03-23-05 February 2007 Page 1 Updated Claim Forms Presentation Presentation by the EDS Provider...

03-23-05February 2007

Updated Claim Forms PresentationUpdated Claim Forms PresentationPresentation by the EDS Provider Field Consultants

03-23-05February 2007

Pharmacy Claim FormsPharmacy Claim FormsPresentation by the EDS Provider Field Consultants

Updated Claim Forms Presentation February 2007

Report Your NPIReport Your NPI

• Report your NPI to the IHCP via the online reporting tool available at www.indianamedicaid.com

• Claims submitted without the necessary NPI information will not be paid.

• Claims submitted with NPI information not registered with the IHCP will not be paid.

• Atypical providers do not need to obtain or report a NPI. An atypical provider is one that does not meet the definition of a health care provider as defined in 45 CFR 160.103 as follows:

– A provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business


Pharmacy Claim FormsPharmacy Claim Forms

• NPI reporting for the prescribing physician and billing pharmacy

• A taxonomy code is not required for prescription claims

Reminder: There are no changes to the required fields currently reported on paper claims

Summary of Compounded Prescription and Drug Claim Form Changes



• Field 3 – PRESCRIBER’S NPI – Enter the Prescriber’s 10-digit NPI.

• Field 25 – BILLING PROVIDER NPI – Enter the billing provider’s 10-digit NPI.

– For Fields 3 and 25, the NPI is required effective May 23, 2007.

Compounded Prescription Drug Claim Form



• Field 2 – PRESCRIBER’S NPI – Enter the Prescriber’s 10-digit NPI.

• Field 21 – BILLING PROVIDER NPI – Enter the billing provider’s 10-digit NPI.

– For Fields 2 and 21, the NPI is required effective May 23, 2007.

Drug Claim Form



• Access the NPI application online at: https://nppes.cms.hhs.gov/NPPES/Welcome.do

• May request a paper application by calling the NPI enumerator (Fox Systems) at 1-800-465-3203

• Submit the completed application to the NPI enumerator

– Mail paper applications to: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059

• Access additional NPI information from the IHCP Web site at www.indianamedicaid.com

Obtaining the National Provider Identifier


Pharmacy Claim FormsPharmacy Claim FormsReporting the National Provider Identifier



• The current Drug Claim Forms will continue to be accepted through May 22, 2007

– Revised paper claim forms received before May 23, 2007 will be returned to the provider unprocessed

• Only the revised Drug Claim Forms are accepted on and after May 23, 2007

– Non-compliant paper claims received on or after May 23, 2007 will be returned to the provider unprocessed

• Both claim forms will be available at www.indianamedicaid.com under the Forms link, effective May 16, 2007

NOTE: There is no transition period for the Drug Claim Forms

Compounded Prescription and Drug Claim Forms

03-23-05February 2007

Dental Claim FormDental Claim Form

Presentation by the EDS Provider Field Consultants



• Number of detail lines increased to ten lines

• NPI reporting for the billing and rendering dentist

• Taxonomy Code

– A 10-digit alphanumeric number

– A taxonomy code identifies the provider’s type, classification, and area of specialization

• Remarks field for entry of TPL paid amount

• New dental claim forms will be accepted on April 15, 2007 (date received).

• Dental bulletin forthcoming

Reminder: The format has changed; however, there are no changes to the required fields currently reported on paper claims

Summary of NPI Requirements



• There will be a transition period for use of the current and new claim forms

– Providers may use either form from April 15, 2007, through May 22, 2007.

• New claim forms received before April 15, 2007 will be returned to the provider unprocessed

• Noncompliant forms received on or after May 23, 2007 will be returned to the provider unprocessed

– During the transition period (April 15 through May 22, 2007) providers must use the legacy provider identifier (LPI) and may also use the NPI.

• Beginning May 23, 2007, all legacy provider numbers will be replaced with the NPI.

NOTE: The legacy provider identifier (LPI) is the same as your current IHCP provider number

Transition Period



• The American Dental Association (ADA) 2006 Dental Claim Form replaces the ADA Dental Claim Form. The following fields are required on the new claim form for processing

– Field 3 - INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION – Company Plan Name, Address, City, State, ZIP Code – Enter primary insurance information with name and address, ZIP Code + 4. Required, if applicable.

