AmeriHealth Caritas PA. Claim Filing Instructions

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1 AmeriHealth aritas PA laim Filing Instructions

2

3 NOTES

4 AmeriHealth aritas PA Table of ontents Section Title Page # laim Filing 1 Procedures for laim Submission 1 laim Mailing Instructions 2 laim Filing Deadlines 2 Exceptions 2 efunds for laims Overpayment 2 laim Form Field equirements 5 equired Fields (MS 1500 laim Form) 5 Professional laims EDI Mapping 14 equired Fields (UB-04 laim Form) 20 Institutional laims EDI Mapping 31 Instructions & Examples of Supplemental Information 39 eporting Supplemental Info on laims 39 eporting ND on Professional laims 40 eporting ND on Institutional laims 41 eporting POA on Institutional laims 43 ommon auses of laim Processing Delays, ejections, or Denials 47 Electronic Data Interchange (EDI) 50 Procedures for Electronic Submission 51 Hardware and Software equirements 51 ontracting with Emdeon and Other Electronic Vendors 51 ontacting the EDI Technical Support Group 51 Specific Data ecord equirements 52 Electronic laim Flow Description 52 Invalid Electronic laim ecord ejections/denials 54 Plan Specific Electronic Edit equirements 54 Exclusions 54 ommon ejections 55 esubmitted Professional orrected laims 55 Electronic Billing Inquiries 57 Tips for Accurate Diagnosis oding 58

5 Table of ontents Section Title Page # Appendix Supplemental Information 60 Ambulance 61 Anesthesia 62 Audiology 62 hemotherapy 62 hiropractic are 62 Dialysis 62 DME 62 EPSDT Billing Guidelines 63 Family Planning 63 Home Health are 66 Infusion Therapy 66 Injectable Drugs 66 Maternity 66 Multiple Surgery eduction Payment Policy 66 Physical Occupational and Speech Therapy 67 Termination of Pregnancy 67

6 laim Filing Procedures for laim Submission AmeriHealth aritas PA, hereafter referred to as the Plan, is required by State and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims. When required data elements are missing or are invalid, claims will be rejected by the Plan for correction and re-submission. laims for billable and capitated services provided to Plan members must be submitted by the provider who performed the services. laims filed with the Plan are subject to the following procedures: Verification that all required fields are completed on the MS 1500 or UB-04 forms. Verification that all Diagnosis and Procedure odes are valid for the date of service. Verification for electronic claims against 837 edits at Emdeon Verification of the referral for Specialist or non-primary are Physician claims. Verification of member eligibility for services under the Plan during the time period in which services were provided. Verification that the services were provided by a participating provider or that the out of plan provider has received authorization to provide services to the eligible member. Verification that the provider participated with the Medical Assistance Program at the time of service. IMPOTANT: ejected claims are defined as claims with invalid or required missing data elements, such as the provider tax identification number, member ID number, that are returned to the provider or EDI* source without registration in the claim processing system. ejected claims are not registered in the claim processing system and can be resubmitted as a new claim. Denied claims are registered in the claim processing system but do not meet requirements for payment under Plan guidelines. They should be resubmitted as a corrected claim. Denied claims must be resubmitted as corrected claims within 365 calendar days from the date of service. Note: These requirements apply to claims submitted on paper or electronically. * For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital laims in this booklet. Verification that an authorization has been given for services that require prior authorization by the Plan. Verification of whether there is Medicare coverage or any other third party resources and, if so, verification that the Plan is the payer of last resort on all claims submitted to the Plan. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 1 Provider Services

