Saturday, October 2, 2010

Paper Claims with Attachments

 When submitting attachments with the CMS-1500 claim form, please follow these guidelines:

Any attachment should be marked with the beneficiary’s name and Medicaid ID number.

For different claims that refer to the same attachment, a copy of the attachment must accompany each claim.

For claims with more than one third- party payor source, include all EOBs that relate to the claim.

For third party payments less than 20% of charges, indicate on the face of the claim, LESS THAN 20%, PROOF ATTACHED.

For Medicare denials, indicate on the claim, MEDICARE DENIAL, SEE ATTACHED.

For other insurance denials, indicate on the claim, TPL DENIAL, SEE ATTACHED


When a claim attachment(s) is required, it must be directly behind the claim it supports and be identified on each page with the beneficiary’s name and Medicaid ID number. Attachments must be on 8 ½" x 11" white paper and one-sided. Do not submit twosided material. Multiple claims cannot be submitted with one attachment. Each claim form that requires an attachment must have a separate attachment. Do not staple or paperclip the documentation to the claim form.

Mail claim forms with attachments flat, with no folding, in a 9" x 12" or larger envelope and print "Ext. material" (for extraneous material) on the outside. Do not put claims that have no attachments in this envelope. Mail claims without attachments separately. Do not send attachments unless the attachment is required as unnecessary attachments delay claim processing.

Claim attachments, such as medical records and EOBs, may be associated to a paper claim via the Document Management Portal. (Refer to the Directory Appendix for website information.)

Once confirmation is received that the consent forms are approved, it is not necessary to submit additional copies when billing for sterilization or hysterectomy services. The notation "Consent form sent via Document Management Portal" must be included in the Remarks section of the paper claim.

Refer to the MDHHS website for Document Management Portal instructions, including fax requirements. (Refer to the Directory Appendix for website information.)

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