Wednesday, June 30, 2010

How to submit CMS 1500 claim form - Healthnet

Claims Submission Information Instructions -- Healthnet for Non-participating Providers

When submitting claims, providers must include, at a minimum, all of the following required information:
•    Member's (subscriber's) ID number
•    Patient's name and date of birth
•    Employer group number
•    Submitting provider's tax ID number or Social Security number
•    State license number of attending provider
•    Submitting provider's name and address
•    ICD-9 diagnosis code
•    Date(s) of service Billed charges
•    Current year CPT or HCPCS procedure code (physician) with all applicable modifiers LML or UB-92 revenue code with narrative description (hospital)
•    CMS place of service code (professional claims only)
•    UB bill type
•    Number of days or units for each service line (professional claims only)
•    Authorization number and all applicable information, when authorization is required
•    UPIN number for professional claims
•    Medicare number for institutional claims when applicable

To avoid possible denial or delay in processing, the above information must be correct and complete.

The following providers must include additional information as outlined:

•    Emergency services providers: The claim must include a legible emergency department report and any state-designated data requirements included in statutes or regulations

•    Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations

•    On-call physicians: Where applicable, physicians who are on call for a primary care physician (PCP) do not require a referral. The name of the PCP should be noted on the claim in Box 19 or 23 on the CMS-1500 claim form. For self-referrals the provider should indicate Self-Referred in Box 17 of the CMS-1500

•    Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with Health Net's specifications and any state-designated data requirements included in statutes or regulations
General Billing Requirements:
•    ID number: Enter the corresponding identification (ID) number as noted:
o    Member ID number (Medi-Cal): The nine-character ID found on patient's Health Net ID card
o    Subscriber ID number (HMO, POS, PPO, EPO, Flex Net,AIM, and Healthy Families Program): The nine-character ID (the letter "R" followed by eight digits) found on patient's Health Net ID card
•    Employer group number: The number assigned to the subscriber's employer group located on the member's ID card.
•    UPIN or state license number:Six-digit universal provider identification number (UPIN) or state license number of all attending providers.
o    When billing for more then one attending provider, indicate the UPIN on the appropriate detail line
o    For physicians, the state license number should be entered as a seven-digit number "A0nnnnn." When "a" is the alpha character shown on the state license (A, C, G), "0" is the filler zero and "nnnnn" are the five numeric characters in the state license number
o    All other providers use their state-assigned license number without modifications

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