– Field 8 – POLICYHOLDER/SUBSCRIBER ID (SSN OR ID#) – Required, if applicable.

– Field 9 - PLAN/GROUP NUMBER – Required, if applicable.

Required Fields: Fields 3-9



– Field 10 – PATIENT’S RELATIONSHIP TO PERSON NAMED IN #5 – Required, if applicable.

– Field 11 – OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME, ADDRESS, CITY, STATE, ZIP CODE – Required, if applicable.

– Field 12 – POLICYHOLDER/SUBSCRIBER INFORMATION (FOR INSURANCE COMPANY NAMED IN #3) – Required, if applicable.

– Field 15 - POLICYHOLDER/SUBSCRIBER ID (SSN OR ID#) – Required, if applicable.

– Field 16 - PLAN/GROUP NUMBER – Required, if applicable.




– Field 17 – EMPLOYER NAME – Required, if applicable.

– Field 20 – NAME (LAST, FIRST, MIDDLE INITIAL, SUFFIX), ADDRESS, CITY, STATE, ZIPCODE – Enter the member’s last name, first name, and middle initial as found on the eligibility verification systems.

– Field 23 – PATIENT ID/ACCOUNT # - Enter the IHCP member identification number (RID).

– Field 24 – PROCEDURE DATE – Enter the date the service was rendered in MM/DD/CCYY format.

– Field 27 - TOOTH NUMBER(S) OR LETTER(S) – Enter the tooth number or letter for the service rendered. Required for any procedure performed on an individual tooth.




– Field 28 – TOOTH SURFACE – Enter the tooth surface for the service rendered. Required, if applicable.

– Field 29 – PROCEDURE CODE – Enter the appropriate ADA Current Dental Terminology (CDT) procedure code.

– Field 31 – FEE – Enter the amount charged for the procedure code. Eight digits are allowed, including two decimal places.

– Field 33 – TOTAL FEE – Enter the total of all the individual service line charges.

• Do not reduce the total fee by payment from the primary insurer.

– Field 35 – REMARKS – Enter the amount paid by the primary insurer. Required if applicable.




– Field 38 – PLACE OF TREATMENT – Indicate the type of facility where treatment was rendered by marking an X in the appropriate box.

– Field 45 – TREATMENT RESULTING FROM – Mark the appropriate box. Required if applicable.

– Field 46 – DATE OF ACCIDENT (MM/DD/CCYY) – Enter date. Required if applicable.

– Field 47 – AUTO ACCIDENT STATE – Enter state of accident. Required if applicable.

– Field 48 – NAME, ADDRESS, CITY, STATE, ZIP CODE – Enter the billing provider service location Name, Address, City, State, and ZIP Code + 4.




– Field 49 – NPI – Enter the billing or group provider NPI. Required on and after May 23, 2007.

– Field 50 – LICENSE NUMBER – Enter the billing Legacy Provider Identifier (LPI). Required through May 22, 2007.

– Field 52A – ADDITIONAL PROVIDER ID – Enter the taxonomy code for the billing provider NPI in field 49. Required on and after May 23, 2007.

– Field 53 – TREATING AND TREATMENT LOCATION INFORMATION – SIGNED (TREATING DENTIST) – An authorized person, someone designated by the provider, or the dentist must sign and date the claim. A signature stamp is acceptable; however, a typed signature is not acceptable. Required unless the signature on file form is on file.




• Field 54 – NPI – Enter the rendering provider NPI. Required on and after May 23, 2007

• Rendering NPI is required for all group providers

– BR200701 addresses the rendering provider requirement

– Billing providers - report your NPI in fields 49 and 54

– Claims will deny with the following edits

• 0231 – Rendering provider number missing

• 0232 – Rendering provider number invalid

• 1008 – Rendering provider must be an individual provider

Note: If two or more dentists perform services on the same patient on the same date of service, these services must be filed on separate claims.

Required Fields: Field 54



– Field 56A – PROVIDER SPECIALTY CODE – Enter the rendering provider taxonomy code for the NPI. Required on and after May 23, 2007.

– Field 58 – ADDITIONAL PROVIDER ID – Enter the LPI for the rendering provider. Required through May 22, 2007.

