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).

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
Items 9a-d Other insurance information
Item 10    Patient's condition related to:
Items 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 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 32 b  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