7 laim Mailing Instructions Submit claims to AmeriHealth aritas PA at the following address: AmeriHealth aritas Pennsylvania laim Processing Department P.O. Box 7118 London, KY The Plan encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon s Provider Support Line at to arrange transmission. Any additional questions may be directed to the EDI Technical Support Hotline at or by at laim Filing Deadlines Original invoices must be submitted to the Plan within 180 calendar days from the date services were rendered or compensable items were provided. e-submission of previously denied claims with corrections and requests for adjustments must be submitted within 365 calendar days from the date services were rendered or compensable items were provided. Exceptions laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer s EOB. Important: laims originally rejected for missing or invalid data elements must be corrected and re-submitted within 180 calendar days from the date of service. ejected claims are not registered as received in the claim processing system. (efer to the definitions of rejected and denied claims on page 1.) efunds for laims Overpayments or Errors AmeriHealth aritas PA and the Pennsylvania Department of Public Welfare encourage providers to conduct regular self-audits to ensure accurate payment. Medicaid program funds that were improperly paid or overpaid must be returned. If the provider s practice determines that it has received overpayments or improper payments, the provider is required to make Important: equests for adjustments may be submitted by telephone to: Provider laim Services (Select the prompts for the correct Plan, and then, select the prompt for claim issues.) If you prefer to write, please be sure to stamp each claim submitted corrected or resubmission and address the letter to: laims Processing Department AmeriHealth aritas PA P.O. Box 7118 London, KY Outpatient medical appeals must be submitted in writing to: Provider Appeals Department AmeriHealth aritas PA PO Box 7316 London, KY Inpatient medical appeals must be submitted in writing to: Provider Appeals Department AmeriHealth aritas PA PO Box 7307 London, KY Written Disputes should be mailed to: Informal Practitioner Dispute AmeriHealth aritas PA P.O. Box 7329 London, KY efer to the Provider Manual or look online at the Provider enter of the AmeriHealth aritas PA website at for complete instructions on submitting appeals. Note: AmeriHealth aritas PA EDI Payer ID# * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 2 Provider Services

8 M 1500 laim Form Field equirements immediate arrangements to return the funds to AmeriHealth aritas PA or follow the DPW protocol for returning improper payments or overpayment. A. ontact AmeriHealth aritas PA Provider laim Services at to arrange the repayment. There are two ways to return overpayments to AmeriHealth aritas PA: 1. Have AmeriHealth aritas PA deduct the overpayment/improper payment amount from future claims payments. 2. Submit a check for the overpayment/improper payment amount directly to: laims Processing Department AmeriHealth aritas PA PO Box 7118 London, KY Note: Please include the member s name and ID, date of service, and laim ID B. Providers may follow the Pennsylvania Medical Assistance (MA) Provider Selfaudit Protocol to return improper payments or overpayments. Access the DPW voluntary protocol process via the following link: DPW Provider Self Audit Protocol * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 3 Provider Services

9 M 1500 laim Form Field equirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 4 Provider Services

10 M 1500 laim Form Field equirements laim Form Field equirements The following charts describe the required fields that must be completed for the standard enters for Medicare and Medicaid Services (MS) MS 1500 or UB-04 claim forms. If the field is required without exception, an (equired) is noted in the equired or onditional box. If completing the field is dependent upon certain circumstances, the requirement is listed as (onditional) and the relevant conditions are explained in the Instructions and omments box. The MS 1500 claim form must be completed for all professional medical services, and the UB- 04 claim form must be completed for all facility claims. All claims must be submitted within the required filing deadline of 180 days from the date of service. Although the following examples of claim filing requirements refer to paper claim forms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic or paper). equired Fields (MS 1500 laim Form) MS 1500 laim Form Field # Field Description 1 Insurance Program Identification Instructions and omments heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. equired or onditional* 1a Insured I.D. Number Health Plan s member identification number. If submitting a claim for a newborn that does not have an identification number, enter the mother s ID number. For electronic submissions, ID must be less than 13 alphanumeric characters. In-network providers: please omit the three alpha characters preceding the member s ID number on the claim. Out of area providers: please enter the three alpha characters preceding the member s ID number on the claim. 2 Patient s Name (Last, First, Middle Initial) 3 Patient s Birth Date / Sex 4 Insured s Name (Last, First, Middle Initial) Enter the patient s name as it appears on the member s Health Plan I.D. card. If submitting a claim for a newborn that does not have an identification number, enter Baby Girl or Baby Boy and last name. efer to page 22 for additional newborn billing information, including Multiple Births. MMDDYY / M or F If submitting a claim for a newborn, enter newborn and DOB/Sex Enter the patient s name as it appears on the member s Health Plan I.D. card, or Enter the newborn s name when the patient is a newborn. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 5 Provider Services

