CO HCPF Fee-for-Service Behavioral Health Benefit — CMS 1500 Paper Claim Reference Table

Thefollowingpaperformreferencetableshowsrequired,optional,andconditionalfieldsanddetailedfieldcompletioninstructionsfortheCMS1500claimform.

CMSFieldNumberandLabel

Fieldis?

Instructions

1.InsuranceType

Required

Placean"X"intheboxmarkedasMedicaid.

1a.Insured'sIDNumber

Required

Enterthemember'sseven(7)-digitHealthFirstColoradoIDnumberasitappearsontheHealthFirstColoradoIdentificationcard.Example:A123456.

2.Patient'sName

Required

Enterthemember'slastname,firstname,andmiddleinitial.

3.Patient'sDateofBirth/Sex

Required

Enterthemember'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedate,andtwo(2)digitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexofthemember.

4.Insured'sName

NotRequired

5.Patient'sAddress

NotRequired

6.ClientRelationshiptoInsured

NotRequired

7.Insured'sAddress

NotRequired

8.ReservedforNUCCUse

NotRequired

9.OtherInsured'sName

NotRequired

9a.OtherInsured'sPolicyorGroupNumber

NotRequired

9b.ReservedforNUCCUse

9c.ReservedforNUCCUse

9d.InsurancePlanorProgramName

NotRequired

10a-c.Ispatient'sconditionrelatedto?

NotRequired

10d.ReservedforLocalUse

11.Insured'sPolicy,GrouporFECANumber

NotRequired

11a.Insured'sDateofBirth,Sex

NotRequired

11b.OtherClaimID

NotRequired

11c.InsurancePlanNameorProgramName

NotRequired

11d.IsthereanotherHealthBenefitPlan?

NotRequired

12.Patient'sorAuthorizedPerson'ssignature

Required

Enter"SignatureonFile","SOF",orlegalsignature.Ifthereisnosignatureonfile,leaveblankorenter"NoSignatureonFile".Enterthedatetheclaimformwassigned.

13.Insured'sorAuthorizedPerson'sSignature

NotRequired

14.DateofCurrentIllnessInjuryorPregnancy

NotRequired

15.OtherDateNot

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Conditional

18.HospitalizationDatesRelatedtoCurrentService

NotRequired

19.AdditionalClaimInformation

Conditional

20.OutsideLab?$Charges

Notrequired

21.DiagnosisorNatureofIllnessorInjury

Required

Enteratleastone(1)butnomorethan12diagnosiscodesbasedonthemember'sdiagnosis/condition.EnterapplicableICD-10indicator.

22.MedicaidResubmissionCode

Conditional

Listtheoriginalreferencenumberforresubmittedclaims.Whenresubmittingaclaim,entertheappropriatebillfrequencycodeintheleft-handsideofthefield.7-Replacementofpriorclaim8-Void/CancelofpriorclaimThisfieldisnotintendedforusefororiginalclaimsubmissions.

23.PriorAuthorization

Conditional

Leaveblank

24.ClaimLineDetail

Information

Thepaperclaimformallowsentryofuptosix(6)detailedbillinglines.Fields24Athrough24Japplytoeachbilledline.Donotentermorethansix(6)linesofinformationonthepaperclaim.Ifmorethansix(6)linesofinformationareentered,theadditionallineswillnotbeenteredforprocessing.Eachclaimformmustbefullycompleted(totaled).Donotfilecontinuationclaims(e.g.,Page1of2).

24A.DatesofService

Required

Thefieldaccommodatestheentryoftwo(2)dates:a"From"dateofservicesanda"To"dateofservice.Enterthedateofserviceusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:010119forJanuary1,2019.

From

To

01

01

19

or

From

To

01

01

19

01

01

19

Spandatesofservice

From

To

01

01

19

01

31

19

SingleDateofService:Enterthesix(6)-digitdateofserviceinthe"From"field.Completionofthe"To"fieldisnotrequired.Donotspreadthedateentryacrossthetwo(2)fields.Spanbilling:permissibleifthesameservice(sameprocedurecode)isprovidedonconsecutivedates.

24B.PlaceofService

Required

EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.

11

Office

24C.EMG

NotRequired

24D.Procedures,Services,orSupplies

Required

Entertheprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.

24D.Modifier

Conditional

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.

24E.DiagnosisPointer

Required

Enterthediagnosiscodereferenceletter(A-L)thatrelatesthedateofserviceandtheproceduresperformedtotheprimarydiagnosis.Atleastone(1)diagnosiscodereferencelettermustbeentered.Whenmultipleservicesareperformed,theprimaryreferenceletterforeachserviceshouldbelistedfirst,otherapplicableservicesshouldfollow.Thisfieldallowsfortheentryoffour(4)charactersintheunshadedarea.

24F.$Charges

Required

Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.SomeCPTprocedurecodesaregroupedwithotherrelatedCPTprocedurecodes.Whenmorethanone(1)procedurefromthesamegroupisbilled,specialmultiplepricingrulesapply.Thebaseprocedureistheprocedurewiththehighestallowableamount.ThebasecodeisusedtodeterminetheallowableamountsforadditionalCPTsurgicalprocedureswhenmorethanone(1)procedurefromthesamegroupingisperformed.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColoradocoveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-payorcommercialinsurancepaymentsfromtheusualandcustomarycharges.

24G.DaysorUnits

Required

Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.

24G.DaysorUnits

GeneralInstructions

Aunitrepresentsthenumberoftimesthedescribedprocedureorservicewasrendered.ExceptasinstructedinthismanualorinHealthFirstColoradobulletins,thebilledunitmustcorrespondtoprocedurecodedescriptions.Thefollowingexamplesshowtherelationshipbetweentheproceduredescriptionandtheentryofunits.

24H.EPSDT/FamilyPlan

NotRequired

EPSDT(shadedarea)NotRequiredFamilyPlanning(unshadedarea)NotRequired

24I.IDQualifier

NotRequired

24J.RenderingProviderID#

Required

Intheshadedportionofthefield,entertheNPIoftheHealthFirstColoradoproviderassignedtotheindividualwhoactuallyperformedorrenderedthebilledservice.Thisnumbercannotbeassignedtoagrouporclinic.

25.FederalTaxIDNumber

NotRequired

26.Patient'sAccountNumber

Optional

Enterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).

27.AcceptAssignment?

Required

Theacceptassignmentindicatesthattheprovideragreestoacceptassignmentunderthetermsofthepayer'sprogram.

28.TotalCharge

Required

Enterthesumofallchargeslistedinfield24F.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.

29.AmountPaid

NotRequired

30.RsvdforNUCCUse

31.SignatureofPhysicianorSupplierIncludingDegreesorCredentials

Required

Eachclaimmustbearthesignatureoftheenrolledproviderorthesignatureofaregisteredauthorizedagent.Eachclaimmusthavethedatetheenrolledproviderorregisteredauthorizedagentsignedtheclaimform.Enterthedatetheclaimwassignedusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070116forJuly1,2016.

32.ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#

Required

Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCodeIftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

33.BillingProviderInfo&Ph#

Required

Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCode

33a-NPINumber

Required

33b-OtherID#

IftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

BacktoTop

BacktoTop