Required Fields: Fields 56A-58



• ADA Web site at http://www.ada.org/prof/resources/topis/claimform.asp

• Purchase the new dental claim form from the ADA by calling 1-800-947-4746

Where to Obtain the ADA 2006 Dental Claim Form

03-23-05February 2007

UB-04 Claim FormUB-04 Claim Form




• Legacy Provider Identifier (LPI) – Your current IHCP provider number

• National Provider Identifier (NPI) – New identifier issued through the NPPES developed by CMS. The NPI will replace all institutional IHCP provider numbers (LPIs) currently used for billing purposes

• Qualifier – Two-digit code that identifies the value indicated to the immediate right on the claim form

• Taxonomy – National code that identifies a provider type and specialty

Definitions



• Covered Days – Report covered days in the Value Code field (use value code 80)

• Page number = continuation billing• Creation Date = billed date• Can accept up to 66 lines of detail (3 pages)• Billing, Attending Physician, and Operating Physician NPI

and taxonomy codes• No signature field• Qualifiers

– B3 – taxonomy code– 0B – physician license number

• Reference BT200702 dated January 30, 2007

Reminder: The format has changed; however, there are no changes to the required fields currently reported on paper claims

Summary of Form Changes



• Access the NPI application online at: https://nppes.cms.hhs.gov/NPPES/Welcome.do

• May request a paper application by calling the NPI enumerator (Fox Systems) at 1-800-465-3203

• Submit the completed application to the NPI enumerator

– Mail paper applications to: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059

• Access additional NPI information from the IHCP Web site at www.indianamedicaid.com

Obtaining the NPI


UB-04 Claim FormUB-04 Claim FormReporting the NPI



• The UB-04 does not have a signature field

• All institutional providers must have a completed Claim Certification Statement for Signature on File Addendum on file

– Claims will deny with edit 0228 – Claim received without a valid signature - if the signature on file document is not completed and returned

• Letters were mailed to approximately 770 providers during late December 2006 to obtain a signature on file

– Return the completed Claim Certification Statement for Signature on File Addendum as soon as possible

Signature on File



• To initiate Signature on File:

– Click on the Forms link at www.indianamedicaid.com

– Download the Claim Certification Statement for Signature on File Addendum

– Mail the completed addendum with a Provider Update Form to:

EDS Provider Enrollment

P.O. Box 7263

Indianapolis, IN 46207-7263

• To verify an active Signature on File:

– Call Customer Assistance at (317) 655-3240 or 1-800-577-1278

– Call Provider Enrollment at 1-877-707-5750

Signature on File



• IHCP Transition Phase:– April 1, 2007 – May 22, 2007

– New form is required on and after May 23, 2007

– Paper claims submitted on a UB-04 claim form will be returned unprocessed if submitted before April 1, 2007

– The UB-92 will be returned to the provider unprocessed if received on or after May 23, 2007

• Medicare Transition Phase:– March 1, 2007 – May 22, 2007

NOTE: All dates are received dates.

Implementation Dates



• Field 1 – PLEASE REMIT PAYMENT TO – Enter the billing provider service location name, address and the expanded ZIP Code + 4 format. Required

• Field 4 – TYPE OF BILL – Enter the code indicating the specific type of bill.

• Field 6 – STATEMENT COVERS PERIOD, FROM/THROUGH – Enter the beginning and ending service dates included on this bill. For all services rendered on a single day, use both the FROM and THROUGH dates. Indicate dates in MMDDYY format, such as 122506.

• Field 8b – PATIENT NAME — Enter the last name, first name, and middle initial of the member.

Required Fields: Fields 1-8b



• Field 12 – ADMISSION DATE – Enter the date the patient was admitted to inpatient care in a MMDDYY format. Required for Inpatient and LTC.

• Field 13 – ADMISSION HOUR – Enter the hour during which the patient was admitted for inpatient care. Required

• Field 14 – ADMISSION TYPE – Enter the code indicating the priority of this admission. Required for Inpatient , Outpatient and LTC.

• Field 17 – STATUS – Enter the code indicating the member status as of the ending service date of the period covered on this bill. Required for Inpatient and LTC.




• Field 18-24 – CONDITION CODES – Enter the applicable code to identify conditions relating to this bill that may affect processing. A maximum of seven codes can be entered. Required, if applicable.