11 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (include area code) 6 Patient elationship To Insured 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) 8 eserved for NU use 9 Other Insured's Name (Last, First, Middle Initial) 9a Other Insured's Policy Or Group # 9b eserved for NU use 9c eserved for NU use 9d Insurance Plan Name Or Program Name 10a,b,c Is Patient's ondition elated To: Instructions and omments Enter the patient s complete address and telephone number. (Do not punctuate the address or phone number.) Always indicate self. efers to someone other than the patient. ompletion of fields 9a through 9d is equired if patient is covered by another insurance plan. Enter the complete name of the insured. Note: "OB claims that require attached EOBs must be submitted on paper. equired if # 9 is completed. equired if # 9 is completed. Indicate Yes or No for each category. Is condition related to: a) Employment b) Auto Accident c) Other Accident equired or onditional* Not equired Not equired Not equired 10d laim odes (Designated To comply with DPW s EPSDT reporting requirements, continue to use this field to report EPSDT referral codes, as follows; * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 6 Provider Services

12 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description by NU) Instructions and omments YD Dental (equired for Age 3 and above) YO Other YV Vision YH Hearing YB Behavioral YM - Medical equired or onditional* For all other claims enter new ondition odes as appropriate. Available 2-digit ondition odes include nine codes for abortion services and four codes for worker s compensation. Please refer to NU for the complete list of codes. Examples include: 11 Insured's Policy Group Or FEA # 11a Insured's Birth 11b AD Abortion Performed due to a Life Endangering Physical ondition aused by, Arising from or Exacerbated by the Pregnancy Itself W3 Level 1 Appeal equired when other insurance is available. omplete if more than one Other Medical insurance is available, or if yes to 10a, b, c. Same as # 3. equired if 11 is completed. Date / Sex Other laim ID Enter the following qualifier and accompanying identifier to report the claim number assigned by the payer for worker s compensation or property and casualty: Y4 Property asualty laim Number 11c Insurance Plan Name Or Program Name 11d Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature Enter qualifier to the left of the vertical, dotted line; identifier to the right of the vertical, dotted line. Enter name of Health Plan. equired if 11 is completed. Y or N by check box. If yes, complete # 9 a-d. Not required * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 7 Provider Services

13 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description 14 Date Of urrent Illness Injury, Pregnancy (LMP) MMDDYY or MMDDYYYY Instructions and omments Enter applicable 3-digit qualifier to right of vertical dotted line. Qualifiers include: 431 Onset of urrent Symptoms or Illness 484 Last Menstrual Period (LMP) equired or onditional* Use the LMP for pregnancy. Example: 15 Other Date MMDDYY or MMDDYYYY Enter applicable 3-digit qualifier between the left-hand set of vertical dotted lines. Qualifiers include: 454 Initial Treatment 304 Latest Visit or onsultation 453 Acute Manifestation of a hronic ondition 439 Accident 455 Last X-ay 471 Prescription 090 eport Start (Assumed are Date) 091 eport End (elinquished are Date) 444 First Visit or onsultation Example: 16 Dates Patient Unable To Work In urrent Occupation 17 Name Of eferring Physician Or Other Source equired if a provider other than the member s primary care physician rendered invoiced services. Enter applicable 2-digit qualifier to left of vertical dotted line. If multiple providers are involved, enter one provider using the following priority order: 1. eferring Provider 2. Ordering Provider 3. Supervising Provider Qualifiers include: * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 8 Provider Services

14 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments DN eferring Provider DK Ordering Provider DQ Supervising Provider Example: equired or onditional* 17a Other I.D. Number Of eferring Physician Enter the Health Plan provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a. If the Other ID number is the Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. The NU defines the following qualifiers used in 5010A1: 0B State License Number 1G Provider UPIN Number G2 Provider ommercial Number LU Location Number (This qualifier is used for Supervising Provider only.) equired if # 17 is completed. 17b National Provider Identifier (NPI) 18 Hospitalization Dates elated To urrent Services 19 Additional laim Information (Designated by NU) Enter the NPI number of the referring provider, ordering provider or other source. equired if #17 is completed. equired when place of service is in-patient. MMDDYY (indicate from and to date) Enter additional claim information with identifying qualifiers as appropriate. For multiple items, enter three blank spaces before entering the next qualifier and data combination. The NU defines the following qualifiers: 0B State License Number 1G Provider UPIN Number G2 Provider ommercial Number LU Location Number (This qualifier is used for Supervising Provider only) N5 Provider Plan Network Identification Number SY Social Security Number Not equired * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 9 Provider Services

