Monday, October 3, 2016

Paper Claim Submission Requirements

All paper CMS 1500 and UB-04 claims must be submitted on standard red claim forms. Black and white versions of these forms, including photocopied versions, faxed versions and resized representations of the form that do not replicate the scale and color of the form required for accurate OCR scanning, will not be accepted and will be returned with a request to submit on the proper claim form.

To avoid a filing deadline denial, rejected paper claims must be submitted within 60 days from the date of service for professional or outpatient services or within 60 days from the date of discharge.

Submitted paper claim forms should include all mandatory fields as noted in the Claim Specifications section of this chapter. Paper claim forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

** Industry-standard codes should be submitted on all paper claims.

** Diagnosis codes must be entered in priority order (primary, secondary condition) for proper adjudication. Up to 12 diagnosis codes will be accepted on the CMS-1500 form.

** Paper claims will be rejected and returned to the submitter if required information is missing or invalid. Common omissions and errors include but are not limited to the following:

** Illegible claim forms

** Member ID number

** Date of service or admission date

** Physician’s signature (CMS-1500 Box 31)

Paper claims should be mailed to the following address:

Tufts Health Plan Medicare Preferred P.O. Box 9183 Watertown, MA 02471-9183

Claims Payment

Clean Claims

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