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ContentsSection 1: General Information .................................................................................................................... 8
Contracts ................................................................................................................................................... 8
Updates and Revisions .............................................................................................................................. 8
Disclaimer .................................................................................................................................................. 8
Total Health Care Contact Numbers ........................................................................................................... 10
Total Health Care Vendor Numbers ............................................................................................................ 11
Provider Roles and Responsibilities ............................................................................................................ 12
Provider Roles and Responsibilities ........................................................................................................ 12
Primary Care Physician (PCP) Roles and Responsibilities ....................................................................... 12
Specialty Care Physician Roles and Responsibilities ............................................................................... 12
Hospital Roles and Responsibilities......................................................................................................... 12
Section 2: Billing and Payment ................................................................................................................... 13
Claim Submission Procedures ................................................................................................................. 13
Claim/Encounter Submission Requirements .......................................................................................... 13
Clean Claim Requirements ...................................................................................................................... 13
Claim Form Field Requirements .............................................................................................................. 14
Tax Identification and National Provider Identifier Requirements ......................................................... 15
NPI CHAMPS Registration Requirements for Medicaid Beneficiaries .................................................... 15
General Claim Billing Requirements ....................................................................................................... 16
EDI Claims Submissions ........................................................................................................................... 16
Paper Claims Submissions ....................................................................................................................... 16
Provider Reimbursement ........................................................................................................................ 17
Claim Filing Deadline ............................................................................................................................... 17
Appeals for Timely Filing ......................................................................................................................... 18
Claim Filing Deadline Exceptions: Michigan Department of Health and Human Services (MDHSS) ...... 18
Claim Filing Deadline Exceptions: Primary Insurance Providers ............................................................. 18
Resubmitting Claims: Process & Filing Limits .......................................................................................... 19
Corrected Claims – Replacement and Void Claims ................................................................................. 19
I ANSl‐837P (Professional) .................................................................................................................. 19
I ANSl‐8371 (Institutional) ................................................................................................................... 19
Rejected Claims ....................................................................................................................................... 20
CMS‐1500 Claim Form Required Fields ................................................................................................... 21
UB‐04 Claim Form Required Fields ......................................................................................................... 34
UB04 Claim Form ................................................................................................................................ 48
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Eligibility and Benefits ............................................................................................................................. 49
Online Verification .................................................................................................................................. 49
Interactive Voice Response (IVR) ............................................................................................................ 50
Telephone Verification ............................................................................................................................ 50
Our Products and Services ...................................................................................................................... 50
Identification Cards ................................................................................................................................. 50
Balance Billing ......................................................................................................................................... 51
Claim Status and Adjudication ................................................................................................................ 52
Clinical Edit Descriptions ......................................................................................................................... 52
Explanation of Benefit Description Codes .............................................................................................. 52
Explanation of Payment (EOP)/Remittance Advice ................................................................................ 53
Electronic Funds Transfer (EFT) .............................................................................................................. 53
Electronic Remittance Advice (ERA) ....................................................................................................... 53
Front‐End Claim Rejections ..................................................................................................................... 53
Authorization and Referral Requirements .............................................................................................. 53
Referral/Authorization Number Reporting Requirement ....................................................................... 54
Requesting an Authorization for Medical Services, Equipment, and Medications ................................ 54
Requesting an Authorization for Therapy Services ................................................................................. 54
Retroactive Referrals .............................................................................................................................. 54
Seeing Patients without Prior Authorization or Referral ........................................................................ 55
Claim Appeals .......................................................................................................................................... 55
Overpayment and Recovery ................................................................................................................... 56
Section 3: Inpatient Facility Billing ............................................................................................................. 58
All Patient Refined Diagnosis‐Related Groups (APR‐DRGs) .................................................................... 58
Hospital Acquired Conditions (HAC) ....................................................................................................... 58
Other Provider Preventable Conditions (OPPC)...................................................................................... 59
ICD‐10‐CM Tabular List of Diseases and Injuries .................................................................................... 59
Late Charges ............................................................................................................................................ 59
Maternity Admissions ............................................................................................................................. 59
Newborn Inpatient Hospital Claim Requirements .................................................................................. 60
Present on Admission Indicators (POA) .................................................................................................. 61
POA Indicators ........................................................................................................................................ 61
POA Indicators Reporting Requirement Paper Claims ............................................................................ 62
POA Indicators Reporting Requirement Electronic Claims ..................................................................... 62
Span Billing Different Years ..................................................................................................................... 62
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Split Bills .................................................................................................................................................. 62
Denied Inpatient Days ............................................................................................................................. 63
Eligibility Termed During Admission ....................................................................................................... 63
Per Diem Reimbursement ....................................................................................................................... 63
Transfers ................................................................................................................................................. 63
15 Day Readmissions .............................................................................................................................. 63
Skilled Nursing Facilities (SNF) ................................................................................................................ 67
Section 4: Outpatient Facility Billing .......................................................................................................... 68
Ambulatory Payment Classifications (APCs) ........................................................................................... 68
Outpatient Code Editor (OCE) ................................................................................................................. 69
Bill Types ................................................................................................................................................. 69
Eligibility .................................................................................................................................................. 69
Emergency Services ................................................................................................................................ 69
Observation ............................................................................................................................................. 70
Outpatient Surgery ................................................................................................................................. 70
Ambulatory Surgical Centers .................................................................................................................. 71
Date of Service ........................................................................................................................................ 71
How to Bill Two Emergency Department/E/M Visits on the Same Day ................................................. 71
Device Codes ........................................................................................................................................... 72
Discounted Procedures ........................................................................................................................... 72
Incidental Procedures ............................................................................................................................. 72
Late Charges ............................................................................................................................................ 72
Outlier Payments .................................................................................................................................... 72
Packaged/Bundled Services .................................................................................................................... 74
Payment Status Indicators ...................................................................................................................... 75
Procedures/HCPCS Codes ....................................................................................................................... 75
Span Date Billing ..................................................................................................................................... 75
Split Bills .................................................................................................................................................. 75
Section 5: Billing For Procedures and Services .......................................................................................... 76
Add on Codes .......................................................................................................................................... 76
Ambulance Billing ................................................................................................................................... 76
Air Ambulance ......................................................................................................................................... 78
Prior Authorization Requirements for Non‐Emergent Ambulance Services ...................................... 79
Non‐Emergent Transports by Ambulance to Residence ..................................................................... 79
Anesthesia Billing .................................................................................................................................... 79
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Audits ...................................................................................................................................................... 81
Clinical Edits ............................................................................................................................................ 81
Types of Coding Clinical Edits .............................................................................................................. 82
Coordination of Benefits ......................................................................................................................... 84
Dental Medical Procedures ..................................................................................................................... 85
Dual‐Eligible Members ............................................................................................................................ 86
Durable Medical Equipment (DME) ........................................................................................................ 86
