Billing for professional charges
Your claim for professional services must be submitted on a standard HCFA 1500 form (also known as CMS-1500, RRB-1500, CWCP-1500).
Mid-level providers
Physician assistants or nurse practitioners employed by a physician group may submit claims for surgical assists or facility rounding using the HCFA 1500 form.
Learn more about mid-level provider coding and reimbursement.
Submitting claims
We prefer to receive claims electronically (learn how to set up electronic data interchange), but you can also mail them to our claims addresses.
- Hand-written claims will not be accepted
- Use black ink. Do not use red ink, highlighters, neon stickers, labels or stamps.
- Fill out an original claim form in its entirety. Do not use copies of claim forms.
- Print claim data within the boxes
- Do not put notes at the top or bottom of the claim
- Use a laser printer (not a dot matrix or impact printer) if possible
- Do not print slashed zeros
Required information
| Item 1 |
Indicate all types of insurance coverage applicable |
| Item 1a |
Contract number plus two digit suffix, for Medicaid it's the patient's recipients ID number |
| Item 2 |
Patient's name |
| Item 3 |
Patient's date of birth and gender |
| Item 4 |
Insured's name |
| Item 5 |
Patient's address |
| Item 6 |
Patient's relationship to the insured |
| Item 7 |
Insured's address |
| Item 8 |
Patient's status |
| Item 9a-d |
Other insurance information |
| Item 10 |
Patient's condition related to: |
| Item 10a-c |
Employment, auto or other accident |
| Item 11 |
Insured's group number |
| Item 12 |
Patient's signature on file |
| Item 13 |
Insured's signature on file |
| Item 14 |
Date of current illness, injury or pregnancy |
| Item 15 |
Indicate if patient has had same or similar illness; give first date |
| Item 17 |
Name of referring physician |
| Item 17b |
NPI of referring physician (required) |
| Item 18 |
Hospitalization dates related to current service, if applicable |
| Item 19 |
Reserved for local use - use for prenatal dates of service, description of unlisted codes, or reason for corrected claim |
| Item 21 |
Diagnosis using standard ICD-9 CM diagnosis code (using primary diagnosis code first) |
| Item 22 |
Corrected claim code, if applicable: See "Making corrections" section of this manual for use |
| Item 23 |
Prior authorization number, if applicable |
| Item 24a |
Date the service was provided |
| Item 24b |
Place of service - Priority Health will accept all standard Medicare place of service codes |
| Item 24d |
CPT and/or HCPCS codes, modifiers when necessary; for unlisted procedure codes, specify what service is being provided. |
| Item 24e |
Link service to any of the four diagnoses listed in Item 21, as applicable |
| Item 24f |
Charges |
| Item 24g |
Days or units |
| Item 24i |
ID Qualifier, for taxonomy codes |
| Item 24j |
Rendering Provider and NPI |
| Item 25 |
Federal Tax ID number |
| Item 26 |
Patient's account number |
| Item 27 |
Accept assignment |
| Item 28 |
Total charges |
| Item 31 |
Typed first name then last name of physician or supplier, including degrees or credentials (no handwritten signatures accepted) |
| Item 32 |
Name and address of facility where services were rendered |
| Item 32a |
NPI of service facility |
| Item 32b |
Taxonomy codes |
| Item 33 |
Physician's or supplier's billing name and address (Social Security number or owner of tax ID number) |
| Item 33a |
NPI of billing provider |
| Item 33b |
Taxonomy codes |