– Do not report information in Fields 25-28.

• Field 31a-34b – OCCURRENCE CODE and DATE – Enter the applicable code and associated date to identify significant events relating to this bill that may affect processing. Dates are entered in a MMDDYY format. A maximum of eight codes and associated dates can be entered. Required, if applicable.

• Field 35a-36b – OCCURRENCE SPAN CODE, FROM/THROUGH – Enter the code and associated dates for significant events relating to this bill. Each Occurrence Span Code must be accompanied by the span From and Through date. Required, if applicable.

Required Fields: Fields 18-36b



• Field 37 – UNLABELED FIELD – Enter the Medicaid Select primary medical provider (PMP) two-character alphanumeric certification code for dates of service rendered. Required for Hoosier Healthwise members enrolled in Medicaid Select.

• Field 39a – 41d – VALUE CODES –Use these fields to identify Medicare Remittance Notice (MRN) information. Value codes and the number of covered days is also entered in these fields.

– Enter value code ’80’ followed by the number of covered days to indicate covered days. Required, if applicable.

Required Fields: Fields 37-39a



• Field 42 – REV. CD. – Enter the applicable revenue code that identifies the specific accommodation, ancillary service, or billing calculation.

• Field 44 – HCPCS/RATES – Use the Healthcare Common Procedure Coding System (HCPCS) code applicable to the service provided. Only one service code per line is permitted. Required, if applicable.




• Field 45 – SERV. DATE – Provide the date the indicated outpatient service was rendered.

– Use field 45, line 23, Creation Date to identify when the bill is submitted.

• Field 46 – SERV. UNITS – Provide the number of units corresponding to the revenue code or procedure code submitted. Seven digits are allowed.

• Field 47 – TOTAL CHARGES – Enter the total charges pertaining to the related revenue code for the STATEMENT COVERS PERIOD.




• Field 50a-c – PAYER – Enter the insurance carrier name.

• Field 54a-c – PRIOR PAYMENTS – Enter the amount paid by the carrier entered in form fields 50a-b. Required, if applicable.

• Field 55c – EST. AMOUNT DUE – Enter the amount billed, minus any TPL payment.

• Field 56 – NPI – Enter the 10-digit NPI for the billing provider.

Required Fields: Fields 50a-56



• Field 57a – OTHER PROVIDER ID – Enter the Medicaid provider number (or LPI) for the billing provider. Required through May 22, 2007.

• Field 58a-c – INSURED’S NAME – Enter member’s last name, first name, and middle initial. IHCP member information is required. Enter TPL information. Required, if applicable.

• Field 60a-c – INSURED’S UNIQUE ID – Enter the member’s identification number for the respective payers entered in form fields 50a-c. The 12-digit member ID (RID) number is required in form field 60c. Other carrier information is required, if applicable.

Required Fields: Fields 57a-60c



• Field 61a-c – GROUP NAME – Enter the name of the group or plan through which insurance is provided to the member by the respective payers entered in form fields 50a–c. Required, if applicable.

• Field 62a-c – INSURANCE GROUP NO. – Enter the identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered, see form fields 50a-b. Enter the policy number as well. Required, if applicable.

• Field 65a-c – EMPLOYER NAME – Enter the name of the employer that provides health care coverage for the insured individual identified in form field 58. Required, if applicable.

Required Fields: Fields 61a-65c



• Field 67 – PRIN. DIAG. CD. – Provide the International Classification of Diseases, 9th Edition Clinical Modification (ICD-9-CM) code describing the principal diagnosis. Required, if applicable.

• Field 67a-q – OTHER DIAGNOSIS CODES – Provide the ICD-9-CM codes corresponding to additional conditions that coexist at the time of admission, or that develop subsequently, and that have an effect on the treatment received or the length of stay. Required, if applicable.

Required Fields: Fields 67-67q



• Field 69 – ADM. DIAG. CD – Enter the ICD-9-CM code provided at the time of admission as stated by the physician. Required for inpatient and LTC.

• Field 70 – PATIENT REASON DX - Enter the ICD-9 CM code that reflects the patient’s reason for visit at the time of outpatient registration. Optional for outpatient.