Early, Periodic, Screening, and Diagnostic Testing (EPSDT) Claims ........................................................ 87
Emergency Services ................................................................................................................................ 87
Physician Services Provided in the Emergency Department .................................................................. 88
Emergency Department Physician Claims Medicaid and Healthy Michigan Beneficiaries ..................... 88
Using Modifiers UD, UA (Medicaid Only) ................................................................................................ 88
Modifier UD: Treated and Released ................................................................................................... 88
Modifier UA: Treated and Admitted/Transferred .............................................................................. 88
Emergency Department Consultation .................................................................................................... 89
Emergency Department Observation Professional ................................................................................ 89
Evaluation and Management (E/M) Services ......................................................................................... 89
Fraud, Waste, and Abuse (FWA) and Payment Integrity Audits ............................................................. 90
Global Surgery Package/Procedures ....................................................................................................... 92
Settings.................................................................................................................................................... 93
Health Risk Assessment .......................................................................................................................... 94
Hearing Aids ............................................................................................................................................ 94
Hearing Aid Repair .................................................................................................................................. 95
Home Infusion and Injectable Drugs ....................................................................................................... 95
Inpatient Professional Services ............................................................................................................... 95
Immunizations ........................................................................................................................................ 96
Vaccine For Children Program ............................................................................................................ 96
Vaccine Administration Codes ............................................................................................................ 96
Travel Immunizations .......................................................................................................................... 97
Laboratory and Pathology Services ......................................................................................................... 97
Maternity Billing ...................................................................................................................................... 97
Antepartum Care Visits CPT Codes ..................................................................................................... 98
Delivery Only CPT Codes ................................................................................................................... 999
Postpartum Care Only CPT Code ...................................................................................................... 999
Multiple Births .................................................................................................................................. 999
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Billing for Multiple Fetal Non‐Stress Tests for Multiple Births (CPT Code 59025) .............................. 99
Billing for Multiple Fetal Ultrasound Tests for Multiple Births ......................................................... 100
Medical Records .................................................................................................................................... 100
Modifiers ............................................................................................................................................... 101
National Correct Coding Initiative (NCCI) Edits ..................................................................................... 101
National Drug Code (NDC) Reporting Requirement for Physician Administered Drugs ....................... 102
Requirement on CMS‐1500 Paper Form: .......................................................................................... 103
Requirements Using the Electronic Claim Format CMS‐1500 .......................................................... 103
Requirement on UB 04 Paper Form .................................................................................................. 104
Requirements Using the Electronic Claim Format UB‐04 ................................................................. 104
Unit of Measure Qualifier ................................................................................................................. 104
Newborn Claims .................................................................................................................................... 105
Nursing Facility Ancillary Services ......................................................................................................... 105
Observation ........................................................................................................................................... 105
Outlier Payment Billing ......................................................................................................................... 105
Per Diem Services .................................................................................................................................. 105
Pharmacy “Buy and Bill” ....................................................................................................................... 106
Physicals ................................................................................................................................................ 106
Preventive Services ............................................................................................................................... 106
Difference Between a Preventive Screening and a Diagnostic Test ................................................. 106
Diagnostic Services Combined with a Preventive E/M Visit ............................................................. 107
How to Bill Preventive Screenings .................................................................................................... 107
Prosthetic and Orthotics ....................................................................................................................... 107
Short Stay Reimbursement ................................................................................................................... 107
Outpatient Hospital Claims Qualification ......................................................................................... 108
Inpatient Hospital Claims Qualification ............................................................................................ 108
Subrogation ........................................................................................................................................... 108
Taxonomy Codes ................................................................................................................................... 109
Third Party Liability ............................................................................................................................... 109
Unlisted Procedure and Not Otherwise Classified Codes ..................................................................... 109
Urgent Care ........................................................................................................................................... 110
Participating Urgent Care Providers ................................................................................................. 111
Non‐Participating Urgent Care Providers ......................................................................................... 111
Adjunct Urgent Care CPT Codes ........................................................................................................ 111
Vision Care – Commercial HMO, Exchange, and POS ........................................................................... 111
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Vision Care ‐ Medicaid .......................................................................................................................... 112
Workers' Compensation ....................................................................................................................... 113
Administrative Actions for Use Out‐of‐Network DME, Laboratory Services, and Cardiac Monitoring 113
Section 6: Member Benefits..................................................................................................................... 114
Covered Services ................................................................................................................................... 114
Excluded Services .................................................................................................................................. 114
Non‐Covered Services ........................................................................................................................... 114
Allergy Testing and Immunotherapy .................................................................................................... 115
Behavioral Health and Substance Abuse Services ................................................................................ 115
Cardiac Monitoring ............................................................................................................................... 116
Chemotherapy ...................................................................................................................................... 116
Chemotherapy Provided at a Member’s Home .................................................................................... 117
Chiropractic Claims ............................................................................................................................... 117
Clinical Trials ......................................................................................................................................... 117
Dental Services ‐ Healthy Michigan Plan............................................................................................... 117
Diabetic Supply Guidelines ................................................................................................................... 118
Genetic Testing ..................................................................................................................................... 118
Genetic Testing For Hereditary Breast and/or Ovarian Cancer Screening (HBOC)............................... 118
Home Health Care ................................................................................................................................. 119
Homeopathic and Holistic Services ....................................................................................................... 119
Podiatry ................................................................................................................................................. 119
School Based Services – Medicaid Beneficiaries ................................................................................... 119
Section 7: Documents and Forms ............................................................................................................ 121
Electronic Funds Transfer (EFT) Authorization Agreement .................................................................. 122
Fraud, Waste and Abuse Reporting Information .................................................................................. 122
Health Risk Assessment Form (Healthy Michigan Plan) ....................................................................... 124
Insurance Refund Request .................................................................................................................... 126
Provider Portal Registration Form ........................................................................................................ 127
Professional/Provider Change Form ..................................................................................................... 128
Therapy Services Authorization Request Form ..................................................................................... 129
Vision Eligibility Form ............................................................................................................................ 130
Section 8: Appendix ................................................................................................................................. 131
Admission Source Codes ....................................................................................................................... 131
Admission Type Codes .......................................................................................................................... 132
Bill Types by Category ........................................................................................................................... 133
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Coding ................................................................................................................................................... 135
Diagnosis Coding ............................................................................................................................... 135
Diagnosis Coding For Age Categories ................................................................................................ 135
Healthcare Common Procedure Coding System (HCPCS) Coding ..................................................... 135
CPT Coding (Level I) ........................................................................................................................... 136
Category II (Level II) .......................................................................................................................... 136
ICD‐10 Procedure Coding System (ICD‐10‐PCS) .................................................................................... 137
National Correct Coding Initiative (NCCI) ............................................................................................. 138
Procedure Coding .................................................................................................................................. 138
Condition Codes .................................................................................................................................... 138
Modifiers ............................................................................................................................................... 146
Occurrence Codes ................................................................................................................................. 151
Patient Status Codes ............................................................................................................................. 154
Payment Status Indicators .................................................................................................................... 157
Place of Service Codes (POS) ................................................................................................................. 157
Revenue Code Table and CPT/HCPCS Requirements............................................................................ 165
Value Codes................................................................................................ Error! Bookmark not defined.
