| earliest compliance date required by CMS for
mandatory use of the CMS-1500 (02/12) claim form for Medicare claims.
The CMS-1500 (08/05) claim form must be completed in compliance with
the special instructions applicable to the data element as described
in this paragraph for clean claims filed by physicians and noninstitutional
providers. However, on notification that an MCC is prepared to accept
claims filed or refiled on form CMS-1500 (02/12), a physician or noninstitutional
provider may submit claims on form CMS-1500 (02/12) before the subsection
(b)(1) of this section mandatory use date described in this paragraph,
subject to the subsection (b)(1) of this section required data elements
set out in the paragraph.
(A) subscriber's or patient's plan ID number (CMS-1500
(08/05), field 1a) is required;
(B) patient's name (CMS-1500 (08/05), field 2) is required;
(C) patient's date of birth and sex (CMS-1500 (08/05),
field 3) is required;
(D) subscriber's name (CMS-1500 (08/05), field 4) is
required, if shown on the patient's ID card;
(E) patient's address (street or P.O. Box, city, state,
ZIP Code) (CMS-1500 (08/05), field 5) is required;
(F) patient's relationship to subscriber (CMS-1500
(08/05), field 6) is required;
(G) subscriber's address (street or P.O. Box, city,
state, ZIP Code) (CMS-1500 (08/05), field 7) is required, but physician
or provider may enter "Same" if the subscriber's address is the same
as the patient's address required by subparagraph (E) of this paragraph;
(H) other insured's or enrollee's name (CMS-1500 (08/05),
field 9) is required if the patient is covered by more than one health
benefit plan, generally in situations described in subsection (d)
of this section. If the required data element specified in subparagraph
(Q) of this paragraph, "disclosure of any other health benefit plans,"
is answered "Yes," this element is required unless the physician or
the provider submits with the claim documented proof that the physician
or the provider has made a good faith but unsuccessful attempt to
obtain from the enrollee or the insured any of the information needed
to complete this data element;
(I) other insured's or enrollee's policy or group number
(CMS-1500 (08/05), field 9a) is required if the patient is covered
by more than one health benefit plan, generally in situations described
in subsection (d) of this section. If the required data element specified
in subparagraph (Q) of this paragraph, "disclosure of any other health
benefit plans," is answered "Yes," this element is required unless
the physician or the provider submits with the claim documented proof
that the physician or the provider has made a good faith but unsuccessful
attempt to obtain from the enrollee or the insured any of the information
needed to complete this data element;
(J) other insured's or enrollee's date of birth (CMS-1500
(08/05), field 9b) is required if the patient is covered by more than
one health benefit plan, generally in situations described in subsection
(d) of this section. If the required data element specified in subparagraph
(Q) of this paragraph, "disclosure of any other health benefit plans,"
is answered "Yes," this element is required unless the physician or
the provider submits with the claim documented proof that the physician
or the provider has made a good faith but unsuccessful attempt to
obtain from the enrollee or the insured any of the information needed
to complete this data element;
(K) other insured's or enrollee's plan name (employer,
school, etc.), (CMS-1500 (08/05), field 9c) is required if the patient
is covered by more than one health benefit plan, generally in situations
described in subsection (d) of this section. If the required data
element specified in subparagraph (Q) of this paragraph, "disclosure
of any other health benefit plans," is answered "Yes," this element
is required unless the physician or the provider submits with the
claim documented proof that the physician or the provider has made
a good faith but unsuccessful attempt to obtain from the enrollee
or the insured any of the information needed to complete this data
element. If the field is required and the physician or the provider
is a facility-based radiologist, pathologist, or anesthesiologist
with no direct patient contact, the physician or the provider must
either enter the information or enter "NA" (not available) if the
information is unknown;
(L) other insured's or enrollee's HMO or insurer name
(CMS-1500 (08/05), field 9d) is required if the patient is covered
by more than one health benefit plan, generally in situations described
in subsection (d) of this section. If the required data element specified
in subparagraph (Q) of this paragraph, "disclosure of any other health
benefit plans," is answered "Yes," this element is required unless
the physician or the provider submits with the claim documented proof
that the physician or the provider has made a good faith but unsuccessful
attempt to obtain from the enrollee or the insured any of the information
needed to complete this data element;
(M) whether the patient's condition is related to employment,
auto accident, or other accident (CMS-1500 (08/05), field 10) is required,
but facility-based radiologists, pathologists, or anesthesiologists
must enter "N" if the answer is "No" or if the information is not
available;
(N) if the claim is a duplicate claim, a "D" is required;
if the claim is a corrected claim, a "C" is required (CMS-1500 (08/05),
field 10d);
(O) subscriber's policy number (CMS-1500 (08/05), field
11) is required;
(P) HMO or insurance company name (CMS-1500 (08/05),
field 11c) is required;
(Q) disclosure of any other health benefit plans (CMS-1500
(08/05), field 11d) is required;
(i) if answered "Yes," then:
(I) data elements specified in subparagraphs (H) -
(L) of this paragraph are required unless the physician or the provider
submits with the claim documented proof that the physician or the
provider has made a good faith but unsuccessful attempt to obtain
from the enrollee or the insured any of the information needed to
complete the data elements in subparagraphs (H) - (L) of this paragraph;
(II) the data element specified in subparagraph (KK)
of this paragraph is required when submitting claims to secondary
payor MCCs;
(ii) if answered "No," the data elements specified
in subparagraphs (H) - (L) of this paragraph are not required if the
physician or the provider has on file a document signed within the
past 12 months by the patient or authorized person stating that there
is no other health care coverage. Although the submission of the signed
document is not a required data element, the physician or the provider
must submit a copy of the signed document to the MCC on request;
(R) patient's or authorized person's signature or a
notation that the signature is on file with the physician or the provider
(CMS-1500 (08/05), field 12) is required;
(S) subscriber's or authorized person's signature or
a notation that the signature is on file with the physician or the
provider (CMS-1500 (08/05), field 13) is required;
(T) date of injury (CMS-1500 (08/05), field 14) is
required if due to an accident;
(U) when applicable, the physician or the provider
must enter the name of the referring primary care physician, specialty
physician, hospital, or other source (CMS-1500 (08/05), field 17).
However, if there is no referral, the physician or the provider must
enter "Self-referral" or "None";
(V) if there is a referring physician noted in CMS-1500
(08/05), field 17, the physician or the provider must enter the ID
Number of the referring primary care physician, specialty physician,
or hospital (CMS-1500 (08/05), field 17a);
(W) if there is a referring physician noted in CMS-1500
(08/05), field 17, the physician or the provider must enter the NPI
number of the referring primary care physician, specialty physician,
or hospital (CMS-1500 (08/05), field 17b) if the referring physician
is eligible for an NPI number;
(X) narrative description of procedure (CMS-1500 (08/05),
field 19) is required when a physician or a provider uses an unlisted
or unclassified procedure code or an NDC code for drugs;
(Y) for diagnosis codes or nature of illness or injury
(CMS-1500 (08/05), field 21), up to four diagnosis codes may be entered.
At least one is required, but the primary diagnosis must be entered
first;
(Z) verification number (CMS-1500 (08/05), field 23)
is required if services have been verified under §19.1719 of
this title (relating to Verification for Health Maintenance Organizations
and Preferred Provider Benefit Plans). If no verification has been
provided, a prior authorization number (CMS-1500 (08/05), field 23)
is required when prior authorization is required and granted;
(AA) date(s) of service (CMS-1500 (08/05), field 24A)
is required;
(BB) place of service code(s) (CMS-1500 (08/05), field
24B) is required;
Cont'd... |
