CO HCPF Vision Care and Eyewear Billing Manual — CMS 1500 Paper Claim Reference Table

ThefollowingpaperformreferencetabledescribesrequiredfieldsforthepaperCMS1500claimformforEarlyInterventionclaims:

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)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.ClientRelationshiptoInsured

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

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'spolicynumberasitappearsontheIDcard.Onlycompleteiffield4iscompleted.

11a.Insured'sDateofBirth,Sex

Conditional

CompleteifthememberiscoveredbyaMedicarehealthinsurancepolicy.Entertheinsured'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070118forJuly1,2018.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

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

15.OtherDate

NotRequired

16.DatePatientUnabletoWorkinCurrentOccupation

NotRequired

17.NameofReferringPhysician

Conditional

18.HospitalizationDatesRelatedtoCurrentService

Conditional

Completeforservicesprovidedinaninpatienthospitalsetting.Enterthedateofhospitaladmissionandthedateofdischargeusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070118forJuly1,2018.Ifthememberisstillhospitalized,thedischargedatemaybeomitted.Thisinformationisnotedited.

19.AdditionalClaimInformation

Conditional

20.OutsideLab?$Charges

Conditional

Completeifalllaboratoryworkwasreferredtoandperformedbyanoutsidelaboratory.Ifthisboxischecked,nopaymentwillbemadetothephysicianforlabservices.Donotcompletethisfieldifanylaboratoryworkwasperformedintheoffice.Practitionersmaynotrequestpaymentforservicesperformedbyanindependentorhospitallaboratory.

21.DiagnosisorNatureofIllnessorInjury

Required

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

22.MedicaidResubmissionCode

Conditional

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

23.PriorAuthorization

Conditional

Enterthesix(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:010124forJanuary1,2024.

From

To

01

01

24

or

From

To

01

01

24

01

01

24

Spandatesofservice

From

To

01

01

24

01

31

24

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.HealthFirstColoradoacceptstheCMSplaceofservicecodes.

03School

04HomelessShelter

11Office

12Home

15MobileUnit

20UrgentCareFacility

21InpatientHospital

22OutpatientHospital

23EmergencyRoomHospital

25BirthingCenter

26MilitaryTreatmentCenter

31SkilledNursingFacility

32NursingFacility

33CustodialCareFacility

34Hospice

41Transportation-Land

51InpatientPsychiatricFacility

52PsychiatricFacilityPartialHospitalization

53CommunityMentalHealthCenter

54IntermediateCareFacility-MR

60MassImmunizationCenter

61ComprehensiveIPRehabFacility

62ComprehensiveOPRehabFacility

65EndStageRenalDialysisTrtmtFacility

71State-LocalPublicHealthClinic

99OtherUnlisted

24C.EMG

Conditional

Entera"Y"forYESorleaveblankforNOinthebottom,unshadedareaofthefieldtoindicatetheserviceisrenderedforalife-threateningconditionorone(1)thatrequiresimmediatemedicalintervention.Ifa"Y"forYESisentered,theserviceonthisdetaillineisexemptfromco-paymentrequirements.

