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CO HCPF Targeted Case Management-Transition Coordination — Targeted Case Management – Transition Coordination Claim Reference Table

TargetedCaseManagement–TransitionCoordinationClaimReferenceTable

activein force · 2026-07-26 – presentas-observed

ThefollowingpaperformreferencetabledescribesrequiredfieldsforthepaperCMS1500claimformforTargetedCaseManagement–TransitionCoordinationclaims.

CMSFieldNumberandLabel

Fieldis:

Instructions

Invoice/PatAcctNumber

Optional

Entertheinformationthatidentifiesthepatientorclaimintheprovider’sbillingsystem.SubmittedinformationappearsontheProviderClaimReport.Upto12characters:letters,numbersorhyphens

Invoice/PatAcctNumber

Optional

Entertheinformationthatidentifiesthepatientorclaimintheprovider’sbillingsystem.SubmittedinformationappearsontheProviderClaimReport.Upto12characters:letters,numbersorhyphens

SpecialProgramCode

Optional

2digits

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)digitsforthedateandtwo(2)digitsfortheyear.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.PatientRelationshiptoInsured

Conditional

Completeifthememberiscoveredbyacommercialhealthcareinsurancepolicy.

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

11a.Insured'sDateofBirth,Sex

NotRequired

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.DateofCurrentIllnessInjuryorPregnancy

NotRequired

15.OtherDateNot

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Conditional

17b.NPIofReferringPhysician

Conditional

18.HospitalizationDatesRelatedtoCurrentService

NotRequired

19.AdditionalClaimInformation

Conditional

Whenapplicable,enterthewords"TRANSPORTCERT"tocertifythatyouhaveatransportationcertificateortripsheetonfileforthisservice.

20.OutsideLab?$Charges

NotRequired

21.DiagnosisorNatureofIllnessorInjury

Required

Enteratleastone(1)butnomorethan12diagnosiscodesbasedonthemember’sdiagnosis/condition.EnterapplicableICD-10indicator.NEMTEnterdiagnosiscodeR68.89.

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

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

From

SingleDateofServiceEnterthesix(6)-digitdateofserviceinthe"From"field.Completionofthe“Tofieldisnotrequired.Donotspreadthedateentryacrossthetwo(2)fields.SpanBillingisnotallowedforNEMT.

24B.PlaceofService

Required

EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.

Transportation-Land

Transportation-AirorWater

24C.EMG

Conditional

Entera"N"orleaveblankforNOinthebottom,unshadedareaofthefieldtoindicatetheservicewasnon-emergentmedicaltransportation.

24D.Procedures,Services,orSupplies

Required

EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.OnlyapprovedcodesfromthecurrentCPTorHCPCSpublicationswillbeaccepted.

24D.Modifier

NotRequired

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.NEMTOnlyA0110mayrequireamodifier(seeTransportationHCPCScodes).

24E.DiagnosisPointer

Required

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

24F.$Charges

Required

Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColoradocoveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-paymentorcommercialinsurancepaymentsfromtheusualandcustomarycharges.

24G.DaysorUnits

Required

Enterthenumberofunitsprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.

24H.EPSDT/FamilyPlan

NotRequired

24I.IDQualifier

NotRequired

24J.RenderingProviderID#

Required

Intheshadedportionofthefield,entertheNPIorProviderIDoftheHealthFirstColoradoproviderwhoactuallyperformedorrenderedthebilledservice.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.

32.32-ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#

Required

Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat: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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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 135ebf01f834d07bfc847fd08cc5a94edddb1c2d8c486b4168f92941ee2d4388

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