• Field 72a-c – ECI (E-CODE) – If used, use the appropriate E-code provided at the time of admission as stated by the physician. The E-code indicates the external cause of injury, poisoning, or adverse effect. Required, if applicable.

Required Fields: Fields 69-72c



• Field 74 – PRINCIPAL PROCEDURE CODE/DATE – Use the ICD-9 code that identifies the principal procedure performed during the period covered by this claim, and the date the principal procedure described on the claim was performed. Required for inpatient procedures.

• Field 74a-e – OTHER PROCEDURE CODE/DATE – Use the ICD-9 codes identifying all significant procedures other than the principal procedure, and the dates, identified by code, the procedures were performed. Required, when appropriate, for inpatient procedures.

Required Fields: Fields 74-74e



• Field 76 – ATTENDING PHYS. ID

– Before May 23, 2007:

• Report the ‘0B’ Qualifier and attending physician license number

– On May 23, 2007, and thereafter:

• Report the attending physician NPI

• Field 77 – OPERATING PHYS ID

– Before May 23, 2007:

• Report the ‘0B’ Qualifier and operating physician license number

– On May 23, 2007 and thereafter:

• Report the operating physician NPI




• Field 78 – OTHER – Enter other physician’s (referring/PMP physician) 10-digit numeric NPI of the referring/PMP. Required for Medicaid Select

• Field 81CCa-b – ADDITIONAL CODES – Enter provider taxonomy qualifier of ‘B3’ and corresponding 10-digit alphanumeric taxonomy code.

– Field 81CCa – First box ‘B3’ qualifier, 2nd box taxonomy code for billing provider from field 56.

– Field 81CCb – First box ‘B3’ qualifier, 2nd box taxonomy code for attending provider from field 76.

Required Fields: Fields 78-81CCa-b

03-23-05February 2007

CMS-1500 (08-05) Claim FormCMS-1500 (08-05) Claim Form



CMS-1500 (08/05) Claim FormCMS-1500 (08/05) Claim Form

• Providers will indicate the state where an accident occurred (for TPL purposes)

• NPI and taxonomy for the referring, rendering, and billing provider

• Shaded detail area for National Drug Code (NDC) information

• Field locator changes in blocks 24a-j• Elimination of block 24k• Qualifiers

– 1D – IHCP Provider Number (or, LPI)– ZZ – Taxonomy

• Reference BT200703 dated January 30, 2007

Reminder: There are no changes to the required information currently reported on paper claims

Summary of Form Changes



• Providers may submit both the current and new CMS-1500 forms to the IHCP beginning February 15, 2007.

– New claim forms received prior to February 15, 2007, are returned to the provider unprocessed

– The NPI should be reported on the claim form in addition to the legacy provider identifier

– The legacy provider identifier must be reported on all claims through May 22, 2007.

• Only the new claim form is accepted on and after April 1, 2007.

– The legacy provider identifier will not be accepted on or after May 23, 2007 (except for non-health care providers).

– Providers must report the NPI on claim forms on and after May 23, 2007.

Transition



• Field 1 – INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid.

• Field 1a – INSURED’S I.D. NUMBER– Enter the member identification (RID) number. Must be 12 numeric digits.

• Field 2 – PATIENT’S NAME (Last Name, First Name, Middle Initial) – Provide the member’s last name, first name, and middle initial obtained from automated voice response (AVR) system, electronic claim submission (ECS), Omni, or Web interChange verification.

Required Fields 1-2



• Field 9 – OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) – If other insurance is available, and the policyholder is other than the member shown in fields 1a and 2, enter the policyholder’s name. Required, if applicable.

• Field 9a – OTHER INSURED’S POLICY OR GROUP NUMBER – If other insurance is available, and the policyholder is other than the member noted in fields 1a and 2, enter the policyholder’s policy and group number. Required, if applicable.

Required Fields 9-9a



• Field 9c - EMPLOYER’S NAME OR SCHOOL NAME – If other insurance is available, and the policyholder is other than the member shown in field 1a and 2, enter the requested policyholder information. Required, if applicable.

• Field 9d - INSURANCE PLAN NAME OR PROGRAM NAME – If other insurance is available, and the policyholder is other than the member shown in field 1a and 2, enter the policyholder’s insurance plan name or program name information. Required, if applicable.

