Paper Claims Submissions Rejections and Resolutions

CMS-1500 (02/12) form

Completed in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17 at www.nucc.org

Any other form will be rejected with a letter sent to the provider indicating the reason for rejection.

UB-04 form. The form must be completed in accordance with the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2018 at www.nubc.org

Any other form will be rejected with a letter sent to the provider indicating the reason for rejection.

1. Flint optical character recognition (OCR) Red, J6983 (or exact match) ink form
2. Required original red form with the backer instructions
3. Typed in black ink
4. 10 or 12 point
5. Times New Roman font

Any of the following formats will be rejected.

1. Submitted on black and white or forms other than CMS-1500 (02/12) and UB-04
2. Handwritten
3. Highlighted, italics, bold text, or staples for multiple page submissions
4. Copies of the form

01

Member's DOB is missing or invalid.

Enter the patient's 8 digit date of birth (MM/DD/YYYY)

CMS-1500 box 3

UB-04 box 10

02

Incomplete or invalid member information.

Enter the patient's Health Net member ID for Commercial and Medicare. Social Security number (SSN) should not be used

CMS-1500 box 1a

UB-04 box 60

06

Missing/invalid tax ID

Include complete 9-character tax identification (ID) number

CMS-1500 box 25

UB-04 box 5

17

Diagnosis indicator is missing.
DRG code is not valid.
POA indicator is not valid.

Ensure 9/0 is billed on the claims
Ensure DRG code and POA indicators are valid when billed
Include principal diagnosis codes matching the ICD indicator

UB-04 box 67
UB-04 box 69
UB-04 box 70
UB-04 box 71
UB-04 box 72

75

The claim(s) submitted is missing, illegible or invalid value for anesthesia minutes

If box 24 is completed, then box 24G must be completed as well

CMS-1500 box 24D and 24G

76

Original claim number and frequency code required

Resubmission code is required for all corrected claims. If resubmission code is 6, 7, or 8 (field 22 on the CMS1500 and field 4 on the UB04), the original claim number is required (field 22 on CMS 1500 and Field 64 on UB04)

CMS-1500 box 22

UB-04 box 4 and 64

77

Type of bill or place of service invalid or missing.

Enter the appropriate Type of Bill (TOB) Code as specified by the NUBC UB-04 Uniform Billing Manual minus the leading "0" (zero). A leading "0" is not needed. Digits should be reflected as follows:

1st Digit - Indicating the type of facility

2nd Digit - Indicating the type of care

3rd Digit - Indicating the bill sequence (Frequency code)

UB-04 box 4

87

One or more of the REV codes submitted is invalid or missing

Include complete 3-4 character revenue code

UB-04 box 42

92

Missing or invalid NPI

Enter provider's 10-character National Provider Identifier (NPI) ID

CMS-1500 box 24J and 33A

UB-04 box 56

A5

NDC or UPIN information missing/invalid

Providers must bill the UPN qualifier, number, quantity, and type. If any of these elements are missing, the claim will reject

CMS-1500 box 24D

UB-04 box 43

A7

Invalid/missing ambulance point of pick-up zip code

If box 24 D is completed, include the pickup/drop off address in attachments

CMS-1500 box 24 or box 32.

Medicare claims require a ZIP in box 23 in addition to the addresses in 24 shaded area or box 32

A9

Provider name and address required at all levels

Include complete billing provider address including City, State and Zip code

CMS-1500 box 33

UB-04 box 1

C8

Valid POA required for all DX fields

Do not include the POA of 1. The valid values for this field are Y or N or blank

UB-04 box 67 - 67Q and 72A - 72C

B7

Review NUCC guidelines for proper billing of the CMS 1500 versions (08/05) and (02/12). Claims will be rejected if data is not submitted and/or formatted appropriately

Only CMS1500 02/12 version is accepted

N/A

C6

Other Insurance fields 9, 9a, 9d and 11d are missing appropriate data

If the member has other health insurance, box 9, 9a, 9d must be populated and box 11D must be marked as yes. If this is not provided, the claim will be rejected

CMS-1500 box 9, 9a, 9d and 11d

AV

Patient's Reason For Visit should not be used when claim does not involve outpatient visits

Include patient reason for visit on all inpatient claims

UB-04 box 70a, b, c

HP

ICD10 is mandated for this date of service

Submit the ICD indicator of 9/0 on both UB-04 and CMS-1500 claim forms 5010 Guidelines requirement to bill this information

CMS-1500 box 21

UB-04 box 66

RE

Black/white, handwriting or Nonstandard format

Use proper CMS-1500 or UB-04 form typed in black ink in 10 or 12 point Times New Roman font

