CO HCPF Pediatric Personal Care Benefit Billing Manual — CMS 1500 Paper Claim Reference Table

Thefollowingpaperformreferencetableshowsrequired,optional,andconditionalfieldsanddetailedfieldcompletioninstructionsfortheCMS1500claimform.

CMSFieldNumber&Label

Fieldis?

Instructions

1.InsuranceType

Required

Placean“X”intheboxmarkedasMedicaid.

1a.Insured’sIDNumber

Required

Enterthemember'sseven-digitHealthFirstColoradoIDnumberasitappearsontheHealthFirstColoradoIdentificationcard.Example:A123456.

2.Patient'sName

Required

Enterthemember'slastname,firstname,andmiddleinitial.

3.Patient'sDateofBirth/Sex

Required

Enterthemember'sbirthdateusingtwodigitsforthemonth,twodigitsforthedate,andtwodigitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexofthemember.

4.Insured'sName

Conditional

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sfulllastname,firstname,andmiddleinitial.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?

NotRequired

Whenappropriate,placean"X"inthecorrectboxtoindicatewhetheroneormoreoftheservicesdescribedinfield24areforaconditionorinjurythatoccurredonthejob,asaresultofanautoaccidentorother.

10d.ReservedforLocalUse

11.Insured'sPolicy,GrouporFECANumber

NotRequired

11a.Insured'sDateofBirth,Sex

NotRequired

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.DateofCurrentIllnessInjuryorPregnancy

NotRequired

15.OtherDateNot

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Required

OPRNPINumberisrequiredinaccordancewithProgramRule10CCR2505-108.125.8.A.

18.HospitalizationDatesRelatedtoCurrentService

Conditional

Completeforservicesprovidedinaninpatienthospitalsetting.Enterthedateofhospitaladmissionandthedateofdischargeusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070115forJuly1,2015.Ifthememberisstillhospitalized,thedischargedatemaybeomitted.Thisinformationisnotedited.

19.AdditionalClaimInformation

Conditional

20.OutsideLab?$Charges

Conditional

Completeifalllaboratoryworkwasreferredtoandperformedbyanoutsidelaboratory.Ifthisboxischecked,nopaymentwillbemadetothephysicianforlabservices.Donotcompletethisfieldifanylaboratoryworkwasperformedintheoffice.Practitionersmaynotrequestpaymentforservicesperformedbyanindependentorhospitallaboratory.

21.DiagnosisorNatureofIllnessorInjury

Required

Enteratleastonebutnomorethantwelvediagnosiscodesbasedonthemember'sdiagnosis/condition.EnterapplicableICD-10indicator.

22.MedicaidResubmissionCode

Conditional

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

23.PriorAuthorization

NotRequired

24.ClaimLineDetail

Information

Thepaperclaimformallowsentryofuptosixdetailedbillinglines.Fields24Athrough24Japplytoeachbilledline.Donotentermorethansixlinesofinformationonthepaperclaim.Ifmorethansixlinesofinformationareentered,theadditionallineswillnotbeenteredforprocessing.Eachclaimformmustbefullycompleted(totaled).Donotfilecontinuationclaims(e.g.,Page1of2).

24A.DatesofService

Required

Thefieldaccommodatestheentryoftwodates:a“From”dateofservicesanda“To”dateofservice.Enterthedateofserviceusingtwodigitsforthemonth,twodigitsforthedateandtwodigitsfortheyear.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

EPSDTAlldatesofservicemustbethesamedateasscreening.

24B.PlaceofService

Required

EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.

12

Home

24C.EMG

Conditional

Entera“Y”forYESorleaveblankforNOinthebottom,unshadedareaofthefieldtoindicatetheserviceisrenderedforalife-threateningconditionoronethatrequiresimmediatemedicalintervention.

Ifa“Y”forYESisentered,theserviceonthisdetaillineisexemptfromco-paymentrequirements.

24D.

Required

EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.AllproceduresmustbeidentifiedwithcodesinthecurrenteditionofPhysiciansCurrentProceduralTerminology(CPT).CPTisupdatedannually.HCPCSLevelIICodesThecurrentMedicarecodingpublication(forMedicarecrossoverclaimsonly).OnlyapprovedcodesfromthecurrentCPTorHCPCSpublicationswillbeaccepted.

24E.DiagnosisPointer

Required

Enterthediagnosiscodereferenceletter(A-L)thatrelatesthedateofserviceandtheproceduresperformedtotheprimarydiagnosis.Atleastonediagnosiscodereferencelettermustbeentered.Whenmultipleservicesareperformed,theprimaryreferenceletterforeachserviceshouldbelistedfirst,otherapplicableservicesshouldfollow.Thisfieldallowsfortheentryof4charactersintheunshadedarea.

24F.$Charges

Required

Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.SomeCPTprocedurecodesaregroupedwithotherrelatedCPTprocedurecodes.Whenmorethanoneprocedurefromthesamegroupisbilled,specialmultiplepricingrulesapply.Thebaseprocedureistheprocedurewiththehighestallowableamount.ThebasecodeisusedtodeterminetheallowableamountsforadditionalCPTsurgicalprocedureswhenmorethanoneprocedurefromthesamegroupingisperformed.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColoradocoveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-paymentorcommercialinsurancepaymentsfromtheusualandcustomarycharges.

24G.DaysorUnits

Required

Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.AnesthesiaServicesAnesthesiaservicesmustbereportedasminutes.Unitsmayonlybereportedforanesthesiaserviceswhenthecodedescriptionincludesatimeperiod.Anesthesiatimebeginswhentheanesthetistbeginsmemberpreparationforinductionintheoperatingroomoranequivalentareaandendswhentheanesthetistisnolongerinconstantattendance.Noadditionalbenefitoradditionalunitsareaddedforemergencyconditionsorthemember’sphysicalstatus.Thefiscalagentconvertsreportedanesthesiatimeintofifteen-minuteunits.Anyfractionalunitofserviceisroundeduptothenextfifteen-minuteincrement.CodesthatdefineunitsasinclusivenumbersSomeservicessuchasallergytestingdefineunitsbythenumberofservicesasaninclusivenumber,notasadditionalservices.

24H.EPSDT/FamilyPlan

Conditional

EPSDT(shadedarea)ForEarly&PeriodicScreening,Diagnosis,andTreatmentrelatedservices,entertheresponseintheshadedportionofthefieldasfollows:AV-Available-NotUsedS2-UnderTreatmentST-NewServiceRequestedNU-NotUsedFamilyPlanning(unshadedarea)NotRequired

24I.IDQualifier

NotRequired

24J.RenderingProviderID#

Required

Intheshadedportionofthefield,entertheNPIoftheHealthFirstColoradoprovidernumberassignedtotheindividualwhoactuallyperformedorrenderedthebilledservice.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.Enterthedatetheclaimwassignedusingtwodigitsforthemonth,twodigitsforthedateandtwodigitsfortheyear.Example:070116forJuly1,2016.Unacceptablesignaturealternatives:

Claimpreparationpersonnelmaynotsigntheenrolledprovider’sname.

Initialsarenotacceptableasasignature.

Typedorcomputerprintednamesarenotacceptableasasignature.

“Signatureonfile”notationisnotacceptableinplaceofanauthorizedsignature.

32.ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#

Required

Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCodeIftheProviderTypeisnotabletoobtainanNPI,entertheeight-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

33.BillingProviderInfo&Ph#

Required

Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCode

33a-NPINumber

Required

33b-OtherID#

IftheProviderTypeisnotabletoobtainanNPI,entertheeight-digitHealthFirstColoradoprovidernumberoftheindividualororganization.

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