CMS-1500 (02-12) Health Insurance Claim Form

Transcription

1 (02-12) Health Insurance laim Physician and Non-Physician, Professional Services, Laboratory, Independent Diagnostic Testing Facilities (IDTF), Ambulance and other Transportation, EPSDT Service, Ambulatory Surgical enter, Family Planning, Behavioral Health Service, Vision, Therapists (Speech, Physical and Occupational), Health Department, and Durable Mical Equipment Supplier must bill on the. Atypical providers are providers who are not eligible for a National Provider Identifier (NPI) under HIPAA and the rules of the National Plan and Provider Enumeration System (NPPES).These providers therefore are exempt from billing with an NPI and must use a Micaid-assign provider identification number. All HIPAA-cover entities, whether individuals or organizations, are requir to obtain and bill with an NPI. ID/DD Waiver and Behavioral Health linic/rehabilitation providers must bill only one procure code and the corresponding prior authorization number on each claim. Multiple (different) procure codes requiring different authorization numbers cannot be submitt on the same claim form. Table of WV Micaid s,, Etc. Indicators: Blank = Not = onditionally R = **Note All requirements will be enforc on January 1, Failure to comply could result in claim rejections. Name 1a R Insur s ID Number 2 R Patient s Name 3 R Patient s Birth date and Sex Enter the 11 (eleven)-digit Micaid member ID (MAID) or the 10 (ten)-digit HIP PIN number for member. Enter name of the patient. Last Name, First Name and Middle Initial. Include any suffix (Jr., Sr.). Enter the valid date of birth. at = MMDDYY or MMDDYY. heck the correct box for patient sex. Male (M) Female (F) 4 Insur s Name No entry requir. Revis 10/17/2018

2 Name 5 R Patient s Address Enter the patient s full address. Street Address, ity, State and 9-digit ZIP code. 6 Patient s Relationship to the Insur No entry requir. 7 Insur s Address No entry requir. 8 Reserv for NU Use No entry requir. 9 Other Insur s Name 9a Other Insur s Policy or Group Number Enter the policyholder s name of Insurance other than Micaid that covers this patient - If no other insurance, skip to locator 10. Enter policy or group number of the Insurance. 9b Reserv for NU Use No entry requir. 9c Reserv for NU Use No entry requir. 9d Insurance Plan Name or Program Name Enter the plan name of insurance other than Micaid. 10 Is Patient s ondition relat to: 10a Employment? 10b Auto Accident? 10c Other Accident? If condition is relat to box 10a, 10b, or 10c then a date is requir in box 14 Indicate yes or no with an X if the Patient s condition is relat to employment; if yes, then a date is requir in box 14. Indicate yes or no with an X if the Patient s condition is relat to an auto accident. If yes, enter the 2-digit state abbreviation of the state where the auto accident occurr and a date is requir in box 14. Indicate yes or no with an X if the Patient s condition is relat to an accident other than an auto accident. If yes, a date is requir in box d laim codes (Designat by NU) 11 Insur s Group Number No entry requir. 12 Patient s Signature No entry requir. 13 Insur s Signature No entry requir. Revis 10/17/2018

3 14 Name Date of urrent Illness, Injury and/or Pregnancy Enter valid date of current accident (auto or other). at = MMDDYY or MMDDYY ** if box 10b Auto Accident&/or box 10c Other Accident is mark Yes. Enter valid date of urrent Onset of Illness if not relat to cause check in 10a, b or c. at = MMDDYY or MMDDYY 15 Other Date No entry requir. 16 Dates Patient Unable to Work No entry requir. 17 Name of Referring Physician or Other Source Enter Last Name and First Name of Referring Physician or other source. NPI is requir unless provider is not eligible per NPPES and uses Atypical Provider Identification (API). 17a Referring Physician s Identification Number 17b Referring Physicians NPI Enter G2 in the first box follow by the referring physician s 10-digit NPI (or API, if applicable) - Leave blank if patient was not referr. Leave blank if NPI is enter in 17b. Enter the 10-digit NPI of the referring physician. 18 Hospitalization Dates No entry requir. 19 Reserv for Local Use: No entry requir. 20 Outside Lab No entry requir. Revis 10/17/2018

4 Name 21 R ID Indicator Enter 0 for ID-10. Note: This is a 1-digit field. 21A-L R Diagnosis code Enter diagnosis codes in priority order (primary, secondary, etc.). Diagnosis code A is requir. 22 Resubmission ode / Original Reference Number 23 Prior Authorization Number 24 R Service Lines Micaid Resubmission code: Valid values = 1, 7 or 8. 1= Initial laim 7= Prior claim/replacement 8= ancellation of Prior laim **es Original Reference (laim) Number if Resubmission code = 7 or 8. This is the Micaid or HIP original claim ID. Enter the prior authorization number, if applicable for the claim - The claim must be split if more than one prior authorization number applies. **At least one service line is requir. Maximum of 6 lines per claim. Revis 10/17/2018

