CO HCPF Lactation Support Services Billing Manual — CMS 1500 Paper Claim Reference Table

Thefollowingpaperclaimformreferencetableshowsrequired,optionalandconditionalfieldsanddetailedfieldcompletioninstructionsfortheCMS1500professionalclaimform.

CMSFieldNumber&Label

Fieldis?

Instructions

1.InsuranceType

Required

Placean"X"intheboxmarkedasMedicaid.

1a.Insured'sIDNumber

Required

Enterthemember'sHealthFirstColoradoseven(7)-digitHealthFirstColoradoIDnumberasitappearsontheMedicaidIdentificationcard.Example:A123456.

2.Patient'sName

Required

Enterthemember'slastname,firstnameandmiddleinitial.

3.Patient'sDateofBirth/Sex

Required

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

4.Insured'sName

Conditional

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sfulllastname,firstnameandmiddleinitial.Iftheinsuredusedalastnamesuffix(e.g.,Jr,Sr),enteritafterthelastnameandbeforethefirstname.

5.Patient'sAddress

NotRequired

6.Patient'sRelationshiptoInsured

Conditional

Completeifthememberiscoveredbyacommercialhealthinsurancepolicy.Placean"X"intheboxthatidentifiesthemember'srelationshiptothepolicyholder.

7.Insured'sAddress

NotRequired

8.ReservedforNUCCUse

NotRequired

9.OtherInsured'sName

Conditional

Iffield11dismarked"YES,"entertheinsured'slastname,firstnameandmiddleinitial.

9a.OtherInsured'sPolicyorGroupNumber

Conditional

Iffield11dismarked"YES,"enterthepolicyorgroupnumber.

9b.ReservedforNUCCUse

9c.ReservedforNUCCUse

9d.InsurancePlanorProgramName

Conditional

Iffield11Dismarked"YES"entertheinsuranceplanorprogramname.

10a-c.Ispatient'sconditionrelatedto?

Conditional

Whenappropriate,placean"X"inthecorrectboxtoindicatewhetherone(1)ormoreoftheservicesdescribedinfield24areforaconditionorinjurythatoccurredonthejob,asaresultofanautoaccidentorother.

10d.ReservedforLocalUse

11.Insured'sPolicy,GrouporFECANumber

Conditional

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'spolicynumberasitappearsontheIDcard.Onlycompleteiffield4iscompleted.

11a.Insured'sDateofBirth,Sex

Conditional

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexoftheinsured.

11b.OtherClaimID

NotRequired

11c.InsurancePlanNameorProgramName

NotRequired

11d.IsthereanotherHealthBenefitPlan?

Conditional

Whenappropriate,placean"X"inthecorrectbox.Ifmarked"YES,"complete9,9aand9d.

12.Patient'sorAuthorizedPerson'sSignature

Required

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

13.Insured'sorAuthorizedPerson'sSignature

NotRequired

14.DateofCurrentIllness,InjuryorPregnancy

Conditional

Completeifinformationisknown.Enterthedateofillness,injuryorpregnancy(dateofthelastmenstrualperiod)usingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070114forJuly1,2014.Entertheapplicablequalifiertoidentifywhichdateisbeingreported.431-OnsetofCurrentSymptomsorIllness484-LastMenstrualPeriod

15.OtherDateNot

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Conditional

17b.NPIofReferringPhysician

Required

RequiredinaccordancewithProgramRule8.125.8.A

18.HospitalizationDatesRelatedtoCurrentService

NotRequired

19.AdditionalClaimInformation

Conditional

20.OutsideLab?$Charges

Conditional

Completeifalllaboratoryworkwasreferredtoandperformedbyanoutsidelaboratory.Ifthisboxischecked,nopaymentwillbemadetothephysicianforlabservices.Donotcompletethisfieldifanylaboratoryworkwasperformedintheoffice.Practitionersmaynotrequestpaymentforservicesperformedbyanindependentorhospitallaboratory.