Section 9: Common Causes of Claim Processing Delays, Rejections and Denials .................................... 166
Non‐discrimination Policy………………………………………………………………….170‐173
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Section 1: General Information
The Total Health Care Claims Provider Manual is designed to
assist the provider in understanding the specific policies,
procedures and billing guidelines of the health plan. Total Health
Care is required by state and federal regulations to capture
specific data regarding services rendered to its members. Plan
providers must adhere to all billing requirements to ensure timely
processing of claims. In most cases, Total Health Care follows
Michigan Medicaid billing requirements.
Contracts Any service or benefit described in this manual is
considered the general rule. The terms and conditions of your
practice or medical group’s responsibilities for claims to the
extent they conflict with this manual shall be governed by your
contract agreement with Total Health Care. For any questions or
clarity about your contract, you can contact our Provider Relations
department at (800) 826-2862.
Updates and Revisions The Claims Provider Manual is a dynamic
tool and will evolve with Total Health Care. Minor updates and
revisions will be communicated to the primary care providers via
our Total Health Care Newsletter or our website. Major revisions of
the information in the Provider Manual will result in publication
of a revised edition. The most current version of the Manual is
always available on our website at www.thcmi.com.
Disclaimer This Manual is a component of your Total Health Care
Provider Agreement and is meant to provide clarity and
implementation guidance. In the event of a conflict or
inconsistency between this Manual and your Agreement, the
provisions of your Agreement will take precedence. Additionally, in
the event of a conflict or inconsistency between this Manual and
the Michigan Department of Health and Human Services, the
provisions of Medicaid will take precedence.
In the event of a conflict or inconsistency between state
regulatory requirements and this Manual, the regulatory provisions
will control, except when the benefit contracts fall outside the
scope of that regulatory control.
Total Health Care makes no representations or warranties with
respect to the content hereof. Further, Total Health Care reserves
the right to revise this publication without obligation on our part
to notify any person or entity of such revision or changes.
Revisions are effective immediately upon publication.
Special Note: This Manual is provided for the convenience of
providers participating in any Total Health Care network and
non-par providers rendering emergent or authorized service.
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Nothing in this Manual shall be interpreted as guaranteeing
coverage of any service, treatment, drugs or supplies because
coverage or non-coverage is always governed exclusively by the
terms of the member’s health benefit coverage documents.
Accordingly, in case of any question or doubt about coverage,
providers should always review the member’s particular health
benefit coverage document.
Current procedural terminology (CPT) codes, descriptions,
numeric modifiers, instructions, guidelines and other material are
copyrighted by the American Medical Association. All Rights
Reserved.
Other policies and procedures, not reflected in this Manual, are
published regularly in our provider newsletter, in official plan
documents, or in other special publications, letters, or notices,
including but not limited to credentialing standards, appeals
policies and procedures, network terms and conditions, and Provider
Agreements. To ensure you have the most current information, please
visit Total Health Care at www.thcmi.com or contact us Monday
through Friday, 8:00 a.m. to 5:00 p.m. at (800) 826-2862 and ask to
speak to a Provider Services Representative.
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Total Health Care Contact Numbers
Department Phone Number Fax Number Email InquiriesCase
Management Coordinate case management services Questions about
Disease Management
Programs
800-826-2862 313-748-1312
Claims Payment Discrepancies Claim Denial Explanations *The
claims department does not status claims over the phone. All
information related to claims status, payment information, denial
information, etc. can be obtained through our provider portal at
https://thcmi.com/provider-central/.
800-826-2862 313-871-6407 [email protected]
Coordination of Benefit Coordination of Benefit questions
800-826-2862 313-871-6407
Customer Service Verify member eligibility Obtain general
information and assistance Record member personal data change
Obtain member benefit interpretation File complaints and
grievances
800-826-2862 313-871-6406
EDI Help Desk 835 Inquiries 837 Inquiries
313-293-6463 [email protected]
Pharmacy Process medication prior authorization
requests
800-826-2862 313-871-6229 [email protected]
Provider Credentialing Contractual issues Primary care
administration Initiate physician affiliation, disaffiliation
&
transfer
800-826-2862 313-748-1390 [email protected]
Provider Relations Discuss recurring problems and concerns
Provider education assistance Primary care administration
800-826-2862 313-748-1390 [email protected]
Provider Portal Help Desk Portal Issues
844-842-3627 ext. 5
Quality Improvement - Requests and questions about Clinical
Practice Guidelines and Quality Initiatives Requests and
questions about Preventive
Healthcare Guidelines Questions about QI Regulatory
requirements
800-826-2862
Process prior authorization requests Perform pre-service review
of select services Conduct inpatient review and discharge
planning activities
800-826-2862 313-748-1312
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Total Health Care Vendor Numbers
Service Provider Phone Number Fax Number Claim Mailing
AddressBehavioral Health/Substance Abuse
Beacon Health Options
800-888-3944 48561 Alpha Drive Suite 150 Wixom, MI 48393
Cardiac Monitoring Medicomp 800-234-3278 321-676-2282
Dental (Healthy Michigan Plan Only)
Healthy Michigan Dental
800-875-2400 313-875-2401 Healthy Michigan Dental PO Box 2819
Detroit, MI 48202-3231
Diabetic Supplies/Insulin Pumps
J&B Medical Supplies
844-236-7933
Durable Medical Equipment Binson’s Home Medical Equipment
888-246-7667
Incontinence Supplies – CSHCS Only
J&B Medical Supplies
800-980-0047
Non-Emergent Ambulance Transportation
Universal Ambulance 586-274-2900
Pharmacy Specialty Medications Envision Specialty 877-437-9012
877-309-0687 Pharmacy Benefit Management
EnvisionRx 844-222-5584 866-422-9119
Pharmacy Department Total Health Care 800-826-2862 Ext. 3300
313-871-6229
Mail Order Pharmacy (Commercial Only)
Envision Mail 866-909-5170 866-909-5171
Prosthetics & Orthotics – PT/OT/ST Navant 734-995-0198 P.O.
Box 21486
Eagan, MN 55121-0486 EDI Payer ID 38201
Transportation (Medicaid Only)
Veyo 800-826-2862 Ext. 3608
Vision Claims (Commercial HMO, Exchange, and POS)
Occupational Eyewear Network
313-565-5600
Occupational Eyewear Network 23469 Michigan Ave, Dearborn, MI
48124
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Provider Roles and Responsibilities
Provider Roles and Responsibilities This section describes the
expectations for PCPs, Specialists, Hospitals and Ancillary
providers who are contracted with Total Health Care.
Primary Care Physician (PCP) Roles and Responsibilities All
covered health services are either delivered by the PCP or are
referred/approved by the PCP and/or Total Health Care, except for
required direct access benefits or self-referral services. There
are certain services that also require prior authorization from
Total Health Care.
Specialty Care Physician Roles and Responsibilities Total Health
Care recognizes that the specialty physician is a valuable team
member in delivering care to our members. Some of the key specialty
physician roles and responsibilities include:
Rendering services requested by the PCP Communicating with the
PCP regarding medical findings in writing Obtaining
prior-authorization before rendering any services not specified on
the original
authorization Confirming member eligibility and benefit level
prior to rendering services Providing a consultation report to the
PCP within 60 days of the consult Providing the lab or radiology
provider with: The PCP and/or prior authorization number (when
necessary) The member’s Medicaid ID number
Specialists may also contact Total Health Care to verify and
request prior authorization for services.
