MassHealth Billing Guide for the CMS-1500 Executive Office of Health and Human Services MassHealth July 2012 BG-CMS-1500 (Rev. 07/12) Billing Guide for the CMS-1500 Table of Contents Introduction ................................................................................ .........................................................1 General Instructions for Submitting Paper Claims ..............................................................................1 CMS-1500 Claim Form............................................................................ ......................................1 Entering Information on the CMS-1500 Claim Form....................................................................2 Time Limitations on the Submission of Claims.......................................................................... ...2 Claims for Members with Medicare or Other Health-Insurance Coverage ...................................2 Provider Preventable Conditions...................................................................... ..............................2 340B Drugs ................................................................................ ...................................................2 Electronic Claims ................................................................................ ...........................................3 Where to Send Paper Claim Forms ................................................................................ ................3 Further Assistance ................................................................................ ..........................................3 How to Complete the CMS-1500 Claim Form ................................................................................ ....4 Appendix A: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Medicare Coverage ................................................................................ ....................................21 Appendix B: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Commercial Insurance ................................................................................ ...............................23 July 2012 Page i Billing Guide for the CMS-1500 Introduction This guide provides detailed instructions for completing the CMS-1500 claim form for MassHealth billing. Additional instructions on other billing matters, including member eligibility, prior authorization, claim status and payment, claim correction, and billing for members with other health insurance, are located in Subchapter 5 of your MassHealth provider manual, or refer to Appendix A of your MassHealth provider manual. Appendix A is available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Provider Manual Appendices. For information about the resulting remittance advice, see the MassHealth Guide to the Remittance Advice for Paper Claims and Electronic Equivalents. Please Note: Effective January 1, 2012, MassHealth is moving toward an all- electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the Provider Online Service Center (POSC) or on paper. Please see All Provider Bulletin 217, dated September 2011 for more information about MassHealth’s paper claims waiver policy. For information on how to submit 90-day waiver requests and final deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 221, dated December 2011. General Instructions for Submitting Paper Claims CMS-1500 Claim Form The following providers must use the CMS-1500 when submitting paper claims to MassHealth. . abortion clinics professional services provided by . acute inpatient hospitals (for hospital-based physicians only) professional services provided by . independent clinical laboratories hospital-based physicians only) . independent diagnostic testing facilities . acute, chronic, and psychiatric . independent living centers outpatient hospitals (for professional . independent nurses services provided by hospital-based . independent nurse midwives physicians only) . independent nurse practitioners . adult day health providers . Indian health centers . adult foster care providers . mental health centers . audiologists . municipally based health service . chiropractors providers . community health centers (professional . ocularists services only) . opticians . day habilitation providers . optometrists . durable medical equipment providers . optometry schools . early intervention providers . orthotics providers . family planning agencies . oxygen and respiratory therapy . freestanding ambulatory surgery centers equipment providers . group adult foster care providers . personal care agencies . hearing instrument specialists . personal care attendant (PCA) fiscal . home-care corporations (elderly waiver) intermediaries . hospital-licensed health centers (for . physicians July 2012 Page 1 Billing Guide for the CMS-1500 . podiatrists . renal dialysis centers . prosthetics providers . speech and hearing centers . psychiatric day treatment providers . sterilization clinics . psychologists . substance abuse treatment programs . qualified-Medicare-beneficiaries-only . targeted case management programs providers (QMB-only) submitting . therapists crossover claims . transportation providers . rehabilitation centers Entering Information on the CMS-1500 Claim Form . Complete a separate claim form for each member to whom services were provided. . Type or print all applicable information (as stated in the instructions) on the claim form, using black ink only. Be sure all entries are complete, accurate, and legible. . For each claim line, enter all required information as applicable, repeating if necessary. Do not use ditto marks or words such as “same as above.” . Attach any necessary reports or required forms to the claim form. . When a required entry is a date, enter the date in MMDDYY or MMDDYYYY format. Example: For a member born on February 28, 1960, the entry would be as follows: 02281960. Time Limitations on the Submission of Claims Claims must be received by MassHealth within 90 days from the date of service or the date of the explanation of benefits from another insurer. For additional information about the deadlines for submitting claims, please see MassHealth billing regulations (beginning at 130 CMR 450.309). Claims for Members with Medicare or Other Health-Insurance Coverage Special instructions for submitting claims for services furnished to members with Medicare or health-insurance coverage are contained in Subchapter 5 of your MassHealth provider manual. Provider Preventable Conditions See Appendix V of your provider manual for more information on how to bill for Provider Preventable Conditions (PPCs). 340B Drugs The enactment of the Veterans Health Care Act of 1992 resulted in the 340B Drug Pricing Program, which is Section 340B of the Public Health Service Act. Through this program, providers who qualify as 340B-covered entities are able to acquire drugs at significantly discounted rates. Because of the discounted acquisition cost, these drugs are not eligible for the Medicaid Drug Rebate Program. Accordingly, state Medicaid programs must be able to distinguish between claims for 340B drugs and claims that are not for 340B drugs. In order for providers to identify when they are submitting claims for physician-administered 340B drugs in an office or clinic setting, the National Medicaid Electronic Data Interchange HIPAA workgroup has recommended the use of the UD modifier. This will allow Medicaid programs to identify claims for 340B drugs and exclude them from the Medicaid drug rebate collection process. July 2012 Page 2 Billing Guide for the CMS-1500 MassHealth is implementing the recommended approach. Providers subject to this billing guide who participate in the 340B program must bill using the UD modifier on the CMS-1500, along with the applicable HCPCS code, when submitting claims for physician administered 340B drugs in an office or clinic setting. Please note that NDC codes are also required on these claims. See Field 24 for instructions. Electronic Claims To submit electronic claims, refer to Subchapter 5, Part 3, of your MassHealth provider manual or contact MassHealth Customer Service. Refer to Appendix A of your MassHealth provider manual for contact information. Please Note: When submitting electronic files to MassHealth, be sure to review this CMS-1500 billing guide, the appropriate companion guides, and our billing tips flyers to determine the appropriate requirements for submitting electronic files to MassHealth. These documents can be found on the MassHealth website at mass.gov/masshealth. Where to Send Paper Claim Forms Appendix A of your MassHealth provider manual describes where to submit paper claims. Keep a copy of the submitted claim for your records. Please note that MassHealth does not accept mail with postage due. Further Assistance If, after reviewing the following instructions for completing the CMS-1500 claim form, you need additional assistance, you can contact MassHealth Customer Service. Please refer to Appendix A of your MassHealth provider manual for all MassHealth Customer Service contact information. July 2012 Page 3 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form A sample CMS-1500 claim form is shown below. Following this sample are instructions for completing each field on the CMS-1500 claim form. Refer to the National Uniform Claim Committee (NUCC) instruction manual available at www.nucc.org. Many types of providers use the CMS-1500 claim form to bill MassHealth for services. In some cases, special instructions have been provided for specific services or situations. Complete each field as instructed generally and follow specific instructions for your provider type or situation, as applicable. July 2012 Page 4 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) July 2012 Page 5 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name 1 (Unnamed) 1a Insured’s I.D. Number 2 Patient's name 3a Patient’s Birth Date (DOB) Sex 4 Insured’s Name 5 Patient's Address 6 Patient Relationship to Insured 7 Insured’s Address 8 Patient Status 9 Other Insured’s Name 9a Other Insured’s Policy or Group Number 9b Other Insured’s Date of Birth Sex 9c Employer’s Name or School Name 9d Insurance Plan Name or Program Name Description 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. Enter