21.DiagnosisorNatureofIllnessorInjury

Required

Enteratleastone(1)butnomorethan12diagnosiscodesbasedonthemember'sdiagnosis/condition.

22.MedicaidResubmissionCode

Conditional

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

23.PriorAuthorization

NotRequired

PriorAuthorizationEnterthesix(6)-characterpriorauthorizationnumberfromtheapprovedPriorAuthorizationRequest(PAR).Donotcombineservicesfrommorethanone(1)approvedPARonasingleclaimform.DonotattachacopyoftheapprovedPARunlessadvisedtodosobytheauthorizingagentorthefiscalagent.

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

24

01

01

24

SingleDateofService:Enterthesix(6)-digitdateofserviceinthe"From"field.Completionofthe"To"fieldisnotrequired.Donotspreadthedateentryacrossthetwo(2)fields.Spanbilling:Notpermitted.Alldatesofservicemusthavetheirowndetailedlineitemontheclaim.

24B.PlaceofService

Required

ReferencethebillingpolicyfoundinthismanualforallowedPlaceofServicecodes.

24C.EMG

Conditional

Entera"Y"forYESorleaveblankforNOinthebottomunshadedareaofthefieldtoindicatetheservicewasrenderedforalife-threateningconditionoronethatrequiresimmediatemedicalintervention.

24D.Procedures,Services,orSupplies

Required

EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested:S9443AllproceduresmustbeidentifiedwithcodesinthecurrenteditionofPhysiciansCurrentProceduralTerminology(CPT).CPTisupdatedannually.HCPCSLevelIICodesThecurrentMedicarecodingpublication(forMedicarecrossoverclaimsonly).OnlyapprovedcodesfromthecurrentCPTorHCPCSpublicationswillbeaccepted.

24D.Modifier

Conditional

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.Pleasereferencethebillingpolicydetailedinthismanualforspecificmodifiercodeuse.

24E.DiagnosisPointer

Required

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

24F.$Charges

Required

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

24G.DaysorUnits

Required

Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly.Donotenterfractionsordecimals.

24H.EPSDT/FamilyPlan

Conditional

EPSDT(shadedarea)ForEarly&PeriodicScreening,DiagnosisandTreatmentrelatedservices,entertheresponseintheshadedportionofthefieldasfollows:AV-Available-NotUsedS2-UnderTreatmentST-NewServiceRequestedNU-NotUsedFamilyPlanning(unshadedarea)IftheserviceisFamilyPlanning(e.g.,contraception,sterilization),enter"Y"forYESor"N"forNOinthebottomunshadedareaofthefield.

24I.IDQualifier

NotRequired

24J.RenderingProviderID#

Required

Intheshadedportionofthefield,entertheNationalProviderIdentifier(NPI)ortheHealthFirstColoradoprovidernumberassignedtotheindividualwhoactuallyperformedorrenderedthebilledservice.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

Conditional

EnterthetotalamountpaidbyMedicareoranyothercommercialhealthinsurancethathasmadepaymentonthebilledservices.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.

30.RsvdforNUCCUse

31.SignatureofPhysicianorSupplierIncludingDegreesorCredentials

Required

Eachclaimmustbearthesignatureoftheenrolledproviderorthesignatureofaregisteredauthorizedagent.Eachclaimmusthavethedatetheenrolledproviderorregisteredauthorizedagentsignedtheclaimform.Enterthedatetheclaimwassignedusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070116forJuly1,2016.Unacceptablesignaturealternatives:Claimpreparationpersonnelmaynotsigntheenrolledprovider'sname.Initialsarenotacceptableasasignature.Typedorcomputerprintednamesarenotacceptableasasignature."Signatureonfile"notationisnotacceptableinplaceofanauthorizedsignature.

32.ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#

Required

Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLine:Name2ndLine:Address3rdLine:City,StateandZIPCodeIfthePTisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

33.BillingProviderInfo&Ph#

Required

Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLine:Name2ndLine:Address3rdLine:City,StateandZIPCode

33a-NPINumber

Required

33b-OtherID#

IfthePTisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

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