Claims Submission Toolkit - AmeriHealth.com
Claims Submission Toolkit - AmeriHealth.com
Claims Submission Toolkit - AmeriHealth.com
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<strong>Claims</strong> submission toolkit for proper<br />
electronic and paper claims submissions<br />
Inside this toolkit you will find tips for submitting your electronic and paper claims. This toolkit also contains the latest news<br />
on electronic and paper claims submissions, the CMS-1500 claim form, key fields, and loop and data elements, plus resources<br />
for finding additional information.<br />
Processing of claims<br />
For purposes of processing a claim, you must submit your registered National Provider Identifier (NPI). In accordance with the<br />
reimbursement terms of your provider contract, you may continue to provide your 10-digit legacy provider ID number. Only a<br />
valid NPI will be accepted by us as the primary identifier on the claim.<br />
Electronic claims submission<br />
<strong>AmeriHealth</strong> systems accept 837P (professional) and 837I (institutional) version 4010A1 electronic claims with an NPI. We<br />
will reject any electronic claim that does not have an NPI as the provider’s primary identifier. If you do not currently have an<br />
NPI registered with <strong>AmeriHealth</strong>, please visit www.amerihealth.<strong>com</strong>/npi for more information.<br />
The information on the following pages regarding loop and data elements will assist you in entering in your NPI and optional<br />
submission of your legacy provider ID number when submitting electronic claims.<br />
Professional loop and data elements<br />
Loop Data element Industry name Content<br />
2000A<br />
PRV03<br />
BILLING PROVIDER SPECIALTY INFORMATION<br />
Provider Taxonomy Code — If 2310B is created, the provider<br />
should not build PRV03 @2000A loop.<br />
Taxonomy<br />
2010AA<br />
2310A<br />
2310B<br />
2310D<br />
2420A<br />
BILLING PROVIDER NAME<br />
NM109 Billing Provider Primary Identifier NPI<br />
REF02 Billing Provider Secondary Identification Number Tax ID<br />
REF02 Billing Provider Secondary Identification Number Legacy<br />
REFERRING PROVIDER NAME<br />
NM109 Referring Provider Primary Identifier NPI<br />
PRV03 Referring Provider Taxonomy Code Taxonomy<br />
REF02 Referring Provider Secondary Identifier Tax ID<br />
REF02 Referring Provider Secondary Identifier Legacy<br />
RENDERING PROVIDER NAME<br />
NM109 Rendering Provider Primary Identifier NPI<br />
PRV03<br />
Rendering Provider Taxonomy Code — If 2310B is created,<br />
the provider should not build PRV03 @2000A loop.<br />
Taxonomy<br />
REF02 Rendering Provider Secondary Identifier Tax ID<br />
REF02 Rendering Provider Secondary Identifier Legacy<br />
SERVICE FACILITY LOCATION<br />
NM109 Laboratory or Facility Primary Identifier NPI<br />
REF02 Laboratory or Facility Secondary Identifier Legacy<br />
REF02 Laboratory or Facility Secondary Identifier Tax ID<br />
RENDERING PROVIDER NAME<br />
NM109 Rendering Provider Primary Identifier NPI<br />
PRV03 Rendering Provider Taxonomy Code Taxonomy<br />
REF02 Rendering Provider Secondary Identifier Tax ID<br />
REF02 Rendering Provider Secondary Identifier Legacy<br />
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<strong>AmeriHealth</strong> HMO, Inc. • <strong>AmeriHealth</strong> Insurance Company of New Jersey •<br />
QCC Insurance Company d/b/a <strong>AmeriHealth</strong> Insurance Company
Institutional loop and data elements<br />
Loop Data element Industry name Content<br />
2000A<br />
BILLING PROVIDER SPECIALTY INFORMATION<br />
PRV03 Provider Taxonomy Code Taxonomy<br />
2010AA<br />
2310A<br />
2310B<br />
2310C<br />
2310D<br />
2310E<br />
2420A<br />
2420B<br />
BILLING PROVIDER NAME<br />