15 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description 20 Outside Lab harges 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) Instructions and omments X5 State Industrial Accident Provider Number ZZ Provider Taxonomy Enter the applicable ID indicator to identify which version of ID codes is being reported: 9 - ID-9-M 0 - ID-10-M Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. equired or onditional* Not equired 22 esubmission ode and/or Original ef. No 23 Prior Authorization Number Enter the codes to identify the patient s diagnosis and/or condition. List no more than 12 ID diagnosis codes. elate lines A L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field. Note: laims with invalid diagnosis codes will be denied for payment. For resubmissions or adjustments, enter the appropriate bill frequency code (7 or 8 see below) left justified in the Submission ode section, and the laim ID# of the original claim in the Original ef. No. section of this field. Additionally, stamp resubmitted or corrected on the claim 7 eplacement of Prior laim 8 Void/cancel of Prior laim Enter the referral or authorization number. efer to the Provider Manual to determine if services rendered require an authorization or referral. 24A 24B Date(s) Of Service Place Of Service From date: MMDDYY. If the service was performed on one day leave To blank or re-enter From Date. See below for Important Note (instructions) for completing the shaded portion of field 24. Enter the MS standard place of service code. 00 for place of service is not acceptable. 24 EMG This is an emergency indicator field. Enter Y for Yes or leave blank for No in the bottom (unshaded area of the field). 24D Procedures, Procedure codes (5 digits) and modifiers (2 digits) must be valid Services Or for date of service. Supplies Note: Modifiers affecting reimbursement must be placed in the 1 st PT/HPS modifier position Modifier *See additional information below for EDI requirements * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 10 Provider Services

16 M 1500 laim Form Field equirements MS 1500 laim Form Field # 24E Field Description Diagnosis Pointer Instructions and omments Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). Diagnosis codes must be valid ID-9 codes for the date of service, and must be entered in field 21. Do not enter diagnosis codes in 24E. 24F harges Enter charges. A value must be entered. Enter zero ($0.00) or actual charged amount. (this includes capitated services.) 24G Days Or Units Enter quantity. Value entered must be greater than or equal to zero. Blank is not acceptable. (Field allows up to 3 digits) 24H EPSDT Family Plan 24I ID Qualifier If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is reported in the qualifier field in 24I. If the Other ID number is the Health Plan ID number, enter G2. If the Other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. equired or onditional* Not required 0B 1G G2 LU State License Number Provider UPIN Number Provider ommercial Number Location Number If the rendering provider does have an NPI see field 24J below.. If the Other ID number is the Health Plan ID number, enter G2. 24J endering Provider ID 25 Federal Tax I.D. Number SSN/EIN 26 Patient's Account No. 27 Accept Assignment The individual rendering the service is reported in 24J. Enter the Health Plan ID number in the shaded area of the field. Enter the NPI number in the unshaded area of the field. Use qualifier The correct qualifier value for NPI values to be sent on the X12 is XX. Physician or Supplier's Federal Tax ID numbers. The provider's billing account number. Always indicate Yes. efer to the back of the MS 1500 (08-05) form for the section pertaining to Medicaid Payments. ecommended 28 Total harge Enter charges. A value must be entered. Enter zero (0.00) or actual charges (this includes capitated services. Blank is not acceptable. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 11 Provider Services

17 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments 29 Amount Paid equired when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing the Plan. Medicaid programs are always the payers of last resort. 30 eserved for NU Use equired or onditional* Not equired 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date 32 Name and Address of Facility Where Services Were endered (If other than Home or Actual signature is required. equired unless #33 is the same Enter the physical location. (P.O. Box # s are not acceptable here) Office) 32a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number. 32b. Other ID# Enter the Health Plan ID # (strongly recommended) Enter the G2 qualifier followed by the Health Plan ID # The NU defines the following qualifiers: 0B State License Number G2 Provider ommercial Number LU Location Number 33 Billing Provider Info & Ph # equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. equired Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 12 Provider Services