Hospital Roles and Responsibilities Total Health Care recognizes
that the hospital is a valuable team member in delivering care to
our members. Some essential hospital responsibilities include:
Coordination of discharge planning with Total Health Care
Utilization Management staff Coordination of mental
health/substance abuse care with the PCP, the health plan and
the
appropriate county agency or provider Obtaining the required
prior authorization before rendering services Communication
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Section 2: Billing and Payment
Claim Submission Procedures Claims for billable services
provided to plan members must be submitted by the provider or an
entity employed by the provider who performed the services. When
required data elements are missing or invalid, claims will be
denied by the plan for correction and resubmission.
Claim/Encounter Submission Requirements Total Health Care
requires all participating providers to properly code all relevant
diagnoses and Service codes on all professional, inpatient and
outpatient facility claims submitted. Total Health Care requires
all diagnosis coding to use ICD-10, as mandated by CMS. In
addition, CPT-4 coding and/or Healthcare Common Procedure Coding
System (HCPCS) is required for all outpatient, surgical,
obstetrical, injectable drugs, diagnostic laboratory and radiology
procedures. When coding, the Provider must select the code(s) that
most closely describe(s) the diagnosis and procedure(s) performed.
When a single code is available for reporting multiple tests or
procedures, that code must be utilized rather than reporting the
tests or procedures individually. Claims submitted with invalid,
incorrect or missing procedure codes will be denied. Total Health
Care tracks billing codes and Providers who continue to apply
incorrect coding rules. Providers will be educated on the proper
use of codes as a part of the retrospective review process. Should
a Provider continue to repeat the inappropriate coding practice,
the Provider will be subject to review by the corporate Special
Investigations Unit and possible adverse action. Providers using
electronic submission shall submit all claims to Total Health Care
or its designee, as applicable, using the HIPAA-compliant 837
electronic format, or a CMS-1500 and/or UB-04. Claims must include
the Provider’s NPI, Tax ID and the valid taxonomy code that most
accurately describes the services reported on the claim. The
Provider acknowledges and agrees that no reimbursement is due for a
Covered Service and/or no claim is complete for a Covered Service
unless performance of that Covered Service is fully and accurately
documented in the Member’s medical record prior to the initial
submission of any claim. The Provider also acknowledges and agrees
that at no time shall Members be responsible for any payments to
the Provider with the exception of Member out-of-pocket expenses
and/or non-Covered Services.
Clean Claim Requirements Clean claim defined: A clean claim has
no defect, impropriety or special circumstance, including
incomplete documentation that delays timely payment. A provider
submits a clean claim by providing the required data elements on
the standard claims forms, along with any attachments and
additional elements, or revisions to data elements, attachments and
additional elements, of which the provider has knowledge. Claims
for inpatient and facility programs and services are to be
submitted on the UB-04 and claims for individual professional
procedures and services are to be submitted on the CMS-1500.
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Required clean claim elements: The Centers for Medicare and
Medicaid Services (CMS) developed claim forms that record the
information needed to process and generate provider reimbursement.
The required elements of a clean claim must be complete, legible
and accurate. Before we can process a claim, it must be a "clean"
or complete claim submission, which includes the following
information, when applicable:
The individual's member number and the patient's name, address,
and date of birth. The day, month, and year the service was
provided. The name, appropriate tax identification number (TIN),
and national provider
identification (NPI) number of the provider and physician
rendering the service, and location of service.
Provider certification required by MCL 400.111b (17) and
identifying information required by MCL 400.111b (21). This
certification allows the provider to file Medicaid claims.
Substantiation of medical necessity and appropriateness of
service as required by the health plan.
An applicable authorization number, if required by the health
plan. Any additional documentation required by the health plan for
the service rendered.
Additional documentation may include, but is not limited to,
medical. Primary carrier Explanation of Benefits (EOB) when Total
Health Care is the secondary
payer. Standard Diagnostic Related Groupings (DRG) or Revenue
codes (facility). Standard Health Care Procedure Coding System
(HCPCS) and Standard Current
Procedural Terminology (CPT®) code sets, and modifiers. Standard
International Classification of Diseases (ICD-10) codes, 10th
revision. Accurate entries for all fields of information contained
in the UB04 and CMS-1500 claim
forms.
Claim Form Field Requirements The following charts describe the
fields that must be completed for the standard Centers for Medicare
& Medicaid Services (CMS) CMS-1500 and UB-04 claim forms. A
sample of each form can be found in the exhibits. If the field is
required without exception, an “R” (required) is noted in the
required or Conditional box. If completing the field depends on
certain circumstances, the requirement is listed as “C”
(conditional), and the relevant conditions are explained in the
Instructions and Comments box. The CMS-1500 claim form must be
completed for all professional medical services, and the UB-04
claim form must be completed for all facility claims. Refer to the
NUCC or NUBC reference manuals for additional information. Claim
data requirements apply to all claim submissions, regardless of the
method of submission (electronic or paper).
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Tax Identification and National Provider Identifier Requirements
Total Health Care requires the payer-issued Tax ID / TIN and NPI on
all claims submissions for both typical and atypical providers.
Total Health Care will reject claim submissions without the Tax ID
and/or NPI. More information on NPI requirements, including HIPAA’s
Administrative Simplification NPI Final Rule, is available on the
CMS website at http://www.cms.gov/.
NPI CHAMPS Registration Requirements for Medicaid Beneficiaries
All Michigan Medicaid Providers, including Out-of-State Providers
must enroll in the Michigan Medicaid Program through CHAMPS in
order for claims to be considered for payment.
Effective with date of service 1/1/2018, MDHHS has mandated that
all providers who participate in Medicaid must be enrolled in
CHAMPS in order to receive payment. This includes:
‘Typical’ Providers: Physicians Nurse Practitioners Physician
Assistants Hospitals
Atypical Providers: Community Health Worker Limited Licensed
Social Worker Home Health Care Provider Dietitian Physical
Therapist Private Duty Nurse Personal Emergency Response System
Speech Pathologists
This includes both Type I and Type II NPIs
Managed Care Plans will be required to “associate” providers to
their health plans Claims will be rejected if the rendering
provider is not listed on a claim. Claims will be rejected if the
rendering provider is not enrolled in CHAMPS.
Applying on CHAMPS:
CHAMPS is a NPI based system and all providers, groups and/or
facilities must obtain and register their NPI with the National
Plan and Provider Enumeration System (NPPES) prior to enrollment in
CHAMPS.
All providers will need to complete an enrollment through the
online CHAMPS system their SSN or EIN/TIN. To register your SSN or
EIN/TIN visit http://www.mi.gov/cpexpress. Provider Enrollment
typically takes a week to complete. A provider may request that
enrollment be retroactive to a specific date when completing the
on‐line application. Enrollment may be
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retroactive one year from the date the request is received if
the provider’s license/certification is effective for that entire
period. Contact Information: Atypical Providers 800‐979‐4662
[email protected] All Providers 800‐292‐2550
[email protected] General Claim Billing
Requirements To ensure timely processing of claims, the correct and
required information must be provided in the designated claim
fields.