NM109 Billing Provider Primary Identifier NPI<br />
REF02 Billing Provider Secondary Identification Number Tax ID<br />
REF02 Billing Provider Secondary Identification Number Legacy<br />
ATTENDING PHYSICIAN NAME<br />
NM109 Attending Physician Primary Identifier NPI<br />
PRV03 Attending Physician Taxonomy Code Taxonomy<br />
REF02 Attending Physician Secondary Identifier Tax ID<br />
REF02 Attending Physician Secondary Identifier Legacy<br />
OPERATING PHYSICIAN NAME<br />
NM109 Operating Physician Primary Identifier NPI<br />
PRV03 Operating Physician Taxonomy Code Taxonomy<br />
REF02 Operating Physician Secondary Identifier Tax ID<br />
REF02 Operating Physician Secondary Identifier Legacy<br />
OTHER PROVIDER NAME<br />
NM109 Other Provider Primary Identifier NPI<br />
PRV03 Other Provider Taxonomy Code Taxonomy<br />
REF02 Other Provider Secondary Identifier Tax ID<br />
REF02 Other Provider Secondary Identifier Legacy<br />
REFERRING PROVIDER NAME<br />
NM109 Referring Provider Primary Identifier NPI<br />
PRV03 Referring Provider Taxonomy Code Taxonomy<br />
REF02 Referring Provider Secondary Identifier Tax ID<br />
REF02 Referring Provider Secondary Identifier Legacy<br />
SERVICE FACILITY NAME<br />
NM109 Facility Primary Identifier NPI<br />
PRV03 Facility Provider Taxonomy Code Taxonomy<br />
REF02 Facility Secondary Identifier Tax ID<br />
REF02 Facility Secondary Identifier Legacy<br />
ATTENDING PHYSICIAN NAME<br />
NM109 Attending Physician Primary Identifier NPI<br />
PRV03 Attending Physician Taxonomy Code Taxonomy<br />
REF02 Attending Physician Secondary Identifier Tax ID<br />
REF02 Attending Physician Secondary Identifier Legacy<br />
OPERATING PHYSICIAN NAME<br />
NM109 Operating Physician Primary Identifier NPI<br />
PRV03 Operating Physician Taxonomy Code Taxonomy<br />
REF02 Operating Physician Secondary Identifier Tax ID<br />
REF02 Operating Physician Secondary Identifier Legacy<br />
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Paper professional claims submission<br />
The CMS-1500 (08/05) claim form must be used if submitting paper claims.<br />
NPIs are required when submitting a CMS-1500 (08/05) claim form. A sample CMS-1500 (08/05) claim form is provided<br />
on page 4. Please note the NPI-specific areas circled in green on the CMS-1500 claim form.<br />
You may continue to report current provider identification numbers in the appropriate shaded areas of the form (17a, 24J,<br />
32b, and 33b) until otherwise notified. Legacy provider ID numbers must be preceded by a two-character qualifier ID. This<br />
qualifier ID is the same as the qualifier ID used when billing electronically. If you do not currently bill electronically, please use<br />
the following qualifier ID: G2.<br />
Tips for proper paper submission<br />
▪▪ Tax ID is required.<br />
▪▪ Legacy provider ID is optional – Legacy provider ID is prefixed with G2.<br />
▪▪ The following identifiers are not valid in the NPI fields: tax ID number, Social Security number, corporate ID number.<br />
▪▪ The NPI is a unique 10-digit identification number. There are no dashes in the NPI. There is no prefix with the NPI.<br />
▪▪ The NPI for a physician may not be used as a billing NPI unless the physician is an individual/sole proprietor.<br />
▪▪ PIN and GROUP numbers have been eliminated from the CMS-1500 (08/05) claim form.<br />
▪▪ Boxes 17a, 32b, and 33b require the prefix: G2.<br />
▪▪ Box 19 requires a ZZ prefix with the Taxonomy Code.<br />
▪▪ Service facility boxes 32a and 32b are optional for New Jersey providers. Entering miscellaneous information in these<br />
fields can delay or reject your claim.<br />
Key fields for proper paper submission<br />
The following key fields must be entered correctly on the CMS-1500 (08/05) to ensure timely and accurate claims processing.<br />
