CO HCPF Residential Child Care Facility (RCCF) Program (Mental Health Program) — CMS 1500 Paper Claim Reference Table

ThepaperclaimreferencetablelistsrequiredandconditionalfieldsfortheCMS1500paperclaimformforRCCFclaims.ForcompleteCMS1500paperclaiminstructions,refertotheGeneralProviderInformationmanuallocatedontheDepartment'sBillingManualswebpage.

TheappropriatePOScodesforRCCFpaperandelectronicclaimsubmissionsservicesare11(Office)or14(GroupHome)andareidentifiedbyusingthespecificmodifiersalongwiththeprocedurecodes(seeabovetable).

InstructionsforcompletingandsubmittingelectronicclaimsareavailablethroughtheX12NTechnicalReport3(TR3)forthe837P(wpc-edi.com),837PCompanionGuide(locatedontheElectronicDataInterchange(EDI)SupportwebpageoftheDepartment'swebsite),andintheProviderWebPortalUserGuide(viawithintheProviderWebPortal).

CMSFieldNumber&Label

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

Conditional

Completeifthememberiscoveredbyacommercialhealthcareinsurancepolicy.

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?

Conditional

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

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

NotRequired

24.ClaimLineDetail

Information

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

24A.DatesofService

Required

Thefieldaccommodatestheentryoftwodates:a"From"dateofservicesanda"To"dateofservice.Enterthedateofserviceusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:010116forJanuary1,2016.

From

To

01

01

19

or

From

To

01

01

19

01

01

19

Spandatesofservice

From

To

01

01

19

01

31

19

Practitionerclaimsmustbeconsecutivedays.SingleDateofService:Enterthesix(6)digitdateofserviceinthe"From"field.Completionofthe"Tofieldisnotrequired.Donotspreadthedateentryacrossthetwo(2)fields.Spanbilling:permissibleifthesameservice(sameprocedurecode)isprovidedonconsecutivedates.SupplementalQualifierToentersupplementalinformation,beginat24Abyenteringthequalifierandthentheinformation.ZZ-NarrativedescriptionofunspecifiedcodeVP-VendorProductNumberOZ-ProductNumberCTR-ContractRateJP-Universal/NationalToothDesignationJO-DentistryDesignationSystemforTooth&AreasofOralCavity

24B.PlaceofService

Required

EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.TheHealthFirstColoradoacceptstheCMSplaceofservicecodes.

11

Office

14

GroupHome

24C.EMG

NotRequired

24D.Procedures,Services,orSupplies

Required

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

24D.Modifier

Conditional

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.

EP

PartofEPSDTProgram

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.ThebasecodeisusedtodeterminetheallowableamountsforadditionalCPTsurgicalprocedureswhenmorethanoneprocedurefromthesamegroupingisperformed.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColoradocoveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-paymentorcommercialinsurancepaymentsfromtheusualandcustomarycharges.

24G.DaysorUnits

Required

Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.

24H.EPSDT/FamilyPlan

Conditional

EPSDT(shadedarea)ForEarly&PeriodicScreening,Diagnosis,andTreatmentrelatedservices,entertheresponseintheshadedportionofthefieldasfollows:

AV

Available-NotUsed

S2

UnderTreatment

ST

NewServiceRequestedNUNotUsed

FamilyPlanning(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

NotRequired

30.RsvdforNUCCUse

31.SignatureofPhysicianorSupplierIncludingDegreesorCredentials

Required

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

32.32-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.

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Formoreinformationontimelyfilingpolicy,includingtheresubmissionrulesfordeniedclaims,refertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageundertheGeneralProviderInformationdrop-downmenu.

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