the complete 12-character member identification (ID) number that is printed on the MassHealth card. If the Medicare box is checked in Field 1 (and if this is a crossover claim), enter the member’s HIC (health insurance claim) number. Enter the name of the MassHealth member receiving services in the following order: last name, first name, middle initial. Enter the patient’s eight-digit birth date in MMDDYYYY format. Enter an X in the correct box to indicate the gender of the patient. Only one box can be marked. If the gender is unknown, leave this field blank. If the member has other insurance, enter the insured’s name in the following order: last name, first name, middle initial. Not required Enter an X in the correct box to indicate the patient’s relationship to the insured. Only one box can be marked. Not required Not required If Field 11d has an entry, complete Fields 9 and 9a through 9d, as applicable. When additional group health coverage exists, enter the name of the other insured in the following order: last name, first name, middle initial. Enter the policy or group number of the other insured, if applicable. Enter the eight-digit date of birth of the other insured in MM/DD/YYYY format. Enter an X in the applicable box to indicate the gender of the other insured. Only one box can be marked. If the gender is unknown, leave this field blank. Enter the name of the other insured’s employer or school. Enter the seven-digit MassHealth third-party-liability carrier code. Refer to Appendix C of your MassHealth provider manual for carrier code values. July 2012 Page 6 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name 10a Is Patient’s Condition Related to: Member’s Employment 10b Auto Accident Place (State) 10c Other Accident 10d Reserved for Local Use 11 Insured’s Policy Group or FECA Number 11a Insured’s Date of Birth, Sex 11b Employer’s Name or School Name 11c Insurance Plan 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 14 Date of Current: Illness, Injury, Pregnancy Description Enter an X in the appropriate box to indicate whether the condition is employment-related. Enter an X in the appropriate box to indicate the type of accident. If Yes is marked, also enter the state postal code where the accident occurred. Enter an X in the appropriate box to indicate if the condition is the result of any other type of accident. If submitting a Medicare crossover claim, enter the complete 12-character member identification (ID) number that is printed on the MassHealth card. If applicable, enter the insured’s policy or group number as it appears on the insured’s health-care identification card. If Field 4 is completed, this field must also be completed. Enter the insured’s eight-digit birth date in MMDDYYYY format. Enter an X in the correct box to indicate the gender of the patient. Only one box can be marked. If the gender is unknown, leave this field blank. Not required Enter the seven-digit MassHealth third-party-liability carrier code. Refer to Appendix C of your MassHealth provider manual for carrier code values. Enter an X in the appropriate box to indicate whether or not there is another health benefit plan. If Yes, complete Fields 9 and 9a through 9d. Make an entry in only one box. Not required Not required Enter the start date of the present illness, injury, or condition in MMDDYYYY or MMDDYY format. For pregnancy, use the date of the last menstrual period (LMP). July 2012 Page 7 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 15 If Patient Has Not required Had Same or Similar Illness 16 Dates Patient Not required Unable to Work in Current Occupation 17 Name of Enter the name and credentials of the professional who referred, ordered, or Referring supervised the service(s) or supply(ies) on the claim in the following order: first Provider or name, middle initial, last name. Other Source 17a Other ID# If the referring provider has an NPI, enter the provider’s taxonomy code with a qualifier of PXC, if applicable. If the referring provider is atypical and does not have an NPI, enter the 10character MassHealth provider ID with a qualifier of G2. 17b NPI Enter the NPI number of the referring provider. If the referring provider does not have an NPI, this field is not required. 18 Hospitalization If the member has been hospitalized, enter the inpatient hospital admission start Dates Related to date and discharge date (if the patient has been discharged) in MM/DD/YYYY Current format. Services If the patient has not been discharged, leave the discharge date blank. Psychiatric Day Treatment Providers: Enter the date of the member’s discharge from the program. 19 Reserve for Not required unless otherwise noted. Local Use Durable Medical Equipment (Repairs): If the repair does not require prior authorization, enter the following information: . the name of the person who requested the repair; . the date of the request and a specific description of the equipment malfunction; . a list of procedures and parts used to complete the repair; . the cost of each procedure and part; and . the time required to complete the repair. If there is not enough space in this field, submit an attachment with the claim containing the above-mentioned information. 