Required Fields 9c-9d



• Field 10 – IS PATIENT’S CONDITION RELATED TO – Enter X in the appropriate box in each of the three categories. This information is needed for follow-up third party recovery actions. Required, if applicable.

• Field 10a – EMPLOYMENT? (CURRENT OR PREVIOUS) – Enter X in the appropriate box. Required, if applicable.

• Field 10b – AUTO ACCIDENT? – Enter X in the appropriate box. Required, if applicable.

• Field 10c - OTHER ACCIDENT? – Enter X in the appropriate box. Required, if applicable.

Required Fields 10-10c



• Field 11 – INSURED’S POLICY GROUP OR FECA NUMBER – Enter the member’s policy and group number of the other insurance. Required, if applicable.

• Field 11a – INSURED’S DATE OF BIRTH – Enter the member’s birth date in MMDDYY format. Required, if applicable. SEX – Enter an X in the appropriate sex box. Required, if applicable.

• Field 11b – EMPLOYER’S NAME OR SCHOOL NAME – Enter the requested member information. Required, if applicable.

Required Fields 11-11b



• Field 11c – INSURANCE PLAN NAME OR PROGRAM NAME – Enter the member’s insurance plan name or program name. Required, if applicable.

• Field 11d – IS THERE ANOTHER HEALTH BENEFIT PLAN? Enter X in the appropriate box. If the response is Yes, complete Fields 9a–9d. Required, if applicable.

Required Fields 11c-11d



• Field 14 – DATE OF CURRENT ILLNESS (First symptom date) OR INJURY (Accident date) OR PREGNANCY (LMP date) – Enter the date of the last menstrual period for pregnancy related services in MMDDYY format. Required for payment of pregnancy related services.

• Field 16 – DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION – If Field 10a is “Yes”, enter the applicable FROM and TO dates in a MMDDYY format. Required, if applicable.

• Field 17 – NAME OF REFERRING PROVIDER OR OTHER SOURCE - Enter the name of the referring physician. Required for Medicaid Select PMP. For waiver services, enter the provider name of the case manager.

Required Fields 14-17



• Field 17a – ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER SOURCE

• Before April 1, 2007:

– Report the ‘1D’ qualifier and LPI in the shaded area.

– Provider LPI may be used until May 22, 2007.

• When reporting NPI information (no later than May 23, 2007):

– Report the ‘ZZ’ qualifier and taxonomy code in the shaded area.

NOTE: Atypical providers are not required to report the NPI; therefore, report the referring provider LPI.

Required Field 17a



• Field 17b – NPI – Enter the 10-digit numeric NPI of the referring provider, ordering provider or other source. Required for healthcare providers on and after May 23, 2007.

• Field 18 – HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – Enter the requested FROM and TO dates in MMDDYY format. Required, if applicable.

Required Fields 17b-18



• Field 19 – RESERVED FOR LOCAL USE – Enter the Medicaid Select PMP two-digit alphanumeric certification code. Required for Medicaid Select members when the physician rendering care is not the PMP or a member of the PMP’s group.

• Field 21.1–21.4 – DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – Complete Fields 21.1., 21.2., 21.3., and/or 21.4 to Field 24E by detail line. Enter the ICD-9-CM diagnosis codes in priority order. A total of four codes can be entered. At least one diagnosis code is required for all claims except those for waiver, transportation, and medical equipment and supply services.

Required Fields 19-21.4



• Field 22 - MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B crossover claims only. For crossover claims the combined total of the Medicare co-insurance, deductible, and psych reduction must be reported on the left side of field 22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must be submitted in field 22 on the right side under the heading Original Ref No.

Required Field 22



• Field 24A to 24H – NATIONAL DRUG CODE INFORMATION - The shaded portion of fields 24A to 24I will be used to report NDC information. To report this information, begin at 24A as follows:

– Enter the NDC qualifier of N4

– Enter the NDC 11-digit numeric code

– Enter the drug description

– Enter the NDC unit qualifier

• F2 International Unit

• GR Gram

• ML Milliliter

• UN Unit

– Enter the NDC Administered Amount in the format 9999.99

NOTE: NDC information not required until July 1, 2007.

Required Fields 24a-h (shaded)



• Field 24A (unshaded area) – DATE OF SERVICE – Provide the FROM and TO dates in MMDDYY format. Up to six FROM and TO dates are allowed per form. FROM and TO dates must be the same per detail line.

