferred provider carrier, or any other entity designated for receipt of claims pursuant to §21.2811 of this title (related to Disclosure of Processing Procedures): (1) for non-electronic claims, the required data elements specified in subsection (b) of this section, or for non-electronic dental claims filed with an HMO, the required data elements specified in subsection (c) of this section; (2) for electronic claims and for electronic dental claims filed with an HMO, the required data elements specified in subsections (e) and (f) of this section; and (3) if applicable, any coordination of benefits or non-duplication of benefits information pursuant to subsection (d) of this section. (b) Required data elements. CMS has developed claim forms which provide much of the information needed to process claims. Insurance Code Chapter 1204 identifies two of these forms, HCFA 1500 and UB-82/HCFA, and their successor forms, as required for the submission of certain claims. The terms in paragraphs (1) - (4) of this subsection are based upon the terms CMS used on successor forms CMS-1500 (08/05), CMS-1500 (12/90), UB-04 CMS-1450, and UB-92 CMS-1450. The parenthetical information following each term refers to the applicable CMS claim form and the field number to which that term corresponds on the CMS claim form. Mandatory form usage dates and optional form transition dates for nonelectronic claims filed or re-filed by physicians or noninstitutional providers are set forth in paragraphs (1) and (2) of this subsection. Mandatory form usage dates and optional form transition dates for nonelectronic claims filed or re-filed by institutional providers are set forth in paragraphs (3) and (4) of this subsection. (1) Required form and data elements for physicians or noninstitutional providers for claims filed or re-filed on or after the later of July 18, 2007, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (08/05) for Medicare claims. The CMS-1500 (08/05) and the data elements described in this paragraph are required for claims filed or re-filed by physicians or noninstitutional providers on or after the later of these two dates: July 18, 2007, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (08/05) for Medicare claims. The CMS-1500 (08/05) must be completed in accordance with the special instructions applicable to the data element as described by this paragraph for clean claims filed by physicians and noninstitutional providers. Further, upon notification that an HMO or preferred provider carrier is prepared to accept claims filed or re-filed on form CMS-1500 (08/05), a physician or noninstitutional provider may submit claims on form CMS-1500 (08/05) prior to the mandatory use date described in this paragraph, subject to the required data elements set forth in this paragraph. (A) subscriber's/patient's plan ID number (CMS-1500 (08/05), field 1a) is required; (B) patient's name (CMS-1500 (08/05), field 2) is required; (C) patient's date of birth and gender (CMS-1500 (08/05), field 3) is required; (D) subscriber's name (CMS-1500 (08/05), field 4) is required, if shown on the patient's ID card; (E) patient's address (street or P.O. Box, city, state, ZIP) (CMS-1500 (08/05), field 5) is required; (F) patient's relationship to subscriber (CMS-1500 (08/05), field 6) is required; (G) subscriber's address (street or P.O. Box, city, state, ZIP) (CMS-1500 (08/05), field 7) is required, but physician or provider may enter "same" if the subscriber's address is the same as the patient's address required by subparagraph (E) of this paragraph; (H) other insured's or enrollee's name (CMS-1500 (08/05), field 9) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; (I) other insured's or enrollee's policy/group number (CMS-1500 (08/05), field 9a) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; (J) other insured's or enrollee's date of birth (CMS-1500 (08/05), field 9b) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; (K) other insured's or enrollee's plan name (employer, school, etc.) (CMS-1500 (08/05), field 9c) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element. If the field is required and the physician or provider is a facility-based radiologist, pathologist, or anesthesiologist with no direct patient contact, the physician or provider must either enter the information or enter "NA" (not available) if the information is unknown; (L) other insured's or enrollee's HMO or insurer name (CMS-1500 (08/05), field 9d) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; (M) whether patient's condition is related to employment, auto accident, or other accident (CMS-1500 (08/05), field 10) is required, but facility-based radiologists, pathologists, or anesthesiologists shall enter "N" if the answer is "No" or if the information is not available; (N) if the claim is a duplicate claim, a "D" is required; if the claim is a corrected claim, a "C" is required (CMS-1500 (08/05), field 10d); (O) subscriber's policy number (CMS-1500 (08/05), field 11) is required; (P) HMO or insurance company name (CMS-1500 (08/05), field 11c) is required; (Q) disclosure of any other health benefit plans (CMS-1500 (08/05), field 11d) is required; (i) if answered "yes," then: (I) data elements specified in paragraph (1)(H) - (L) of this subsection are required unless the physician or provider submits with the claim documented proof that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete the data elements in paragraph (1)(H) - (L) of this subsection; (II) the data element specified in paragraph (1)(II) of this subsection is required when submitting claims to secondary payor HMOs or preferred provider carriers; (ii) if answered "no," the data elements specified in paragraph (1)(H) - (L) of this subsection are not required if the physician or provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage; although the submission of the signed document is not a required data element, the physician or provider shall submit a copy of the signed document to the HMO or preferred provider carrier upon request; (R) patient's or authorized person's signature or notation that the signature is on file with the physician or provider (CMS-1500 (08/05), field 12) is required; (S) subscriber's or authorized person's signature or notation that the signature is on file with the physician or provider (CMS-1500 (08/05), field 13) is required; (T) date of injury (CMS-1500 (08/05), field 14) is required if due to an accident; (U) when applicable, the physician or provider shall enter the name of the referring primary care physician, specialty physician, hospital, or other source (CMS-1500 (08/05), field 17); however, if there is no referral, the physician or provider shall enter "Self-referral" or "None"; (V) if there is a referring physician noted in CMS-1500 (08/05), field 17, the physician or provider shall enter the ID Number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (08/05), field 17a); (W) for claims filed or re-filed on or after May 23, 2008, if there is a referring physician noted in CMS-1500 (08/05), field 17, the physician or provider shall enter the NPI number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (08/05), field 17b) if the referring physician is eligible for an NPI number; (X) narrative description of procedure (CMS-1500 (08/05), field 19) is required when a physician or provider uses an unlisted or not classified procedure code or an NDC code for drugs; (Y) for diagnosis codes or nature of illness or injury (CMS-1500 (08/05), field 21), up to four diagnosis codes may be entered, but at least one is required (primary diagnosis must be entered first); (Z) verification number (CMS-1500 (08/05), field 23) is required if services have been verified pursuant to §19.1724 of this title (relating to Verification). If no verification has been provided, a prior authorization number (CMS 1500 (08/05), field 23) is required when prior authorization is required and granted; (AA) date(s) of service (CMS-1500 (08/05), field 24A) is required; (BB) place of service code(s) (CMS-1500 (08/05), field 24B) is required; (CC) procedure/modifier code (CMS-1500 (08/05), field 24D) is required; (DD) diagnosis code by specific service (CMS-1500 (08/05), field 24E) is required with the first code linked to the applicable diagnosis code for that service in field 21; (EE) charge for each listed service (CMS-1500 (08/05), field 24F) is required; (FF) number of days or units (CMS-1500 (08/05), field 24G) is required; (GG) for claims filed or re-filed on or after May 23, 2008, the NPI number of the rendering physician or provider (CMS-1500 (08/05), field 24J, unshaded portion) is required if the rendering provider is not the billing provider listed in CMS-1500 (08/05), field 33, and if the rendering physician or provider is eligible for an NPI number; (HH) physician's or provider's federal tax ID number (CMS-1500 (08/05), field 25) is required; (II) whether assignment was accepted (CMS-1500 (08/05), field 27) is required if assignment under Medicare has been accepted; (JJ) total charge (CMS-1500 (08/05), field 28) is required; (KK) amount paid (CMS-1500 (08/05), field 29) is required if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan in accordance with paragraph (1)(P) of this subsection and as required by subsection (d) of this section; (LL) signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier (CMS-1500 (08/05), field 31) is required; (MM) name and address of facility where services rendered (if other than home) (CMS-1500 (08/05), field 32) is required; (NN) for claims filed or re-filed on or after May 23, 2008, the NPI number of facility where services are rendered (other than home) is required (CMS-1500 (08/05), field 32a) if the facility is eligible for an NPI; (OO) physician's or provider's billing name, address and telephone number (CMS-1500 (08/05), field 33) is required; (PP) for claims filed or re-filed on or after May 23, 2008, the NPI number of billing provider (CMS-1500 (08/05), field 33a) is required if the billing provider is eligible for an NPI number; and Cont'd... |