20 Outside Lab? Not required $ Charges July 2012 Page 8 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name 21 Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line) 22 Medicaid Resubmission Code, Original Ref. No. 23 Prior Authorization Number Description Enter the ICD-9-CM diagnosis code. If there is a fourth or fifth digit, it is a required part of the code. Enter up to four ICD-9-CM codes. Relate lines 1, 2, 3, and 4 to the lines of service in Field 24E by line number. Use the highest level of specificity. Do not provide a narrative description in this field. When entering the number, include a space (accommodated by the period) between the two sets of numbers. If entering a code with more than three beginning digits (for example, E codes), enter the fourth digit over the period. For Adjustments: When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) assigned to the paid claim. This ICN appears on the remittance advice on which the original claim was paid. Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction. For Resubmittals: When resubmitting a denied claim, enter an “R” followed by the 13-character ICN assigned to the denied claim. This ICN appears on the remittance advice on which the original claim was denied. Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction. Enter the prior-authorization number or referral number assigned by MassHealth, if applicable. July 2012 Page 9 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description (Unnamed Enter the following information in the shaded area of Lines 1-6 from the Shaded Area) beginning of 24A to the end of 24G for up to 61 characters. For Drugs or Injectable Devices Administered in the Office or in a Clinic setting: If billing for physician-administered drugs (including 340B drugs) or injectable devices administered in an office or clinic setting, except vaccines, enter the following information. . Qualifier N4; . the 11-digit national drug code (NDC); . the NDC unit of measure; and . the quantity of the drug administered. This information is in addition to the Healthcare Common Procedure Coding System (HCPCS) code entered in the unshaded section on the same line. Use the following qualifiers when reporting NDC unit descriptors. . F2: international unit (for example, anti-hemophilia factor); . GR: gram (for creams, ointments, and bulk powders); . ME: milligram (for creams, ointments, and bulk powders); . ML: milliliter (for liquids, suspensions, solutions, and lotions); and . UN: unit (for tablets, capsules, suppositories, and powder-filled vials). Compound Drugs When billing for compound drugs, use the following qualifiers. . VY: used to identify that a compound drug is being dispensed; and . the compound drug association number (a three-digit compound drug association number indicates that the ingredients are part of the same compound drug). This number can only be three digits in length, and the submitter must make sure that all ingredients of the compound prescription have the same compound drug association number. List each drug ingredient that is part of the compound on a separate line with the VY qualifier and a compound drug association number segment. Make sure that all the individual ingredients that make up the compound have the same compound drug association number. July 2012 Page 10 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description (Unnamed Shaded Area) cont. Examples If billing for a drug administered in a doctor’s office other than a compound drug, enter the following in the shaded area. . Qualifier N4; . the 11-digit national drug code (NDC); . the NDC unit of measure (use one of the following qualifiers when reporting NDC units (F2, GR, ME, ML or UN)); and . the quantity of the drug administered, which includes fractions. If billing for a compound drug administered in a doctor’s office, enter the following in the shaded area. . Qualifier N4; . the 11-digit national drug code (NDC); . the NDC unit of measure (use one of the following unit descriptors when reporting NDC units (F2, GR, ME, ML or UN)); . the quantity of the drug administered, which includes fractions; . reference identification qualifier – Value is VY; and . compound drug association number (a three-digit compound drug association number indicating that the ingredients are part of the same compound drug). This number can only be three digits in length, and the submitter must make sure that all ingredients of the compound prescription have the same compound drug association number. Please Note: The shaded area should be completed for each ingredient that makes up the compound prescription. Please use a separate line for each ingredient. July 2012 Page 11 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 24. (Unnamed For Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, Shaded Area) Prosthetics and Orthotics: cont. When billing HCPCS service codes that do not require prior authorization, and are payable on an individual consideration (I.C.) basis, enter the acquisition cost in addition to the quantity dispensed in the shaded area. Also attach a copy of the