EDI Claims Submissions We encourage providers to submit claims
electronically. Electronic claims submission is fast, accurate, and
reliable and is available 24 hours a day, seven days a week. If
complete information is provided, electronic claims are typically
processed seven to 10 days faster than paper claims. Electronic
claims submitted to Total Health Care must be in ANSI X12N 837 5010
format. Total Health Care receives claims through Emdeon or Ingenix
with payor ID 38201. To submit through another clearinghouse or
have questions related to EDI submission; contact our EDI
Department at (313) 293-6434. Paper Claims Submissions Paper claims
must be submitted using an industry-standardized form. Handwritten
claims are not acceptable. Paper claims for medical services must
be submitted to Total Health Care at:
Total Health Care, Inc., Michigan P.O. Box 21486
Eagan, MN 55121-0486
Multiple Page Paper Claim Submission All services provided
should be billed on one claim. If the services extend to more than
one claim, do not place a TOTAL CHARGES amount on the claims pages
unless it is the last page of the claim; and then that should be
for the total for all pages. Attachments Individual claim forms are
separated. Each claim is processed separately. Do not staple
original claims together. Paper claims must be standardized to meet
imaging specifications as follows:
Use only the red and white CMS-1500 claim form with pre-printed
patch code for all submissions including status claims. No copies
or other forms will be accepted.
Use only the red and white UB 04 OCR/original claim for all
submissions including status claims. No copies or other forms will
be accepted.
Make certain print type on the claim is a dark and legible print
and printed within the correct column/ box. Make certain that no
data is on the red dividing line.
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17
All claims must be typed or electronically generated. Type all
claim information and comments. Handwritten claims are not
acceptable.
Eliminate all character symbols, i.e., periods, commas, etc. Do
not staple claims and attachments. Multi-page paper claims: Omit
the total charges until the final page. Billed charges must match
the amount shown as billed on the EOB or your claim will be
rejected as "Inappropriate EOB - does not match claim." You will
then have to rebill the claim.
Faxed or emailed claims, original or corrected, will not be
accepted. NOTE: Secondary claims can only be submitted on paper and
must include a copy of the primary EOB.
Provider Reimbursement Contracted Providers Contracted providers
will be reimbursed at their contracted fee schedule. Plan
guidelines and benefits must be followed for payment consideration.
Cofinity, First Health, and Multiplan Providers For providers in
the Cofinity, First Health, or Multiplan networks, services related
to out of area emergency room, inpatient admissions, and urgent
care services for commercial, Exchange, and POS members will be
reimbursed at the repricing negotiated rate. Plan guidelines and
benefits must be followed for payment consideration. Out of Network
Commercial, Exchange, and POS Providers Out of network providers
will be reimbursed at Total Health Care’s usual and customary fee
schedule or the negotiated rate for commercial, Exchange, and POS
members. Plan guidelines and benefits must be followed for payment
consideration. Out of Network Medicaid Providers Out of network
providers will be reimbursed at the Medicaid fee schedule for
Medicaid beneficiaries. Plan guidelines and benefits must be
followed for payment consideration. Out of Network Services
Provided to POS Members Out of network services provided to POS
members not related to emergency care, inpatient admissions, or
urgent care must be rendered by Cofinity or First Health providers
only. Providers that are not in the Cofinity or First Health
network will be denied as out of network providers and the member
will be liable.
Claim Filing Deadline Total Health Care’s filing limit is 365
days from the date of service. All claims, resubmissions, and
corrected claims must be submitted within our filing limit. Total
Health Care uses the line item ‘From’ date to determine the date of
service for claims filing timeliness for claims submitted by health
care professionals and suppliers that include span dates of
service. (This includes Durable Medical Equipment (DME) supplies
and rental items.).
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18
For inpatient facility claims, the filing limit begins with the
discharge date.
Appeals for Timely Filing Total Health Care encourages you to
submit your bills as soon as possible to facilitate prompt payment.
Total Health Care will deny claims if they arrive after the
deadline date. Claims denied as a result of timeliness are not
subject to appeals. The provider is liable for filing limit
denials. Exception: A clearinghouse electronic acknowledgement
indicating claim was electronically accepted by Total Health Care
can be accepted as proof that a claim was submitted timely if the
claim in question was submitted without any billing errors causing
the claim not to be a “clean” submission. A copy of the provider’s
billing screen is not acceptable as evidence of timely submission.
Remember: Total Health Care prohibits balance billing your patient
if claims are denied because they were not submitted within the
time frame outlined above.
Claim Filing Deadline Exceptions: Michigan Department of Health
and Human Services (MDHSS) Per MDHHS policy, providers have sixty
(60) days from the Medicaid Remittance Advice Date to submit claims
to the Medicaid Health Plans. The Medicaid Remittance Advice must
be submitted with the claim for payment. If the claim and
remittance are not received within sixty (60) days from the
takeback remittance advice, the claim will be denied for filing
limit as provider liability.
Claim Filing Deadline Exceptions: Primary Insurance Providers
When another payer makes or recovers payment near or after our
filing limit, Total Health Care will allow the provider to rebill
for secondary consideration within 120 days from the primary payer
remittance advice date.
Attach the EOB to the claim so we can verify the claim was
submitted to us within the 120 days and mail to our paper claims
mailing address.
If follow-up is not completed within 120 days, any request will
deny without appeal rights.
Corrected or augmented information received after that date will
be automatically denied as the provider's responsibility.
Denials related to authorizations/medical necessity or
coding/clinical edits still follow the filing limit rules.
Negligence by the provider's staff does not justify an exception
to this policy.
*Please note our system is set-up to systematically deny claims
received after the filing limit. If your claim is denied and the
claim and primary EOB was submitted within 120 days please contact
our claims department for review.
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19
Resubmitting Claims: Process & Filing Limits All follow-up,
including resolving all claim denials and discrepancies, must be
completed within one year of the date of service. Claims received
after the filing limit will be denied as provider liability.
Corrected Claims – Replacement and Void Claims Denied claims are
registered in the claim processing system, but do not meet
requirements for payment under plan guidelines. Corrected claims
should be resubmitted with the appropriate frequency type and the
original claim number. These are required elements and the claims
will be denied if not coded correctly. Corrected claims must be
resubmitted within one year of the claim DOS.
A corrected claim is defined as a claim that has been altered in
any way from the original. Charges must have been previously
submitted and processed. If there is no prior claim in history the
claim will be denied for invalid bill type unless
appropriate documentation is attached to the claim detailing a
prior submission. Claims resubmitted with proof of timely filing or
a primary carrier’s EOB do not require
a corrected bill type.