18 M 1500 laim Form Field equirements MS 1500 laim Form Field # Field Description Instructions and omments 33a. NPI number equired unless endering Provider is an Atypical Provider and is not required to have an NPI number 33b. Other ID# Enter the Health Plan ID # (strongly recommended) equired or onditional* Enter the G2 qualifier followed by the Health Plan ID # The NU defines the following qualifiers: 0B State License Number G2 Provider ommercial Number ZZ Provider Taxonomy equired when the endering Provider is an Atypical Provider and does not have an NPI number. Enter the two-digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 13 Provider Services

19 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 1 Insurance Program Identification 2000B, SB09 = I ommercial Insurance 1a Insured ID Number <Plan Name> Member s identification number 2 Patient s Name (Last, First, Middle Initial) 2010BA/NM1 Use 2330A for OB Data 2010BA/NM1 New Born (2010A/NM1) 2010A/NM1 2010A/NM1 3 Patient s Birth Date/Sex 2010BA/DMG 2010A/DMG - Newborn 4 Insured s Name (Last, First, Middle Initial) 2010BA/NM1 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (Include Area ode) 2010A/N3/N4 6 Patient elationship To Insured 2000/PAT01 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) Us 2330A for OB data 8 eserved for NU use Blank N 9 Other Insured's Name (Last, First, Middle Initial) 2330A/NM1 9a Other Insured's Policy Or Group # 2320/SB N 9b eserved for NU use Not in IG N 9c eserved for NU use Not in IG N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 14 Provider Services

20 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 9d Insurance Plan Name Or Program Name 2330 NM1 10d laim odes (Designated by NU) Not in IG 2300/PWK 11 Insured's Policy Group Or FEA # 2000B/SB 11a Insured's Birth Date / Sex 2010BA/DMG A/DMG02 11b Other laim ID Not in IG 11c 11d Insurance Plan Name Or Program Name Is There Another Health Benefit Plan? 12 Patient's Or Authorized Person's Signature 13 Insured's Or Authorized Person's Signature 14 Date Of urrent Illness Injury, Pregnancy (LMP) 2000B/SB B/SB LM /OI LM /OI /DTP03 N 15 Other Date 16 Dates Patient Unable To Work In urrent Occupation 17 Name Of eferring Physician Or Other Source 17a 17b Other ID Number Of eferring Physician (Plan Provider ID#) National Provider Identifier (NPI) (Enter the referring provider s NPI) 2300/DTP A/NM1 2310A/EF A/NM109. N * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 15 Provider Services

21 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 19 Additional laim Information (Designated by NU) 2300/NTE01 20 Outside Lab 2400/PS102 N N 21 Diagnosis Or Nature Of Illness Or Injury. (elate To 24E) 2300, HIXX 22 esubmission ode and/or Original ef. No Used for Original laim # 2300/EF/Qualifier F8 2300/EF/ Qualifier 9F N equired when LM05-3 (laim Frequency ode) indicates this claim is a replacement or void to a previously adjudicated claim. 23 Prior Authorization Number 24A eferral Number Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J 2300/EF/Qualifier G1 2300/EF/ Qualifier 9F 2400/DTP 24B Place Of Service 2400/SV EMG 2400/SV109 N 24D Procedures, Services Or Supplies PT/HPS Modifier 2400/SV1 24E Diagnosis Pointer 2400/SV1 24F harges 2300/LM 24G Days Or Units 2400/SV1 24H EPSDT Family Plan 2400/SV1 24I ID Qualifier 2310B/EF01 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 16 Provider Services

22 Professional laims EDI Mapping MS 1500 laim Form Gap Analysis Field # Field Description Instructions and omments equired or onditional* 24J endering Provider ID 2310B/NM B/EF02 25 Federal Tax ID Number SSN/EIN of Billing Provider 2010AA/EF 26 Patient's Account No. 2300/ML01 27 Accept Assignment Not in IG N 28 Total harge Loop 2300/LM 29 Amount Paid OB data should be submitted as it was received from other payer 2300/AMT 2430/AMT 30 Balance Due 2430/AMT N 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date 32 Name And Address Of Facility Where Services Were endered (If Other Than Home Or Office). NOTE: Ambulance information should be sent as per 837 IG Not in IG D/2310E 2300/ & 1 N 32a. NPI number of Supervising Provider name 32b. Other ID# (AmeriHealth aritas PA issued Provider Identification Number) Strongly recommended 2310D 2310B/EF01=G2 * equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. efer to the NU or NUB eference Manuals for additional 17 Provider Services

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