Claims and Encounter Data Submissions
You must submit a claim and/or encounter for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member. If you have questions about submitting claims to us, please call us at the phone number listed on the member’s health care ID card.
It is important to accurately code the claim because a member’s level of coverage under their benefit plan may vary for different services. To help correctly code your claims, use the Claim Estimator. It includes a feature called Professional Claim Bundling Logic. This helps you determine allowable bundling logic and other commercial claims processing edits for a variety of procedure codes. This is not available for all products.
Pricing and payment calculations for professional commercial claims are available under the Pre-Determination of Benefits option. Allow 45 calendar days for us to process your claim, unless your Agreement says otherwise. Check the status on claimsLink before sending second submissions or tracers. If you do need to submit a second submission or a tracer, please submit it electronically no sooner than 45 days after original submission.
Complete claims by including the information listed under the Requirements for Complete Claims and Encounter Data Submission section. We prefer to receive claims electronically, but we do accept claims submitted on paper. Send the completed and appropriate forms to the claims address listed on the back of the member’s healthcare ID card.
If we receive a claim electronically with missing information or invalid codes, we may reject the claim, not process it or, if applicable, not submit it to CMS for consideration in the risk adjustment calculation.
If we receive a similar claim using the paper form, we may pend it to get the correct information. We may also require additional information for particular types of services, or based on particular circumstances or state requirements.
To order CMS 1500 and CMS-1450 (also known as UB-04) forms, contact the U.S. Government Printing Office at 202-512-0455, or visit the Medicare website.
We may pend or deny your claim if you do not list:
- Member’s name, address, gender, date of birth, relationship to subscriber (policy owner)
- Subscriber’s name (enter exactly as it appears on the member’s health care ID card), ID number, employer group name and employer group number
- Rendering care provider’s name, signature or representative’s signature, address where service was rendered, “Remit to” address, phone number, NPI, taxonomy and federal TIN
- Referring care provider’s name and NPI (for Medicare Advantage), as well as TIN (if applicable)
- Complete service information, including date of service(s), place of service(s), number of services (day/units) rendered, current CPT and HCPCS procedure codes, with modifiers where appropriate, current ICD-10-CM diagnostic codes by specific service code to the highest level of specificity. It is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item.
- Charge per service and total charges
- Detailed information about other insurance coverage
- Information regarding job-related, auto or accident information, if available
- Retail purchase cost (or a total retail rental cost) greater than $1,000 for DME
- Current National Drug Code (NDC) 11-digit number, NDC unit of measure (F2, GR, ML, UN, ME) and NDC units dispensed (must be greater than 0) for all claims submitted with drug codes. Enter the NDC information for the drug(s) administered in the 24D field of the CMS-1500 Form, field 43 of the UB-04 form, or the LIN03 and CTP04-05 segments of the HIPAA 837 Professional or institutional electronic form.
- Method of administration (self or assisted) for hemophilia claims – note the method of administration and submit with the claim form with applicable J-CODES and hemophilia factor, to enable accurate reimbursement. Method of administration is either noted as self or assisted.
Include a detailed description of the procedure or service for claims submitted with:
- Unlisted medical/surgical CPT
- “Other” revenue codes
- Experimental services
- Reconstructive services
Your claim may be pended or not processed if you do not include:
- Date and hour of admission
- Date and hour of discharge
- Member status-at-discharge code
- Type of bill code (three digits)
- Type of admission (e.g., emergency, urgent, elective, newborn)
- Current four digit revenue code(s)
- Attending physician ID
- For outpatient services/procedures, the specific CPT or HCPCS codes, line item date of service, and appropriate revenue code(s) (e.g., laboratory, radiology, diagnostic or therapeutic)
- Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449)
- Submit claims according to any special billing instructions that are in your Agreement
- On an inpatient hospital bill type of 11x, use the actual time the member was admitted to inpatient status
- If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, report a nominal monetary amount ($01 or $100) on all other surgical revenue code lines to assure appropriate adjudication
- Include the condition code designated by the National Uniform Billing Committee (NUBC) on claims for outpatient preadmission non-diagnostic services that occur within three calendar days of an inpatient admission and are not related to the admission
Your claim must be filed within your timely filing limits or it may be denied. If you dispute a claim that was denied due to timely filing, you will be asked to show proof you filed the claim within your timely filing limits.
Timely filing limits can vary based on state requirements and contracts. Refer to your Provider Agreement for your specific timely filing requirements.