part ii policies and procedures for rural health clinic services

APPENDIX EBILLING INSTRUCTIONS AND CLAIM FORMSDetailed information and instructions for completion and submittal of claim forms can be foundin this section. Claims must be filed on the required form with appropriate information inspecific blocks for payment. Claim form for Rural Health Center Services is:Health Insurance Claim Form (CMS-1500)Claim (s) must be submitted within (6) months from the month of service. Claim(s) withthird party resource(s) must be submitted within twelve (12) months from the month ofservice.UB-04 (National Uniform Billing Form)Claim (s) must be submitted within (6) months from the month of service. Claim(s) withthird party resource(s) must be submitted within twelve (12) months from the month ofservice.Medicaid/Medicare Crossover CMS-1500A special crossover claim form is no longer required when billing Medicaid/Medicarecrossover. Claim(s) must be submitted in the same format as they are submitted toMedicare. This claim must have an Explanation of Medicare Benefits (EOMB) fromMedicare for Medicaid payment. Claim(s) must be submitted within twelve (12) monthsfrom the month of service.For specific Medicare crossover claims instructions and tips for submitting crossoverclaims, RHC providers should refer to the “Medicaid Secondary Claims User Guide”located online at www.mmis.georgia.gov under Medicaid Provider Manuals.Billing ManualThe Billing Manual has been added to Part 1 of the Policies and Procedures for Medicaid/PeachCare for Kids Manual. Please refer to this Billing Manual for general billinginstructions, questions, and the appeals process.Note: Appendix F should be referred to by RHC providers for specific billinginstructions.January 2012Rural Health Clinic Services E-1