5 R or Name ND number-shad area (requir when billing PT/HPS codes for a drug) Shad area: Drug codes require ND. See for the Drug ode List for procure codes that require ND codes and additional ND billing instructions/faqs. Enter the ND qualifier of N4, follow by an 11-digit ND number. 24a Do not enter a space between the qualifier and ND. Do not enter hyphens or spaces within the ND number. The ND number submitt to Micaid must be the actual ND number on the package or container from which the mication was administer. R Dates of Service-Unshad area Unshad area: Enter the From and To date(s) the service was provid, using the following format MMDDYY. From Date must be greater or equal to the To Date. 24b R Place of Service - (unshad area) Enter the appropriate 2-digit code for place of service. Refer to MS for the most current POS table: ace-of-servicecodes/place_of_service_ode_set.html 24c EMG unshad area If emergency, then enter Y for Yes. Revis 10/17/2018

6 Name ND unit measurement-shad area Shad area: Enter the ND unit of measurement and numeric quantity administer to the patient. Enter the actual metric decimal quantity (units) administer to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may prece the decimal point and three numbers may follow the decimal. The unit of measurement codes are: F2 -International Unit 24d GR-Gram ML-Milliliter UN- Unit Refer to for additional ND billing instructions/faq s R Procure ode- Unshad area 24e R Diagnosis Pointer unshad area Unshad area: Enter the 5-digit PT or HPS procure code that describes the procure perform. If service provid requires modifier(s), enter up to four modifiers in the column(s) provid following the PT or HPS code. Enter the letters from block 21 that identify the diagnosis codes. Applicable to the procure bill on the line. The reference letters A - H are requir. Note: I L are not allow at this time. Enter the total charge for the procure perform. 24f R harges **Note** If no decimal point is present, the amount left of the divider on claim form will be captur as whole dollars and the amount to the right of divider as cents. Revis 10/17/2018

7 Name 24g R Unit(s) 24h EPSDT/Family Planning (For providers participating in EPSDT and Family Planning programs only) 24i ID Qualifier Shad Area Enter the quantity or number of units of the service provid. PT 0 codes: Bill 15 minute time units for DOS prior to 7/1/2017; bill minutes for DOS 7/1/2017 and after for paper claims only (Do Not bill base units). WV Micaid valid values include: Y = EPSDT N = Non-EPSDT Enter PX when entering the taxonomy code for the servicing provider in block 24j. Or, enter G2 as a qualifier for legacy Micaid ID. If the rendering provider is a One to Many provider (one NPI to more than one Micaid legacy number), enter the provider s taxonomy code in 24j along with the qualifier PX in block 24i if applicable. NPI is requir unless provider is not eligible per NPPES and uses Atypical Provider Identification (API). 24j Rendering provider s Legacy Micaid ID Shad area Rendering provider s NPI - Unshad area Shad area: Enter the atypical provider s 10-digit Micaid provider number if no NPI is provid. Unshad area: Enter the rendering provider s NPI number on each line bill. Entry is requir if the provider is a physician, APRN, therapist, etc.; a person and the payment/remit is going to a group or pay-to location document in block 33. Revis 10/17/2018

8 Name 25 R F Tax ID 26 R Patient s Account Number Indicate whether the Feral tax ID# is SSN or EIN. Enter Feral Tax ID#. Must be 9 numeric characters. Enter patient s account number or name. Alphanumeric characters may be us (maximum of 20). The account number or name will be print on the WV Micaid remittance advice. 27 Accepts Assignment No entry requir. 28 R Total harge Enter total charges. Note: For multiple page claims, enter total charges on the last page only. Multiple page claims must specify page (1 of 2, 2 of 3, etc.) on the top of the claim. 29 Amount Paid Attach Micare and/or TPL EOBs to claim form. Write Micare HMO on the paper EOB from Micare HMOs. TPL and Micare HMOs denials must be bill on paper with the EOB showing denial codes and the descriptions. (Services approv by TPL and Micare HMOs may be bill electronically.) Bill deni and approv claim lines on separate claims. Note: Micare (not Micare HMO) deni claims or claim lines on paid claims, may be bill electronically with the Micare Action odes. 30 Balance Due No entry requir. 31 R Signature and Date Signature of person authoriz to certify this claim. By signing the BMS Provider Enrollment Agreement providers have certifi that all information list on a claim for reimbursement by Micaid is true, accurate and complete. Therefore, claims may be endors with a computer-generat, manual or stamp signature. Enter the claim submission date. Revis 10/17/2018

9 32 Name Service Facility Location Information Enter Facility Name, address, city, state and 9-digit ZIP code. ** if 32A contains Service Facility Location NPI. 32a & b Servicing Facility NPI Servicing Facility Taxonomy Enter Service Facility if ne in the following format. Provider 10-digit NPI, dash, 3 digit facility code. OR Provider 10-digit Micaid ID, dash, 3-digit facility code (service location identifier). Example: (no spaces). Enter requir billing provider information as follow: 33 R 33a R Billing Provider Info and Phone number NPI number of Physician, Group, or Supplier Phone Name Street Address ity, State & 9-digit ZIP code Enter the NPI of the billing provider, group or pay-to. If there is a servicing/rendering in 24j then enter the pay to or group NPI number in 33a. Enter PX (qualifier) if you are entering in a taxonomy code for the provider in 33A. 33b Taxonomy code of Physician, Group, Supplier, or Pay To (No spaces between qualifier and value.) *For Atypical providers, enter qualifier G2 follow by the Micaid legacy ID number. Revis 10/17/2018