• Field 24B (unshaded area) – PLACE OF SERVICE – Use the POS code for the facility where services were rendered.

• Field 24C (unshaded area) – EMG – Emergency indicator. This field indicates services were for emergency care. Enter Y or N. Required, if applicable.

Required Fields 24a-24c (unshaded)



• Field 24D (unshaded area) – PROCEDURES, SERVICES, OR SUPPLIES

– CPT/HCPCS – Use the appropriate procedure code for the service rendered. Only one procedure code is provided on each detail line.

– MODIFIER – Use the appropriate modifier, if applicable. Up to four modifiers are allowed for each procedure code. Required, if applicable.

Required Field 24d (unshaded)



• Field 24E (unshaded area) – DIAGNOSIS CODE POINTER – Enter number 1–4 corresponding to the applicable diagnosis codes in Field 21. A minimum of one and a maximum of four diagnosis code references can be entered on each line.

• Field 24F (unshaded area) – $ CHARGES – Enter the total amount charged for the procedure performed, based on the number of units indicated in field 24G.

• Field 24G (unshaded area) – DAYS OR UNITS – Provide the number of units being claimed for the procedure code. Six digits are allowed.

• Field 24H (unshaded area) – EPSDT Family Plan – If the patient is pregnant, indicate with a ‘P’ in this field on each applicable line. Required, if applicable.

Required Fields 24e-24h (unshaded)



• Field 24I (shaded area) – RENDERING ID QUALIFIER– Before May 23, 2007:

• Report the ‘1D’ qualifier for the rendering provider LPI.


• Report the ‘ZZ’ qualifier for rendering provider taxonomy code.

• Field 24J (shaded area) – RENDERING PROVIDER ID– Before May 23, 2007:

• Report the rendering provider LPI.


• Report the rendering provider taxonomy code.

• Field 24J (unshaded area) – RENDERING PROVIDER NPI - Enter the NPI of the rendering provider in the bottom half of field 24J. Required if applicable.

Required Fields 24i-24j



• Field 28 – TOTAL CHARGE – Enter the total of all service line charges in column 24F. This is a ten-digit field.

• Field 29 – AMOUNT PAID – Enter the payment received from any other payor source, including Medicare HMO plans.

– Other insurance – Enter the amount paid by the other insurer. If the other insurer paid zero, enter 0 in this field. Required, if applicable.

• Field 30 – BALANCE DUE - Field 28, TOTAL CHARGE minus field 29 AMOUNT PAID must equal field 30, BALANCE DUE. This is an eight-digit field.



CMS-1500 (08/05) Claim FormsCMS-1500 (08/05) Claim Forms

• Field 31 – SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS – An authorized person, someone designated by the agency or organization, must sign and date the claim. A signature stamp is acceptable; however, a typed name is not. Required, if applicable.

DATE – Enter the date the claim was filed




• Field 33 – BILLING PROVIDER INFO & PH # - Enter the billing provider service location name, address and the expanded ZIP Code + 4 format.

– Field 33a – Enter the billing provider NPI. Required, if applicable.

– Field 33b – Enter a billing provider qualifier of ‘ZZ’ and taxonomy code for a NPI.

• Providers with a NPI must report the ‘1D’ qualifier and LPI through May 22, 2007.

• Atypical providers must always enter the qualifier ‘1D’ and the LPI.




• IHCP Web site at http://www.indianamedicaid.com

• NPI information at https://nppes.cms.hhs.gov/NPPES or by telephone 1-800-465-3203

• Taxonomy information at http://www.wpc-edi.com/taxonomy/more_information

• Atypical provider information at http://www.wedi.org/npioi

• Customer Assistance(317) 655-32401-800-577-1278

• Written CorrespondenceP.O. Box 7263Indianapolis, IN 46207-7263

• Provider Field Consultants

Resources


QuestionsQuestions

03-23-05February 2007

EDS950 N. Meridian St., Suite 1150Indianapolis, IN 46204

Presentation by EDS Provider Field Consultants

EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2005 Electronic Data Systems Corporation. All rights reserved.

03-23-05 February 2007 Page 1 Updated Claim Forms Presentation Presentation by the EDS Provider...

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