CMS-1500 Claim Form Instructions

Transcription

1 Alaska edical Assistance Program S-1500 laim Form Instructions This document is intended to provide Alaska edicaid-specific instructions and clarifications for completion of the 1500 claim form, version 02/12. It is to be used as a companion to, and not a replacement for, the National Uniform laim ommittee (NU) 1500 laim Form Reference Instruction anual, available at Each number listed in the instructions corresponds to a field on the S-1500 claim form; additional fields may be required for providers billing electronically in a HIPAA-compliant format. These claim form instructions are intended for the following provider types/services: Advanced Nurse Practitioner/Nurse idwife Audiologist Behavioral Rehabilitation Services are oordinator/are oordination Agency ertified Registered Nurse Anesthetist hiropractor ommunity Behavioral Health ommunity Health Aide/Practitioner Dietician Direct-Entry idwife Durable edical Equipment/Respiratory Therapy Early & Periodic Screening, Diagnosis, & Treatment Environmental odifications Family Planning linic Federally Qualified Health enter/rural Health enter Ground Ambulance Services Health Professional Group Home and ommunity Based Agency Home Infusion Therapy Independent Laboratory Services Indian Health Services & Tribal Services/Tribal linic ental Health Physician linic Nutrition Personal are Assistant/Agency Physician Physician Assistant Podiatry Private Duty Nurse Prosthetic and Orthotic Supplier Psychologist Radiology Services Residential Supported Living School-Based Services Targeted ase anagement Therapies: Occupational, Physical, Speech-Language Vision Services S-1500 laim Form Instructions (rev. 09/24/2015)

2 S-1500 laim Form Instructions (rev. 09/24/2015) Sample S-1500 laim Form

3 : andatory : andatory- Alaska edicaid-specific Instructions 1. edicare/edicaid/triare/etc. Select edicaid. For edicare crossover claims, select edicaid and edicare. 1a. Insured s ID Number Enter the edicaid-eligible patient s (recipient s) 10-digit edicaid identification number. 2. Patient s Name Enter the edicaid recipient s name as it appears on the eligibility card or coupon. 3. Patient s Birth Date, Sex O 4. Insured s Name O edicaid recipient is always the insured. 5. Patient s Address O 6. Patient s Relationship to Insured Select Self (see field 4). 7. Insured s Address O 8. Reserved for NU Use B 9. Other Insured s Name omplete if the recipient has other insurance (as indicated in field 11d). 9a. Other Insured s Policy or Group # Exception: If an approved TPL avoidance record applies to the services billed, leave blank. 9b. Reserved for NU Use B 9c. Reserved for NU Use B 9d. Insurance Plan Name or Program Name 10a. Is Patient s ondition Related to Employment? 10b. Is Patient s ondition Related to Auto Accident? 10c. Is Patient s ondition Related to Other Accident? omplete if the recipient has other insurance (as indicated in field 11d). Exception: If an approved TPL avoidance record applies to the services billed, leave blank. S-1500 laim Form Instructions (rev. 09/24/2015) Page 1 of 5

4 : andatory : andatory- Alaska edicaid-specific Instructions 10d. laim odes (Designated by NU) An attachment is required for each reported code. Refer to the provider billing manual for details on attachment requirements for abortion and sterilization services. 11. Insured s Policy, Group, or FEA Number For edicare crossover claims, enter edicare, even if another TPL exists. 11a. Insured s Date of Birth, Sex Use to report TPL-related insured s information, only. 11b. Other laim ID (Designated by NU) 11c. Insurance Plan Name or Program Name B Use to report TPL-related information, only. 11d. Is There Another Health Benefit Plan? hoose yes to report health plans other than edicaid. 12. Patient s or Authorized Person s Signature 13. Insured s or Authorized Person s Signature 14. Date of urrent Illness, Injury, or Pregnancy (LP) O If date is reported, applicable qualifier is required. 15. Other Date O 16. Dates Patient Unable to Work in urrent Occupation 17. Name of Referring Provider or Other Source O Referring, ordering, and prescribing providers must be enrolled with Alaska edical Assistance. If the recipient is enrolled in the are anagement Program and rendering provider is not the primary care provider (PP), a copy of the PP s referral must be attached to the claim. 17a. Other ID# 17b. NPI # 18. Hospitalization Dates Related to urrent Services Required if a provider is entered in field 17. B S-1500 laim Form Instructions (rev. 09/24/2015) Page 2 of 5