CMS-1500 Claims Use “7” for replacement of a prior claim Use “8”
to void or cancel a prior claim Include the original claim number
in field 22 of the paper claim or the appropriate EDI
segment
CMS UB-04 Claims Use TOB XX7 for replacement of a prior claim
Use TOB XX8 to void or cancel a prior claim Include the original
claim number in field 54 of the paper claim or the appropriate
EDI
segment I ANSl-837P (Professional) Both items listed below must
be completed to be considered a corrected claim. In the 2300 Loop,
the CLM segment (Claim Information), CLMOS-3 (claim frequency type
code) must indicate one of the following qualifier codes:
7 - REPLACEMENT (Replacement of Prior Claim) 8 - VOID
(Void/Cancel of Prior Claim)
In the 2300 Loop, the REF02 segment (Original Reference Number
(ICN DCN)) must include the Original Claim Number issued to the
claim being corrected. The original claim number can be found on
your Remittance Advice. I ANSl-8371 (Institutional) Both items
listed below must be reported to be considered a corrected claim.
In the 2300 Loop, the CLM segment (Claim lnformation),the CLMOS-3
(Claim Frequency Type Code) must indicate the third digit of the
Type of Bill being sent The third digit of the Type of
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20
Bill is the frequency and can indicate if the bill is an
Adjustment, a Replacement or a Voided claim as follows:
7 - REPLACEMENT (Replacement of Prior Claim) 8 - VOID
(Void/Cancel of Prior Claim)
In the 2300 Loop, the REF02 segment (Original Reference Number
(ICN/DCN)) must include the Original Claim Number issued to the
claim being corrected. The original claim number can be found on
your Remittance Advice. When submitting a void claim, the provider
should include the reason the claim is voided (e.g. “Other
Insurance Primary”, “Filed in Error”, etc. (If another insurer is
primary, please include the primary carrier information). NOTE:
Corrected claims are subject to timely filing claims submission
guidelines.
Rejected Claims Rejected claims are claims with invalid or
required missing data elements, such as the provider Tax ID number
or the member ID number, that are returned to the provider or EDI
vendor. Rejected claims are not registered in the claim processing
system and are to be resubmitted as a ‘new’ claim.
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21
CMS-1500 Claim Form Required Fields
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
N/A Carrier Block Enter in the white, open carrier area the
name and address of the payer to whom
this claim is being sent. Enter the name
and address information in the following
format:
• First line: Name
• Second line: First line of address
• Third line: Second line of address, if
necessary
• Fourth line: City, state (two
characters) and ZIP code
2010BB NM103
N301
N302
N401
N402
N403
For an address with three lines, enter it in the following
format:
• First line: Name
• Second line: Line of address
• Third line: Leave blank
• Fourth line: City, state (two characters) and ZIP code
PATIENT INFORMATION (Fields 1-13) 1
(Split Field)
Coverage Optional Indicate the type of health insurance coverage
applicable to this claim by placing an X in the appropriate box.
Only one box can be marked.
2000B SBR09 Titled Claim Filing Indicator in the 837P.
1a Insured’s ID Number
Required Enter the insured’s ID number as shown on insured’s ID
card for the payer to which the claim is being submitted. If the
patient has a unique Patient Identification Number assigned by the
payer, then enter that number in this field.
2010BA NM109 Titled Subscriber Primary Identifier in the
837P.
2 Patient’s Name Required Enter the patient’s full last name,
first name, and middle initial. If the patient uses a last name
suffix (e.g., Jr, Sr), enter it after the last name and before the
first name.
2010CA or
2010BA
NM103
NM104
NM105
NM107
3 Patient’s Birth Date and Gender
Required Enter the patient’s 8-digit birth date (MM | DD |
YYYY). Enter an X in the correct box to indicate sex (gender) of
the patient.
2010CA or
2010BA
DMG02
DMG03
Sex is titled Gender in the 837P.
4 Insured’s Name Required Enter the insured’s full last name,
first name, and middle initial. If the insured uses a last name
suffix (e.g., Jr, Sr), enter it after the last name and before the
first name.
2010BA NM103
NM104
NM105
NM107
Titled Subscriber in the 837P
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22
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
5 Patient’s Address, City, State, Zip Code, and Telephone
Number
Required Enter the patient’s address. The first line is for the
street address; the second line, the city and state; the third
line, the ZIP code. If the patient’s address is the same as the
insured’s address, then it is not necessary to report the patient’s
address.
2010CA N301
NM302
N401
N402
N403
6 Patient Relationship to Insured
Required Enter an X in the correct box to indicate the patient’s
relationship to insured when Item Number 4 is completed. Only one
box can be marked.
If the patient is a dependent, but has a unique Member
Identification Number and the payer requires the identification
number be reported on the claim, then report “Self”, since the
patient is reported as the insured.
2000B
2000C
N404
SBR02
PAT01
Titled Individual Relationship Code in the 837P.
7 Insured’s Address, City, State, Zip Code, and Telephone
Number
Required Enter the insured’s address. If Item Number 4 is
completed, then this field should be completed. The first line is
for the street address; the second line, the city and state; the
third line, the ZIP code.
FOR WORKERS COMPENSATION CLAIMS: Enter the address of the
Employer.
FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the address of the
insured noted in Item Number 4.
2010BA N301
N302
N401
N402
N403
Titled Subscriber Address in the 837P.
8 Reserved for NUCC use
N/A
9 (Split Field)
Other Insured’s Name
Conditional If Item Number 11d is marked, complete fields 9, 9a,
and 9d, otherwise leave blank. When additional group health
coverage exists, enter other insured’s full last name, first name,
and middle initial of the enrollee in another health plan if it is
different from that shown in Item Number 2.
2330A N103
N104
N105
N107
N10Y
Titled Other Subscriber Name in the 837P.
9a Other Insured’s Policy or Group Number
Conditional Enter the policy or group number of the other
insured.
2320 SBR03 Titled Group or Policy Number in the 837P.
9b Reserved for NUCC Use
N/A
9c Reserved for NUCC Use
N/A
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23
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
9d Other Insured’s Insurance Plan Name or Program Name
Conditional Enter the other insured’s insurance plan or program
name.
2320 SBR04 Titled Other Insurance Group Name in the 837P.
10 (Split Field)
Is Patient’s Condition Related To:
Required Only one box on each line can be marked.
10a-c Employment?
Auto Accident
Other Accident
Required When appropriate, enter an X in the correct box to
indicate whether one or more of the services described in Item
Number 24 are for a condition or injury that occurred on the job or
as a result of an automobile or other accident. NOTE: The state
postal code where the accident occurred must be reported if “YES”
is marked in 10b for “Auto Accident.” Any item marked “YES”
indicates there may be other applicable insurance coverage that
would be primary, such as automobile liability insurance. Primary
insurance information must then be shown in Item Number 11.
2300 CLM11 Titled Related Causes Code in the 873P.
10d Claim Codes (Designated by NUCC)
Conditional When applicable, use to report appropriate claim
codes. Applicable claim codes are designated by the NUCC. Please
refer to the most current instructions from the public or private
payer regarding the need to report claim codes.
2300 HI HI is for reporting other condition codes.
11 (Split Field)
Insured’s Policy, Group, or FECA Number
Required Enter the insured’s policy or group number as it
appears on the insured’s health care identification card. If Item
Number 4 is completed, then this field should be completed.
2000B SBR03 Titled Subscriber Group or Policy Number in the
837P.
