Also see: Mid-level provider coding and reimbursement.
Claim guidelines
- We prefer to receive claims electronically (learn how to set up electronic data interchange), but you can also mail them to our claims addresses using the standard CMS-1500 form (02-12 version or later).
- Hand-written or faxed claims will not be accepted.
- Do not use red ink, highlighters, neon stickers, labels or rubber 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.
- Do not print slashed zeros.
Documenting urgent or emergency surgery or treatment
If treating a member for an accident or emergency related to an employment, auto or other accident, complete the appropriate information on your claim:
- CMS-1500: complete fields 10a-c
Emergency indicator: complete field 24c - 837: complete loop 2300
Emergency indicator: complete loop 2400, Segment/data element SV109
Failure to populate this information may result in claim denials for prior authorization requirements or other claim denials.
Required CMS-1500 field information
Item 1: Indicate all types of insurance coverage applicable
Item 1a: Contract number plus two-digit suffix. For Medicaid use the patient's recipient's 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 9a & 9d: 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; other date
Item 17: Qualifier and name of referring physician
Item 17b: NPI of referring physician; required except if patient is self-referring
Item 18: Hospitalization dates related to current service, if applicable
Item 19: Additional claim information; use for prenatal dates of service, description of unlisted codes, or reason for corrected claim
Item 21: Diagnosis using standard ICD-10 CM diagnosis code; use primary diagnosis code and indicator first
Item 22: Corrected claim code, if applicable: See Making corrections 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 diagnosis 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 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