supplier’s current invoice. Invoices submitted with a claim must be dated no more than 12 months before the date of service. Providers must submit the current invoice, and identify on the invoice the item(s) being billed on the claim by circling the item on the invoice, and the associated HCPCS service code being billed. Providers should refer to the MassHealth regulations, Subchapter 6 (Service Codes and Descriptions) of their MassHealth provider manual, and the MassHealth Payment and Coverage Guidelines Tool(s) for more information on payment and coverage criteria for service codes that are payable on an individual consideration (I.C.) basis. July 2012 Page 12 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name 24A Date(s) of Service Description Enter the date the service was provided in MMDDYYYY format. For a Single Date of Service: In the “From” column, enter the date the service was provided in MMDDYYYY format. Leave the “To” column blank. For Consecutive Dates of Service: In the “From” column, enter the first date of service. In the “To” column, enter the last date of service. Billing for consecutive dates of service on a single claim line is allowed for only certain services. For example, a physician may bill for hospital visits on successive days by entering the dates of service in the “From” and “To” boxes, but a physician may not bill for office visits on successive days on a single claim line. Early Intervention Providers: For Assessments: Enter the date the assessment was completed in the "From” column. In Field 24G, enter the total number of units spent on the assessment, regardless of the date. For All Other Early Intervention Services: Follow the instructions given in the general description. Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, and Pharmacy providers that have a DME and/or Oxygen specialty: For Monthly Rentals: Enter the last date of the monthly rental period in “From.” Leave “To” blank. Use a separate claim line for each monthly rental period. For Substitute Rentals: Enter the date of service in “From.” Leave “To” blank. Use a separate claim line for each rental day. For Purchases and Repairs: Enter the date when the service was furnished in “From.” Leave “To” blank. July 2012 Page 13 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 24B Place of Service 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: http://www.cms.gov/Medicare/Coding/place-of-service- codes/Place_of_Service_Code_Set.html. Acute Hospitals billing for Professional Services where the service is provided by hospital-based physicians only: To help define the type of facility billing for medical services on a professional claim please use the following place-of-service codes. 21 – Inpatient hospital 22 – Outpatient hospital 23 – Emergency room 99 – Hospital-licensed health center Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, Orthotics and Prosthetic Providers: Providers should refer to the MassHealth Payment and Coverage Guideline Tool(s) for the place-of-service codes attached to the HCPCS. 12 – Home 31 – Skilled nursing facility 32 – Nursing facility 33 – Custodial care July 2012 Page 14 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name 24C EMG 24D Procedures, Services, or Supplies 24E Diagnosis Pointer Description Indicate if the service is the result of an emergency. Enter Y or leave it blank. Enter the CPT or HCPCS code(s) and modifier(s). This field accommodates up to four two-digit modifiers. See Subchapter 6 of the applicable MassHealth provider manual for lists of payable or nonpayable service codes and modifiers and their descriptions. Municipally Based Health Service Providers: Municipally based health service providers should refer to relevant municipally based health service provider bulletins to determine the correct service code. Transportation Providers: Use modifier “TS” when billing for more than two one-way trips for the same member on the same date of service. 340B-Covered Entities: 340B-Covered Entities (e.g., Community Health Centers, Family Planning Clinics, Group Practices, and other providers participating in the 340B program). Use modifier “UD” next to appropriate HCPCS code when billing for a 340B drug. If applicable, enter the diagnosis code reference number (pointer) as shown in Field 21 to relate the date of service and the procedures performed to the primary diagnosis. (ICD-9-CM diagnosis codes must be entered in Field 21 only. Do not enter them in Field 24E.) When multiple services are performed, enter the primary reference number for each service first, followed by other applicable services. The reference number should be a 1, 2, 3, 4, or multiple numbers as explained in the previous sentence. Enter numbers left-justified in the field. Do not use commas between the numbers. July 2012 Page 15 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 24F $ Charges Enter the provider’s usual and customary fee (amount charged to a person who is not a MassHealth member). Enter the amount right-justified in the dollar area of the field. Do not use commas or dollar signs when reporting dollar amounts. Do not enter negative dollar amounts. Enter “00” in the cents area if the amount is a whole number. For Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, Prosthetics, and Orthotics: When billing for these DME, oxygen/respiratory therapy equipment, orthotics, or prosthetics products that do not require prior authorization, and are listed in Subchapter 6 (Service Codes and Descriptions) of your MassHealth provider manual, and the MassHealth Payment and Coverage Guideline Tool(s) as not requiring individual consideration (IC), enter the provider’s usual and customary charge on the claim. For Medications and Injectables: Enter the actual acquisition cost and attach a copy of the supplier’s invoice to the claim. Invoices submitted with a claim must be dated no more than 12 months before the date of service. Personal Care Agencies: For Functional Skills Training: Enter the standard charge per member per month, regardless of the number of skills training sessions provided to the member in the month. For Initial Evaluations and Reevaluations: Enter the provider’s usual and customary fee. July 2012 Page 16 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 24G Days or Units Enter the appropriate number of units billed on the claim line for the service date. For Consecutive Days of Service: Enter the total number of days or units within the billing period. For Nonconsecutive Dates of Service: Enter “1” for each date of service or unit entered on the claim form. For Anesthesia: Enter the total number of minutes that make up the beginning and ending clock time for the anesthesia service. One minute equals one unit. See 130 CMR 433.000 for regulations about reporting anesthesia time. If no units are entered, the service is paid at the base rate. 24H EPSDT/Family Early and Periodic Screening, Diagnosis, and Treatment: Plan Enter the response in the shaded portion of the field as follows. If there is no requirement (for example, state requirement) to report a reason code for EPSDT, enter “Y” for yes, or “N” for no. If there is a requirement to report a reason code for EPDST, enter the appropriate reason code as noted below. . AV: Available–Not Used (Patient refused referral.) . S2: Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.) . ST: New Service Requested (referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals) . NU: Not Used (when no EPSDT patient referral was given) Family Planning: If the service is for family planning, enter “Y” for yes, or “N” for no in the bottom unshaded area of the field. July 2012 Page 17 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 24I ID Qual. In the shaded area of Field 24I, enter the appropriate qualifier if the number is a non-national provider identifier (NPI). If the provider is an atypical provider and does not have an NPI, enter “G2.” If the provider has an NPI and is providing taxonomy information, enter “PXC.” 24J Rendering Provider ID # Please Note: This field is required for group practices only. All other providers must leave this field blank. If the shaded area of Field 24I is “G2,” enter your MassHealth provider ID in the shaded area of Field 24J. If the shaded area of Field 24I is “PXC,” enter the provider taxonomy code if applicable in the shaded area of Field 24J. Enter the provider’s NPI in the unshaded area of Field 24J. 25 Federal Tax ID Number Enter the service or supplier federal tax ID (employer identification number) or social security number for the provider. 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. Enter the patient’s account number, if one is assigned. Enter the member’s last name if a patient account number is not assigned. 27 Accept Assignment? Yes or No For Non-Crossover Claims: Leave this field blank. For Medicare Crossover Claims: Enter an X in the appropriate box to indicate whether the provider accepts assignment. 28 Total Charge Enter the total charges for the services (that is, the total of all charges in Field 24F). Enter the amount in the dollar area of the field. Do not use commas or dollar signs when reporting dollar amounts. Do not enter negative dollar amounts. Enter “00” in the cents area if the amount is a whole number. This is a required field. July 2012 Page 18 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 29 Amount Paid Enter the total amount the patient or other payers paid on the covered services only. Do not use commas or dollar signs when reporting dollar amounts. Do not enter negative dollar amounts. Enter “00” in the cents area if the amount is a whole number. 30 Balance Due Enter the total amount due. Do not use commas or dollar signs when reporting dollar amounts. Do not enter negative dollar amounts. Enter “00” in the cents area if the amount is a whole number. 31 Signature of Physician or Supplier Including Degrees or Credentials, Date Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative, “Signature on File,” or “SOF.” Enter either a six-digit date (MM/DD/YY), eight-digit date (MM/DD/YYYY), or alphanumeric date (for example, January 10, 2008) that the form was signed. 