Sunday, May 1, 2011

CMS 1500 - Helpful Claims Filing Hints

Helpful Claims Filing Hints

To prevent claims processing and payment delays, follow the claims filing hints below:

• Verify coverage. Groups often have changes in their health insurance benefit plans. Make reverifying
coverage through the Availity Health Information Network or the telephone self-service
option a routine part of your practice.

• Submit the entire member ID number including alpha prefix. Submit the member ID number not
the member's Social Security number. Remember to correct your billing system when there are

• Complete all claim entry fields. To receive proper reimbursement, the claim information must be
completed in its entirety. Incomplete or inaccurate information will result in a claim denial.

• Enter the date of onset, if applicable. All ICD diagnosis codes in the 800-900 range require a date
of onset (injury, accident, first symptom, etc.).

• Use valid codes. CPT, HCPCS, and ICD codes are updated quarterly. Make sure you or your billing
service is using the most up-to-date codes.

• Report an unlisted code only if unable to find a procedure code that closely relates to or
accurately describes the service performed. Unlisted codes require documentation and therefore
cannot be submitted electronically.

• Use diagnosis codes that indicate a general medical exam when billing for “preventive” health
screening exams. Claims for these services will be denied if other diagnosis codes are used.

• Submit modifiers affecting reimbursement in the first and second position on claims. A
procedure code modifier, when applicable, provides important additional information about the service

• Submit multiple procedures on one claim. All procedures performed on the same date of service,
by the same provider for the same patient should be submitted on one claim.

• Submit all applicable diagnosis codes. Code to the highest level of specificity possible. Most 3-
digit codes require a fourth or fifth digit.

• Include the NPI for rendering physician and billing physician or group. Both the CMS-1500 and
UB-04 include fields for the NPI.


*  Block 24J is for Type 1 NPIs (Rendering Physician)
*  Block 32a is for Type 2 NPIs (Service Facility)
*  Block 33a is for Type 1 or 2 NPIs (Billing Physician/Group)

The above blocks are split to allow your BCBSF provider number in the shaded area and your NPI in
the unshaded area labeled NPI.

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