11a Insured’s Date of Birth, Gender
Conditional Required if the member is not the insured. Enter the
8-digit date of birth (MM│DD│YYYY) of the insured and an X to
indicate the sex (gender) of the insured. Only one box can be
marked. If gender is unknown, leave blank.
2010BA DMG02
DMG03
Titled Subscriber Birth Date and Subscriber Gender Code in the
837P.
11b Other Claim ID (Designated by NUCC)
Conditional Enter the “Other Claim ID.” Applicable claim
identifiers are designated by the NUCC.
2010BA REF01
REF02
Changed to Other Claim ID.
Insured’s Employer Name and School Name do not exist in the
837P.
11c Insurance Plan Name or Program Name
Conditional Enter the name of the insurance plan or program of
the insured. Some payers require an identification number of the
primary insurer rather than the name in this field.
2000B SBR04 Titled Subscriber Group Name in the 837P.
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24
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
11d Is there another Health Benefit Plan?
Conditional When appropriate, enter an X in the correct box. If
marked “YES”, complete 9, 9a, and 9d. Only one box can be
marked.
2320 Presence of loop 2320 indicates Y (yes) to the
question.
12 Patient’s or Authorized Person’s Signature
Not Required
Enter “Signature on File,” “SOF,” or legal signature. When legal
signature, enter date signed in 6-digit (MM|DD|YY) or 8-digit
format (MM|DD|YYYY) format. If there is no signature on file, leave
blank or enter “No Signature on File.”
2300 CLM09 Titled Release of
Information Code in the 837P.
13 Insured’s or Authorized Person’s Signature
Not Required
Enter “Signature on File,” “SOF,” or legal signature. If there
is no signature on file, leave blank or enter “No Signature on
File.”
2300 CLM08 Titled Benefit Assignment
Certification in the 837P.
PHYSICIAN OR SUPPLIER INFORMATION (FIELDS 14-33) 14 Date of
Current
Illness, Injury, or Pregnancy (LMP)
Conditional Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY)
date of the first date of the present illness, injury, or
pregnancy. For pregnancy, use the date of the last menstrual period
(LMP) as the first date. Enter the applicable qualifier to identify
which date is being reported.
431 Onset of Current Symptoms or Illness
484 Last Menstrual Period
Enter the qualifier to the right of the vertical, dotted
line.
2300 DTP01
DTP03
Titled in the 837P. Date - Onset of Current Illness or Symptom
Date – Last Menstrual Period
15 Other Date Conditional Enter another date related to the
patient’s condition or treatment. Enter the date in the 6-digit
(MM│DD│YY) or 8-digit (MM│DD│YYYY) format. Enter the applicable
qualifier to identify which date is being reported.
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-ray
471 Prescription
2300 DTP01
DTP03
If Patient Has Had Same or Similar Illness does not exist in the
837P.
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25
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date)
444 First Visit or Consultation
Enter the qualifier between the left-hand set of vertical,
dotted lines.
16 Dates Patient Unable to Work in Current Occupation
Conditional If the patient is employed and is unable to work in
current occupation, a 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY)
date must be shown for the “from–to” dates that the patient is
unable to work. An entry in this field may indicate
employment-related insurance coverage.
2300 DTP03 Titled Disability From and Work Return Date in
the
837P.
17 (Split Field)
Name of Referring Provider or Other Source
Conditional Enter the name (First Name, Middle Initial, Last
Name) followed by the credentials of the professional who referred
or ordered the service(s) or supply(ies) on the claim.
If multiple providers are involved, enter one provider using the
following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
2310A
(Referring)
2310D
(Supervising)
2420E
(Ordering)
NM101
NM103
NM104
NM105
NM107
17a Other ID# Conditional The Other ID number of the referring,
ordering, or supervising provider is reported in 17a in the shaded
area. The qualifier indicating what the number represents is
reported in the qualifier field to the immediate right of 17a.
2310A
(Referring)
2310D
(Supervising)
2420E
(Ordering)
REF01
REF02
Titled Referring Provider Secondary Identifier, Supervising
Provider Secondary Identifier, and Ordering Provider
Secondary Identifier in the 837P.
17b NPI # Required Enter the NPI number of the referring,
ordering, or supervising provider in Item Number 17b.
2310A
(Referring)
NM109 Titled Referring Provider Identifier, Supervising Provider
Identifier, and
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26
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
2310D
(Supervising)
2420E
(Ordering)
Ordering Provider Identifier in the 837P.
18 Hospitalization Dates Related to Current Services
Conditional Enter the inpatient 6-digit (MM│DD│YY) or 8-digit
(MM│DD│YYYY) hospital admission date followed by the discharge date
(if discharge has occurred). If not discharged, leave discharge
date blank. This date is when a medical service is furnished as a
result of, or subsequent to, a related hospitalization.
2300 DTP03 Titled Related
Hospitalization Admission Date and Related Discharge
Date in the 837P. 19 Additional
Claim Information (Designated by NUCC)
Not Required
Please refer to the most current instructions from the public or
private payer regarding the use of this field. Some payers ask for
certain identifiers in this field. If identifiers are reported in
this field, enter the appropriate qualifiers describing the
identifier.
2300 NTE
PWK
20 Outside Lab? $Charges
Conditional Complete this field when billing for purchased
services by entering an X in “YES.” A “YES” mark indicates that the
reported service was provided by an entity other than the billing
provider (for example, services subject to Medicare’s anti-markup
rule). A “NO” mark or blank indicates that no purchased services
are included on the claim.
If “Yes” is marked, enter the purchase price under “$Charges”
and complete Item Number 32. Each purchased service must be
reported on a separate claim form as only one charge can be
entered.
2400 PS102 Titled Purchased Service Charge Amount in the
837P.
21 Diagnosis or Nature of Illness or Injury
Required Enter the applicable ICD indicator to identify which
version of ICD codes is being reported:
0 ICD-10-CM
Enter the indicator between the vertical, dotted lines in the
upper right-hand portion of the field.
Enter the codes left justified on each line to identify the
patient’s diagnosis and/or condition. Do not include the decimal
point in the diagnosis code, because it is implied. List no more
than 12 ICD-10-CM diagnosis codes.
2300 HI01-2,
HI02-2,
HI03-2,
HI04-2,
HI05-2,
HI06-2,
HI07-2,
HI08-2,
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27
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
Relate lines A - L to the lines of service in 24E by the letter
of the line. Use the greatest level of specificity. Do not provide
narrative description in this field. NOTE: Claims with invalid
diagnosis codes
will be denied for payment.
“External cause” codes are not acceptable as a primary
diagnosis.
HI09-2,
HI10-2,
HI11-2,
HI12-2
22 Resubmission and/or Original Reference Number
Conditional For resubmissions adjustments, enter the appropriate
frequency code. List the original reference number for resubmitted
claims.
When resubmitting a claim, enter the appropriate bill frequency
code left justified in the left-hand side of the field, and the
claim ID number of the original claim in the Original Reference
Number section of this field. This is required for corrected,
resubmitted, or adjusted claims:
6 Corrected claim
7 Replacement of prior claim
8 Void/cancel of prior claim
This Item Number is not intended for use for original claim
submissions.