N/A

Medicare advantage HMO & PPO

Health Net of Oregon, Inc. (and/or)
Health Net Life Insurance Company
Medicare Claims
PO Box 9030
Farmington, MO 63640-9030

EPO, POS, ppo, & CommunityCare

Health Net of Oregon, Inc.
Commercial Claims
PO Box 9040
Farmington, MO 63640-9040

1

Insurance program identification

Required

1a

Insured identification (ID) number

Required

2

Patient's name (Last name, first name, middle initial)

Required

3

Patient's birth date and sex

Required

4

Insured's name

Conditional - Needed if different than patient

5

Patient's address (number, street, city, state, ZIP code)
Telephone number (include area code)

Conditional

6

Patient's relationship to insured

Conditional - Always mark to indicate self if the same.

7

Insured's address
(number, street, city, state, ZIP code) Telephone number (include area code)

Conditional

8

Reserved for NUCC

Not required

9

Other insured's name (last name, first name, middle initial)

Conditional Refers to someone other than the patient.

REQUIRED if patient is covered by another insurance plan.

9a

Other insured's policy or group number

Conditional

REQUIRED if field 9 is completed. Enter the policy of group number of the other insurance plan

9b

Reserved for NUCC

Not required

9c

Reserved for NUCC

Not required

9d

Insurance plan name or program name

Conditional

REQUIRED if field 9 is completed.

10 a, b, c

Is patient's condition related to:

Required

10d

Claims codes
(designated by NUCC)

Conditional

11

Insured policy or FECA number

Conditional

REQUIRED when other insurance is available.

11a

Insured date of birth and sex

Conditional

11b

Other claims ID
(designated by NUCC)

Conditional

11c

Insurance plan name or program number

Conditional

11d

Is there another health benefit plan

Required

12

Patient's or authorized person's signature

Conditional - Enter "Signature on File," "SOF," or the actual legal signature.

13

Insured's or authorized person's signature

Not required

14

Date of current:
Illness (First symptom) or Injury (Accident) or Pregnancy (LMP)

Conditional

15

If patient has same or similar illness. Give first date.

Conditional

16

Dates patient unable to work in current occupation

Conditional

17

Name of referring physician or other source

Conditional - Enter the name of the referring physician or professional (first name, middle initial, last name, and credentials)

17a

ID number of referring physician

Conditional

REQUIRED if field 17 is completed.

17b

NPI number of referring physician

Conditional

REQUIRED if field 17 is completed. If unable to obtain referring NPI, servicing NPI may be used

18

Hospitalization on dates related to current services

Conditional

19

Reserved for local use - new form: Additional claim information

Conditional

20

Outside lab/ charges

Conditional

21

Diagnosis or nature of illness or injury (related items A-L to item 24E by line). New form allows up to 12 diagnoses, and ICD indicator

Required - Include the ICD indicator

22

Resubmission code /original REF

Conditional - For resubmissions or adjustments, enter the original claim number of the original claim.

23

Prior authorization number or CLIA number

If authorization then conditional
If CLIA then required
If both, submit the CLIA number

Enter the authorization or referral number. Refer to the provider operations manual for information on services requiring referral and/or prior authorization.

CLIA number for CLIA waived or CLIA certified laboratory services

24 A-G Shaded

Supplemental information

Conditional - The shaded top portion of each service claim line is used to report supplemental information for:

NDC

Narrative description of unspecified codes

Contract rate

For detailed instructions and qualifiers refer to Appendix IV of this guide

24A Unshaded

Dates of service

Required

24B Unshaded

Place of service

Required

24C Unshaded

EMG

Not required

24D Unshaded

Procedures, services or supplies CPT/HCPCS modifier

Required - Ensure NDC or UPN are included if applicable.

24 E Unshaded

Diagnosis code

Required

24 F Unshaded

Charges

Required

24 G Unshaded

Days or units

Required

24 H Shaded

EPSDT (Family Planning)

Conditional - Leave blank or enter "Y" if the services were performed as a result of an EPSDT referral

24 H Unshaded

EPSDT (Family Planning)

Conditional - Enter the appropriate qualifier for EPSDT visit

24 I Shaded

ID qualifier

Required

24 J Shaded

Non-NPI provider ID#

Required

24 J Unshaded

NPI provider ID

Required

25

Federal Tax ID number SSN/EIN

Required

26

Patient's account NO

Conditional - Enter the provider's billing account number

27

Accept Assignment?

Conditional - Enter an X in the YES box. Submission of a claim for reimbursement of services provided to a recipient using state funds indicates the provider accepts assignment.

28

Total charge

Required

29

Amount paid

Conditional

REQUIRED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing.

