Professional billing

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

Item 33b: Taxonomy codes