Box Requirement Instructions<br />
17a Optional Enter referring provider’s two-character qualifier ID (G2) in the first segment and<br />
referring provider’s legacy provider ID in the second segment.<br />
17b Optional Enter referring provider’s NPI.<br />
19 As applicable Enter ZZ qualifier ID and billing provider’s primary Taxonomy Code.<br />
24I (shaded) Optional Enter rendering provider’s two-character qualifier ID (G2).<br />
24J (shaded) Optional Enter rendering provider’s legacy provider ID.<br />
24J (unshaded) Required Enter rendering provider’s NPI.<br />
32a As applicable Enter service facility NPI. This box applies to lab or radiology providers in<br />
Pennsylvania who perform outpatient services in a facility with a place of<br />
service code 22, 23, and/or 24.<br />
32b Optional Enter service facility two-character qualifier ID (G2) and legacy provider ID.<br />
33a Required Enter billing provider NPI.<br />
33b Optional Enter billing provider two-character qualifier ID (G2) and legacy provider ID.<br />
If you have any questions about <strong>com</strong>pleting the CMS-1500 (08/05) form, the NPI application process, or reporting your NPI<br />
to us, please call your Network Coordinator or contact Customer Service at 1-800-275-2583.<br />
Note: CMS-1500 (08/05) form submissions with incorrect or in<strong>com</strong>plete information entered in key fields may be rejected or<br />
returned to the provider. Refer to the illustration on page 4 for additional information.<br />
Important resources<br />
For additional information about NPI or Medicare NPI implementation, please visit the Centers for Medicare & Medicaid<br />
Services main NPI website at www.cms.hhs.gov/NationalProvIdentStand.<br />
For claims submission addresses, visit our website at www.amerihealth.<strong>com</strong>/claim_submission.<br />
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CMS-1500 (08/05)<br />
ABC1234567800<br />
Doe, John B.<br />
1234 Main Street<br />
03 20 7 1<br />
Doe, John B.<br />
1234 Main Street<br />
Anytown<br />
NJ<br />
Anytown<br />
NJ<br />
08999 856 555-2222<br />
Doe, Mary<br />
72431<br />
10 21 70<br />
self-employed<br />
08999 856 555-2222<br />
15974<br />
03 20 71<br />
Watch Repair, Inc.<br />
<strong>AmeriHealth</strong> PPO<br />
HMO, Inc.<br />
Referring Provider’s<br />
two-character qualifier ID<br />
Referring Provider’s<br />
Current Provider ID<br />
10 28 06<br />
Josephine Smith, M.D.<br />
ZZ207LP2900X<br />
ZZ qualifier ID and Billing Provider’s<br />
Primary Taxonomy Code<br />
G2 0123456789<br />
999999999<br />
Referring Provider’s NPI<br />
11 01 06 11 04 06<br />
401<br />
251 8<br />
123456789<br />
11 02 06 11 02 06 21 6<br />
99205<br />
1 $50 00 1<br />
G2<br />
1234567000<br />
8888888888<br />
11 03 06 11 03 06 21 6<br />
20600 25<br />
2<br />
$250 00 1<br />
Two-character qualifier ID<br />
of the Rendering Provider<br />
22-1234567<br />
Richard B. Smith, M.D.<br />
11/5/06<br />
Service<br />
Facility<br />
NPI<br />
ABC Hospital<br />
123 Street<br />
Anytown, NJ 08999<br />
Service Facility<br />
two-character<br />
qualifier and<br />
Current Provider<br />
ID number<br />
0000001234 G21234567002<br />
Billing<br />
Provider<br />
NPI<br />
100 00<br />
ABC Medical Group<br />
8 North American Street<br />
Anytown, NJ 08999<br />
856 555-5555<br />
2222222222 G21234567001<br />
Billing Provider<br />
two-character<br />
qualifier ID and<br />
current Provider<br />
ID number<br />
Red items are required by <strong>AmeriHealth</strong> for payment.<br />
Blue items are required for payment when applicable to the patient’ s condition/situation.<br />
Black items are optional.<br />
Indicates new field and/or requirement.<br />
Circled items are NPI-specific.<br />
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