32 Service Facility Location Information Enter the name, address, city, state, and zip code of the location where the services were provided. Providers of the service (physicians) must identify the supplier’s name, address, zip code, and NPI when billing for purchased diagnostic tests. When more than one supplier is used, use a separate CMS-1500 claim form for each supplier. Enter the name and address information in the following format: . 1st line: name . 2nd line: address (The billing provider address must be a street address. Do not use P.O. or lock boxes.) . 3rd line: city, state, and zip code Do not use commas, periods, or other punctuation in the address (for example, enter 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. When entering a nine-digit zip code, include a hyphen. Do not use P.O. or lock boxes. 32a NPI Enter the NPI of the service facility location in Field 32. July 2012 Page 19 Billing Guide for the CMS-1500 How to Complete the CMS-1500 Claim Form (cont.) Field No. Field Name Description 32b Other ID No. Enter the appropriate two or three-character qualifier. If the provider is an atypical provider and does not have an NPI, enter “G2” followed by the provider’s 10-character MassHealth provider ID. If the provider has an NPI and is providing taxonomy information, enter “PXC” followed by the taxonomy code. 33 Billing Provider Info & Phone # Enter the provider’s or supplier’s billing name, doing business as (DBA) address, zip code, and phone number. Enter the phone number in the area to the right of the field title. Enter the name and address information in the following format: . 1st line – name . 2nd line – address (The billing provider address must be a street address. Do not use P.O. or lock boxes.) . 3rd line – city, state, and zip code Field 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Do not use commas, periods, or other punctuation in the address (for example, enter 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Do not use P.O. or lock boxes. When entering a nine-digit zip code, include a hyphen. Do not use a hyphen or space as a separator within the telephone number. 33a NPI Enter the NPI of the billing provider. 33b Other ID No. Enter the appropriate two or three-character qualifier. If the provider is an atypical provider and does not have an NPI, enter “G2” followed by the provider’s 10-character MassHealth provider ID. If the provider has an NPI and is providing taxonomy information, enter “PXC” followed by the taxonomy code. July 2012 Page 20 Billing Guide for the CMS-1500 Appendix A: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Medicare Coverage Please Note: Effective January 1, 2012, MassHealth is moving toward an all- electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the POSC or on paper. Please see All Provider Bulletin 217, dated September 2011, for more information about MassHealth’s paper claims waiver policy. For information on how to submit 90-day waiver requests and final deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 221, dated December 2011. Important: The table below lists specific fields on the CMS-1500 that must be completed for claims when the member has Medicare in addition to MassHealth. Field # Field Name TPL Required Information 1 1a 4 6 9 9a 9b 9d 10d 11 11a Unnamed Insured’s I.D. Number Insured’s Name Patient Relationship to Insured Other Insured’s Name Other Insured’s Policy or Group Number Other Insured’s Date of Birth, Sex Insurance Plan Name or Program Name Reserved for Local Use Insured’s Policy Group or FECA Number Insured’s Date of Birth, Sex Check box marked “Medicare.” Enter the member’s Medicare ID number Enter insured’s name (subscriber and insured’s name may be different from the MassHealth member’s name) Check the correct box to indicate the patient’s relationship to the insured. Only one box can be marked. If 11d is checked “yes,” enter the name of the insured if different from patient name. If 11d is checked “yes,” enter the group or policy number for the commercial insurance plan. If 11d is checked “yes,” enter the date of birth and gender of the insured noted in Field 9. When 11d is checked “yes,” enter the appropriate MassHealth carrier code. The Third-Party Liability MassHealth Carrier Code list can be found in Appendix C of your MassHealth provider manual. Enter the complete12-character member ID number that is printed on the MassHealth card. Enter the policy or group number of the primary commercial insurance resource as it appears on the member’s insurance card. Enter insured’s date of birth. July 2012 Page 21 Billing Guide for the CMS-1500 Appendix A: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Medicare Coverage (cont.) Field # Field Name TPL Required Information 11c 11d 27 29 Insurance Plan or Program Name Is There Another Health Benefit Plan? Accept Assignment? Yes or No Amount Paid Enter the appropriate MassHealth carrier code. The Third-Party Liability MassHealth Carrier Code list can be found in Appendix C of your MassHealth provider manual. Check the box indicating whether the patient has insurance in addition to MassHealth and Medicare. If this box is checked “yes,” complete Fields 9, and 9a through 9d with information applicable to the other commercial health plan. Check the appropriate box to indicate whether the provider accepts assignment. Enter the total amount paid by all insurers other than MassHealth. Instructions for submitting claims with Explanation of Medicare Benefits (EOMB) 1. Complete the CMS-1500 claim form according to this MassHealth Billing Guide for the CMS-1500. 