Sunday, October 4, 2015

CMS 1500 claim submission tips from Medicare to avoid rejection

Here are some tips to keep in mind when completing the CMS-1500 (02/12) claim form to accommodate our scanning process:

** Print claims using 10, 11 or 12 point Courier or Arial font.

** Use capital letters. Mixed case can throw off character recognition (ex. '5' can become 'S').

** Use black ink. Red ink and highlighting cannot be read by the OCR equipment.

** 25% of the paper claims sent to us are either too light or too dark to be read accurately by our optical scanning equipment. Please ensure ink used on the claim is not too light or too dark. ** Do not use dot-matrix print.

** Avoid touching characters. Be sure there is adequate spacing between characters. ** Check the alignment of data on your printed claims before submitting them. Information should be contained within the specifically designated fields. ** Do not use whiteout/correction tape to make corrections for resubmitted claim data. ** Do not use rubber stamps or any other form of stamps to submit information on the claim ** Do not enter any data in item 17a, the shaded portion of item 24J, item 32b or item 33b. Claims submitted with data in these legacy provider fields will be returned to the provider. ** Claims that are too light, too dark, misaligned or not legible may be returned to the provider.

Palmetto GBA has created an interactive CMS-1500 (02/12) Claim Form Tool to assist providers in correctly completing the paper claim form. On this tool, you can click on each field of the claim form to see instructions for completing that field. You can access the interactive form in the Forms/Tools section of our website homepage at

Here are tips for completing some specific fields of the CMS-1500 (02/12) claim form:

** Item 1a is for the beneficiary’s Health Insurance Claim (HIC) number. Make sure the HIC that you enter is a Railroad Medicare number. All Railroad Medicare HIC numbers begin with 1, 2 or 3 letters followed by 6 or 9 digits.

** Items 2 and 5 are specifically for the patient information. The name of the person who received the services must be indicated in Item 2. To reduce the possibility of claim rejections, it is imperative that the name match exactly as typed on the Railroad Medicare card.

 ** Items 4 and 7 are for the insured’s information. If the patient is the same as the insured, you may put the word 'SAME' in Items 4 and 7. ** Item 11 is for insurance that is primary to Medicare. Block 11 cannot be left blank on paper claims.

o If there is no insurance primary to Medicare, enter the word ‘NONE’.

o If there is insurance that is primary to Medicare, enter the insured’s policy or group number and complete Items 11a-11c as well as Items 4, 6 and 7.

** Item 17 is used to report the ordering or referring provider.

o In the space to the left of the dotted vertical line, before the provider’s name, enter a valid two-letter qualifier to identify the role of the provider. Choose the appropriate qualifier: DN (referring provider), DK (ordering provider) or DQ (supervising provider).

o Enter the provider’s name in the order of first name then last name.

o Submit the provider’s complete name spelled as it appears on the CMS Ordering and Referring File at

o Include a hyphen in the last name only if the last name is hyphenated on the CMS file

o Do not submit middle initials or suffixes such as MD, DO, Jr, etc.

o Do not submit Dr. before the name ** Item 17a must be left blank. Do not enter your Railroad PTAN or any other number in the shaded area. ** Item 17b is for the ordering/referring/supervising provider’s NPI. ** Item 21 is for the diagnosis code(s) and the ICD indicator.

o In the ICD Indicator field, enter either a 9 for ICD-9 codes or 0 for ICD-10 codes. Claims submitted without a valid ICD indicator will be rejected as unprocessable.

o You can enter up to 12 diagnosis codes in priority order in the fields coded from A to L, and displayed in left to right order on the claim form.

** Item 24E is for the diagnosis pointer. Enter the appropriate diagnosis code reference letter (AL) from Item 21 that corresponds with the primary diagnosis for date of service and procedure performed. Enter only one reference number/letter per line item. If multiple services are performed, enter the primary reference number/letter for each service.

** Item 24J is for the rendering provider’s NPI number. The shaded portion must be blank. Do not enter your Railroad PTAN or any other number in the shaded area.

** Item 24d requires only a valid five (5) character HCPCS or CPT-4 procedure code plus modifier(s). Do not type a description of the procedure code(s). Up to four modifiers are allowed per service line.

** The Item 24 A-J service area can have no more than six (6) lines of service and no more than one service per line.

o The shaded memo fields of the 24 A-J service area should be blank. These fields are not used by Medicare with the exception of NDC information for physician-administered drugs for Medicare/Medicaid patients.

** Item 29 should only be used to report the total amount the patient paid on covered services. Do not use this field to report the amount a primary insurance paid. ** Item 32 requires the name and complete address of where the services were rendered. Cannot be a PO Box. ** Item 32b must be left blank. Do not enter your Railroad PTAN or any other number in the shaded area.

** Item 33 requires your legal business name and complete payment address.

** Item 33a is for the NPI of the billing provider or group.

** Item 33b must be blank. Do not enter your Railroad PTAN or any other number in the shaded area.

** In Item 32 and Item 33 enter the address using the postal address code format (Company Name on Row 1, Company Address on Row 2, and City/State/Zip on Row 3) to help increase readability.

** In Item 32 and Item 33 do not submit a phone number below the address. Phone numbers below the address are often picked up as PTANs or zip codes by the scanners.

Problems can occur when modifiers are used incorrectly. The following table provides some useful hints of when to use the modifier, and a brief description of the modifier. While this list is not all- inclusive, it is comprised of modifiers mo st commonly seen by Railroad Medicare, as well as other nationally accepted modifiers. Railroad Medicare only recognizes national modifiers. Local MAC assigned modifiers will cause denials. Some modifiers are informational only and do not affect claim pay ment with Railroad Medicare. Refer to the Healthcare Common Procedure Coding System (HCPCS) Level II Code Book, the Current Procedural Terminology (CPT) Book, and the Railroad Medicare Modifier Lookup tool on our website for additional modifiers and/or more information.

** Our sy stem can accept four modifiers. If more than four modifiers are needed to describe the service, modifier 99 should be used on the claim line. Each modifier should then be entered on the claim in Item 19 of the CMS-1500 (02/12) form or the Narrative section of the ANSI 5010 EMC Claim.

Important instructions for paper claim form CMS-1500 (version 02/12)

Recently, First Coast Service Options (First Coast) has noticed a reoccurring issue for several claims when they go through the optical character recognition (OCR) process. To avoid these issues, we wanted to reiterate some important instructions for our paper claim submitters:

• All paper claims are required to be submitted using the CMS-1500 (02/12) form.

• When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L" in Item 24E.

• Claims submitted with a national provider identifier (NPI) and without one of the Item 17 qualifiers or an invalid qualifier will be returned as an unprocessable claim (RUC).

• Reminder: Providers cannot submit ICD-10 codes for claims with dates of service prior to October 1, 2015.

ASCA reminder

Only providers that meet the Administrative Simplification Compliance Act (ASCA) exception requirements are permitted to submit their claims to Medicare on paper, which must be submitted on a valid CMS-1500 claim form. Providers meeting these exceptions are permitted to submit their claims to Medicare on paper.

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