2300
--------------
2300
CLM05-3
------------
REF02
Titled Claim Frequency Code in the 837P.
-------------------------
Titled Payer Claim Control Number in the 837P. List the original
reference number for resubmitted claims.
(Resubmission means the code and original reference number
assigned by the payer to indicate a previously submitted
claim.)
23 Prior Authorization Number
Conditional Enter any of the following: prior authorization
number or referral number. Please refer to the Provider Manual or
Total Health Care website: www.thcmi.com to determine if services
rendered require an authorization. If the service requires an
authorization or a referral and this number is missing the claim
will reject.
2300 REF02
REF0-G1
Titled Prior Authorization Number in 837P is the payer assigned
number authorizing the service(s).
24 (Split Field)
Service/Procedure Information
Supplemental information can only be entered with a
corresponding, completed service line. The six service lines in
section 24 have been divided horizontally to accommodate submission
of both the NPI and another/proprietary identifier and to
accommodate the submission of supplemental information to support
the billed service. The
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28
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
top area of the six service lines is shaded and is the location
for reporting supplemental information. It is not intended to allow
the billing of 12 lines of service.
The supplemental information is to be placed in the shaded
section of 24A through 24G as defined in each Item Number.
Providers must verify requirements for this supplemental
information with the payer.
24A Date(s) of Service [lines 1–6]
Required Enter date(s) of service, both the “From” and “To”
dates. If there is only one date of service, enter that date under
“From.” Leave “To” blank or re-enter “From” date. If grouping
services, the place of service, procedure code, charges, and
individual provider for each line must be identical for that
service line. Grouping is allowed only for services on consecutive
days. The number of days must correspond to the number of units in
24G.
When required by payers to provide additional narrative
description of an unspecified code, NDC, etc. enter the applicable
qualifier and number/code/information starting with the first space
in the shaded line of this field.
2400 DTP03 Titled Service Date in the 837P.
24B Place of Service [lines 1–6]
Required In 24B, enter the appropriate two-digit code from the
Place of Service Code list for each item used or service performed.
The Place of Service Codes are available at:
www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html.
2300
2400
CLM05-1
SV105
Facility Code Value. Titled Facility Code Value in the
837P. Place of Service Code.
Titled Facility Code Value in the 837P.
24C EMG [lines 1–6]
Conditional Emergency indictor. EMG identifies if the service
was an emergency. Enter Y for “YES” if the service is related to an
emergency service/procedure billed with POS 22.
2400 SV109 Emergency Indicator. Titled
Emergency Indicator in the 837P.
24D Procedures, Services, or Supplies CPT/HCPCS [lines 1–6]
Required Enter the CPT or HCPCS code(s) and modifier(s) (if
applicable) from the appropriate code set in effect on the date of
service. This field accommodates the entry of up to four two-digit
modifiers. The specific procedure code(s) must be shown without a
narrative description.
2400 SV101 (2-6) Titled Product/Service ID and Procedure
Modifier in the 837P.
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29
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
24E Diagnosis Pointer [lines 1–6]
Required In 24e, enter the diagnosis code reference letter
(pointer) as shown in Item Number 21 to relate the date of service
and the procedures performed to the primary diagnosis. When
multiple services are performed, the primary reference letter for
each service should be listed first, other applicable services
should follow. The reference letter(s) should be A – L or multiple
letters as applicable. ICD-10-CM diagnosis codes must be entered in
Item Number 21 only. Do not enter them in 24E.
2400 SV107 (1-4) Alpha pointers (A – J) on the CMS-1500 claim
form must be converted to numeric pointers (1–12) in the 837P.
Titled Diagnostic
Code Pointer in 837P.
24F $Charges [lines 1–6]
Required Enter the charge for each listed service. 2400 SV102
Titled Line Item Charge Amount in the 837P.
24G Days or Units [lines 1–6]
Required Enter the number of days or units. This field is most
commonly used for multiple visits, units of supplies, anesthesia
units or minutes, or oxygen volume. If only one service is
performed, the numeral 1 must be entered.
2400 SV104 Titled Service Unit Count in the 837P.
24H EPSDT/Family Plan [lines 1–6]
Conditional For Early & Periodic Screening, Diagnosis, and
Treatment related services, enter the response in the shaded
portion of the field as follows:
If there is no requirement (e.g., state requirement) to report a
reason code for EPDST, enter Y for “YES” or N for “NO” only.
2300
2400
CRC
SV111
SV112
Titled EPSDT Indicator and Family Planning Indicator in the
837P.
If there is no requirement (e.g., state requirement) to report a
reason code for EPDST, enter Y for “yes” or N for “no” only.
24I ID Qualifier [lines 1–6]
Conditional Enter in the shaded area of 24I the qualifier
identifying if the number is a non-NPI. The Other ID# of the
rendering provider should be reported in 24J in the shaded
area.
2310B PRV
REF01
Titled Reference
Identification Qualifier in the 837P.
The Other ID Number of the rendering provider should be reported
in 24J in the shaded area.
24J Rendering Provider ID # (shaded portion) [lines 1–6]
Required The individual rendering the service should be reported
in 24J. Enter the NPI number in the unshaded area of the field.
2310B PRV03
REF02
Titled Rendering Provider
Taxonomy/Secondary
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30
CMS-1500 Claim Form Required Fields Field Number
Field Description
Data Type Instructions Loop ID Segment NOTEs
Identifier in the 837P.
24J Rendering Provider ID # (unshaded portion) [lines 1–6]
Required The individual rendering the service should be reported
in 24J. Enter the NPI number in the unshaded area of the field.
2310B NM109 Titled Rendering Provider Identifier (NPI) in the
837P.
25 Federal Tax ID Number
Required Enter the “Federal Tax ID Number” (employer ID number
or SSN) of the Billing Provider identified in Item Number 33. This
is the tax ID number intended to be used for 1099 reporting
purposes. Enter an X in the appropriate box to indicate which
number is being reported. Only one box can be marked.
2010AA REF01
REF02
Titled Reference
Identification Qualifier and Billing Provider TIN in the
837P.
This is the tax ID number intended to be used for 1099 reporting
purposes. Enter an X in the appropriate box to indicate which
number is being reported. Only one box can be marked.
26 Patient’s Account No.
Required Enter the patient’s account number assigned by the
provider of service’s or supplier’s accounting system.
2300 CLM01 Titled Patient Control
Number in the 837P.27 Accept
Assignment? Not Required
Enter an X in the correct box. Only one box can be marked.
2300 CLM07 Titled Assignment or Plan Participation code in the
837P.
28 Total Charge Required Enter total charges for the services
(i.e., total of all charges in 24F).
2300 CLM02 Titled Total Claim Charge Amount in the 837P. May be
$0.00 but negative dollar amounts are not allowed. Do not use
special characters. Enter 00 in the cents area if the amount is a
whole number.
29 Amount Paid Conditional Enter total amount the patient and/or
other payers paid on the covered services only. Required when
another carrier is the primary payer. Enter the payment received
from the primary payer prior to invoicing the plan.
2300
--------------
2300
AMT02
------------ AMT02
Titled Patient Amount Paid in the 837P.
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31
CMS