2. Attach the original or a copy of the other insurance carrier’s EOMB, to the claim form. a. The dates of service, provider name, and patient's name on the EOMB must correspond to the information on the MassHealth claim. b. If more than one member is listed on the EOMB, circle the member information on the EOMB that corresponds to the member on the MassHealth claim. c. If you are submitting claims with one or more EOMB attachments, you must write the appropriate MassHealth assigned carrier code on each EOMB. Please Note: MassHealth-assigned carrier codes may be found in Appendix C: Third-Party-Liability Codes of your MassHealth provider manual or at www.mass.gov/masshealth. Go to MassHealth Regulations and Other Publications, and then to the Provider Library. July 2012 Page 22 Billing Guide for the CMS-1500 Appendix B: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Commercial Insurance Please Note: Effective January 1, 2012, MassHealth is moving toward an all- electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the POSC or on paper. Please see All Provider Bulletin 217, dated September 2011, for more information about MassHealth’s paper claims waiver policy. For information on how to submit 90-day waiver requests and final deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 221, dated December 2011. Important: The table below lists specific fields on the CMS-1500 that must be completed for all MassHealth claims where the member has commercial insurance in addition to MassHealth. In addition to completing all applicable fields, all claims for members with commercial insurance must be submitted with the appropriate explanation of benefits (EOB) or other necessary TPL documentation. Providers must ensure that the appropriate carrier code is clearly written on the EOB. Field # Field Name TPL Required Information 1 1a 4 6 9 9a 9b 9d 10d 11 11a Unnamed Insured’s ID Number Insured’s Name Patient Relationship to Insured Other Insured’s Name Other Insured’s Policy or Group Number Other Insured’s Date of Birth, Sex Insurance Plan Name or Program Name Reserved for Local Use Insured’s Policy Group or FECA Number Insured’s Date of Birth, Sex Check box marked “Medicaid.” Enter the 12-digit MassHealth member ID. Enter insured’s name (subscriber and insured’s name may be different from the MassHealth member’s name) Check the correct box to indicate the patient’s relationship to the insured. Only one box can be marked. If 11d is checked “yes,” enter the name of the insured if different from patient name. If 11d is checked “yes,” enter the group or policy number for the commercial insurance plan. If 11d is checked “yes,” enter the date of birth and gender of the insured noted in Field 9. When 11d is checked “yes,” enter the appropriate MassHealth carrier code. The Third-Party Liability MassHealth Carrier Code list can be found in Appendix C of your MassHealth provider manual. Enter the complete12-character member ID number that is printed on the MassHealth card. Enter the policy or group number of the primary commercial insurance resource as it appears on the member’s insurance card. Enter insured’s date of birth July 2012 Page 23 Billing Guide for the CMS-1500 Appendix A: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for Members with Commercial Insurance (cont.) Field # Field Name TPL Required Information 11c 11d 29 Insurance Plan or Program Name Is There Another Health Benefit Plan? Amount Paid Enter the appropriate MassHealth carrier code. The Third- Party Liability MassHealth Carrier Code list can be found in Appendix C of your MassHealth provider manual. Check the box indicating whether the patient has insurance in addition to MassHealth and the commercial insurance identified in Fields 11-11c. If this box is checked “yes,” complete Fields 9, and 9a through 9d with information applicable to the other commercial health plan. Enter the total amount paid by all insurers other than MassHealth. Instructions for submitting claims with Explanation of Benefits (EOB) 1. Complete the CMS-1500 claim form according to this MassHealth Billing Guide for the CMS-1500. 2. Attach the original or a copy of the other insurance carrier’s EOB, to the claim form. a. The dates of service, provider name, and patient's name on the EOB must correspond to the information on the MassHealth claim. b. If more than one member is listed on the EOB, circle the member information on the EOB that corresponds to the member on the MassHealth claim. c. If you are submitting claims with one or more EOB attachments, you must write the appropriate MassHealth assigned carrier code on each EOB. Please Note: MassHealth-assigned carrier codes may be found in Appendix C: Third-Party-Liability Codes of your MassHealth provider manual or at www.mass.gov/masshealth. Go to MassHealth Regulations and Other Publications, and then to the Provider Library. July 2012 Page 24