24D.Procedures,Services,orSupplies

Required

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

24D.Modifier

Conditional

Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.24UnrelatedEvaluation/Management(E/M)servicebythesamephysicianduringapostoperativeperiodUsewithE/Mcodestoreportunrelatedservicesbythesamephysicianduringthepostoperativeperiod.Claimdiagnosiscode(s)mustidentifyaconditionunrelatedtothesurgicalprocedure.26ProfessionalcomponentUsewithdiagnosticcodestoreportprofessionalcomponentservices(readingandinterpretation)billedseparatelyfromtechnicalcomponentservices.Reportseparateprofessionalandtechnicalcomponentservicesonlyifdifferentprovidersperformtheprofessionalandtechnicalportionsoftheprocedure.ReadCPTdescriptorscarefully.Donotusemodifiersifthedescriptorspecifiesprofessionalortechnicalcomponents.51MultipleProceduresUsetoidentifyadditionalproceduresthatareperformedonthesamedayoratthesamesessionbythesameprovider.Donotusetodesignate"add-on"codes.55PostoperativeManagementonlySurgeryrelatedeyewearUsewitheyewearcodes(lenses,lensdispensing,frames,etc.)toidentifyeyewearprovidedaftereyesurgery.Benefitforeyewear,includingcontactlenses,formembersoverage20mustberelatedtosurgery.Modifier-55takestheplaceoftherequiredclaimcommentthatidentifiesthetypeanddateofeyesurgery.Theprovidermustretainand,uponrequest,furnishrecordsthatidentifythetypeanddateofsurgery.59DistinctProceduralServiceUsetoindicateaservicethatisdistinctorindependentfromotherservicesthatareperformedonthesameday.Theseservicesarenotusuallyreportedtogetherbutareappropriateunderthecircumstances.Thismayrepresentadifferentsessionormemberencounter,differentprocedureorsurgery,differentsiteororgansystemorseparatelesionorinjury.62Two(2)surgeonsUsewhentwo(2)surgeonsworktogetherasprimarysurgeonsperformingdistinctpart(s)ofaprocedure,eachsurgeonshouldreporthis/herdistinctoperativeworkbyaddingmodifier62totheprocedurecodeandanyassociatedadd-oncode(s)forthatprocedureaslongasbothsurgeonscontinuetoworktogetherasprimarysurgeons76Repeatprocedureorservicebythesamephysician/provider/otherqualifiedhealthcareprofessionalUsetoidentifysubsequentoccurrencesofthesameserviceonthesamedaybythesameprovider.NotvalidwithE/Mcodes.77Repeatprocedurebyanotherphysician/provider/otherqualifiedhealthcareprofessionalUsetoidentifysubsequentoccurrencesofthesameserviceonthesamedaybydifferentrenderingproviders.79UnrelatedprocedureorservicebythesamesurgeonduringthepostoperativeperiodUnrelatedproceduresorservices(otherthanE/Mservices)bythesurgeonduringthepostoperativeperiod.Usetoidentifyunrelatedservicesbytheoperatingsurgeonduringthepostoperativeperiod.Claimdiagnosiscode(s)mustidentifyaconditionunrelatedtothesurgicalprocedure.80AssistantsurgeonUsewithsurgicalprocedurecodestoidentifyassistantsurgeonservices.Note:Assistantsurgeonservicesbynon-physicianpractitioners,physicianassistants,perfusionists,etc.arenotreimbursable.GYItemorservicesstatutorilyexcludedordoesnotmeettheMedicarebenefit.Usewithpodiatricprocedurecodestoidentifyroutine,non-Medicarecoveredpodiatricfootcare.Modifier-GYtakestheplaceoftherequiredprovidercertificationthattheservicesarenotcoveredbyMedicare.TheMedicarenon-coveredservicesfieldontheclaimrecordmustalsobecompleted.KXSpecificrequireddocumentationonfileUsewithlaboratorycodestocertifythatthelaboratory'sequipmentisnotfunctioningorthelaboratoryisnotcertifiedtoperformtheorderedtest.The-KXmodifiertakestheplaceoftheprovider'scertification,"Icertifythatthenecessarylaboratoryequipmentwasnotfunctioningtoperformtherequestedtest",or"Icertifythatthislaboratoryisnotcertifiedtoperformtherequestedtest."

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.LensmaterialsOne(1)lensequalsone(1)unitofservice.Iftwo(2)lensesofthesamestrengthareprovided,completeone(1)billingclaimline,enteringtwo(2)unitsofserviceandthetotalchargeforbothlenses.Lensesofdifferentstrengthsarebilledonseparateclaimlines.LensdispensingAdispensingfeeisallowedforeachlens.Fortwo(2)lenses,completeonclaimlinewithtwo(2)unitsofserviceandchargeforbothlenses.

24H.EPSDT/FamilyPlan

Conditional

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

AV-Available-NotUsed

S2-UnderTreatment

ST-NewServiceRequested

NU-NotUsed

FamilyPlanning(unshadedarea)IftheserviceisFamilyPlanning,enter"Y"forYESor"N"forNOinthebottom,unshadedareaofthefield.

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.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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