5 19. Additional laim Information (Designated by NU) : andatory : andatory- O Alaska edicaid-specific Instructions 20. Outside Lab? $ harges B 21. Diagnosis or Nature of Illness or Injury Required of all provider types. Enter the ID indicator appropriate for the date of service. Enter 9 to indicate ID-9 diagnosis codes; required for dates of service prior to 10/01/2015. Enter 0 to indicate ID-10 diagnosis codes; required for dates of service on and after 10/01/2015. Enter the appropriate diagnosis code(s) in A L. For dates of service prior to 10/01/2015, only ID-9 diagnosis codes will be accepted. For dates of service on and after 10/01/2015, only ID-10 diagnosis codes will be accepted. 22. Resubmission and/or Original Reference Number B Atypical/Non-Diagnosing Providers: Alaska edicaid recommends the following providers use the following diagnosis codes when a documented diagnosis is not known. ID-9 prior to 10/01/2015 ID-10 on and after 10/01/2015 Behavioral Rehabilitation V606 Z74.8 are oordination Agency Z02.9 Environmental odification V601 Z59.1 Home and ommunity Based Agency Use plan of care diagnosis Hotel V630 Z75.3 Personal are Agency 7999 Z74.1 Pre-aternal Home V222 Z75.8 Residential Supported Living V606 Z74.8 School-Based Services Use IEP diagnosis Taxi V630 Z Prior Authorization Number If service billed requires authorization, enter the alpha-numeric prior (service) authorization ID. S-1500 laim Form Instructions (rev. 09/24/2015) Page 3 of 5

6 : andatory : andatory- Alaska edicaid-specific Instructions Section 24 In the shaded area of section 24, enter supplemental information to support the billed service. Refer to Section II: Professional laims anagement for examples. For J odes, record the following in the shaded area of the claim line. Do not insert spaces or hyphens. 1. N4 qualifier digit ND number, 3. ND unit of measure, and 4. ND units administered. Example: N4XXXXXXXXXXXL1.0 24a. Date(s) of Service Submit single dates of service only; spanned dates will be denied. 24b. Place of Service 24c. EG Note: Emergency services are not subject to cost sharing. Refer to provider billing manuals for definition of emergency. 24d. Procedures, Services, or Supplies 24e. Diagnosis Pointer 24f. $harges 24g. Days or Units If the recipient is a resident of a long-term-care facility, enter LT in the shaded area. For J odes, use the NPDP billing unit standard for the medication; correct billing units are available at 24h. EPSDT/Family Plan Alaska edicaid requires reporting EPSDT related services. Use the appropriate reason code found in the NU manual to represent the EPSDT-related service. Enter Y in the unshaded area if the service is family planning. 24i. ID Qualifier Typical (NPI) Providers: Alaska edicaid strongly recommends indicating the rendering provider s taxonomy and qualifier ZZ. Atypical Providers: Enter qualifier G2 in the shaded area. S-1500 laim Form Instructions (rev. 09/24/2015) Page 4 of 5

7 : andatory : andatory- Alaska edicaid-specific Instructions 24j. Rendering Provider ID # Refer to your Alaska edicaid provider billing manual to determine if you are required to identify the rendering provider on your claims. 25. Federal Tax ID Number O Typical Providers: In the shaded area, enter the rendering provider s taxonomy/edicaid ontract ID as indicated by field 24i. Atypical Providers: Enter 7-digit provider ID number. 26. Patient s Account No. O If used, this provider-assigned account number will appear on the remittance advice. 27. Accept Assignment? * *Required of all providers except the following, which should leave field blank: 28. Total harge Environmental odifications Home and ommunity-based Agency Personal are Agency 29. Amount Paid If claim was billed to other insurance (including edicare), attach explanation of benefits (EOB) indicating paid amount. 30. Reserved for NU Use B 31. Signature of Physician or Supplier Including Degrees or redentials 32. Service Facility Location Information ZIP+4 is required. 32a. NPI# [Service Location] O 32b. Other ID# [Service Location] O 33. Billing Provider s Info & Ph # Submitted info should match demographics on the edicaid Provider Agreement. 33a. NPI# [Billing Provider] * *Atypical Providers: Leave blank 33b. Other ID# [Billing Provider] Typical (NPI) Providers: Enter the appropriate qualifier and billing provider s taxonomy. Atypical Providers: Enter the appropriate qualifier and billing provider s edicaid ontract ID. S-1500 laim Form Instructions (rev. 09/24/2015) Page 5 of 5