30

Balance due

Conditional

REQUIRED when field 29 is completed.
Enter the balance due (total charges minus the amount of payment received from the primary payer).

31

Signature of physician or supplier including degrees or credentials

Required

32

Service facility location information

Conditional

REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

32a

NPI - Services rendered

Conditional

Typical providers ONLY: REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

32b

Other provider ID

Conditional

REQUIRED if the location where services were rendered is different from the billing address listed in field 33.

33

Billing provider INFO & PH#

Required

33a

Group billing NPI

Required

33b

Group billing other ID

Required 

1

Unlabeled field

Required

2

Unlabeled field

Not required

3a

Patient control no

Not required

3b

Medical record number

Required

4

Type of bill

Required

5

Fed Tax No

Required

6

Statement covers period from/through

Required

7

Unlabeled field

Not required

8a

Patient name

Not required

8b

Patient address

Required

9

Patient address

Required - Except line 9e county code.

10

Birthdate

Required - Ensure DOB of patient is entered and not the insured)

11

Sex

Required

12

Admission date

Required

13

Admission hour

Required

14

Admission type

Required

15

Admission source

Required

16

Discharge hour

Conditional - Enter the time using two-digit military times (00-23) for the time of the inpatient or outpatient discharge.

17

Patient status

Required

18-28

Condition codes

Conditional

REQUIRED when condition codes are used to identify conditions relating to the bill that may affect payer processing.

29

Accident state

Not required

30

Unlabeled Field

Not required

31-34 a-b

Occurrence code and occurrence date

Conditional

REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing.

35-36 a-b

Occurrence
SPAN code and Occurrence date

Conditional

REQUIRED when occurrence codes are used to identify events relating to the bill that may affect payer processing.

37

Unlabeled field

Conditional

REQUIRED for re-submissions or adjustments. Enter the DCN (document control number) of the original claim

38

Responsible party name and address

Not required

39-41 a-d

Value codes and amounts

Conditional

REQUIRED when value codes are used to identify events relating to the bill that may affect payer processing.

42 Lines 1-22

REV CD

Required

42 Line 23

Rev CD

Required

43 Lines 1-22

Description

Required

43 Line 23

PAGE ___ OF ___

Conditional - Enter the number of pages. (Limited to 4 pages per claim)

44

HCPCS/Rates

Conditional

REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed.

45 Lines 1-22

Service date

Conditional

REQUIRED on all outpatient claims. Enter the date of service for each service line billed (MMDDYY). Multiple dates of service may not be combined for outpatient claims

45 Line 23

Creation date

Required

46

Service units

Required

47 Lines 1-22

Total charges

Required

47 Line 23

Totals

Required

48 Lines 1-22

Non-covered charges

Conditional - Enter the non-covered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts

48 Line 23

Totals

Conditional - Enter the total non-covered charges for all service lines

49

Unlabeled field

Not required

50 A-C

Payer

Required

51 A-C

Health plan identification number

Not required

52 A-C

REL information

Required

53

ASG. BEN.

Required

54

Prior payments

Conditional - Enter the amount received from the primary payer on the appropriate line when Health Net is listed as secondary or tertiary

55

EST amount due

Not required

56

National Provider Identifier or provider ID

Required

57

Other provider ID

Required

58

Insured's name

Required

59

Patient relationship

Not required

60

Insured unique ID

Required

61

Group name

Not required

62

Insurance group no.

Not required

63

Treatment authorization code

Conditional - Enter the prior authorization or referral when services require precertification

64

Document control number

Conditional - Enter the 12-character original claim number of the paid/denied claim when submitting a replacement or void on the corresponding A, B, C line reflecting Payer from field 50.

65

Employer name

Not required

66

DX version qualifier

Required

67

Principal diagnosis code

Required

67 A-Q

Other diagnosis code

Conditional - Enter additional diagnosis or conditions that coexist at the time of admission

68

Present on admission indicator

Required

69

Admitting diagnosis code

Required

70

Patient reason code

Required

71

PPS/DRG code

Not required

72 a, b, c

External cause code

Not required

73

Unlabeled field

Not required

74

Principal procedure code/date

Conditional - Enter the ICD-10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code; it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY).

74 a-e

Other procedure code date

Conditional

REQUIRED on inpatient claims when a procedure is performed during the date span of the bill.

75

Unlabeled field

Not required

76

Attending physician

Required

77

Operating physician

Conditional

REQUIRED when a surgical procedure is performed. Enter the NPI and name of the physician in charge of the patient care.

78 & 79

Other physician

Conditional

80

Remarks

Not required

81

CC

Required

82

Attending Physician

Required