CMS 1500 Claims Filing Highlights

To expedite processing, please complete your claims carefully. Clear, accurate information is essential for HMSA to process your claims correctly and without delay. The following CMS 1500 claims filing highlights will help you prepare claims that can be processed quickly and accurately.

• Ask your patient, each time he or she visits, if there has been a change in his or her medical coverage. Doing so will enable you to provide HMSA with a correct member ID number and reduce the number of claims that are returned to you for corrected membership information. Membership information can also be validated on HHIN+.
• Be sure to enter the patient's date of birth in Block 3, carefully and in the proper format. Both MMDDYY and MM DD YY are the acceptable formats. The century portion of the birth year should be excluded. Please do not use slashes or dashes when typing dates.
• Both the provider's signature (or the signature of an authorized representative) and the correct HMSA provider number are needed to process the claim. If a signature stamp or electronic signature is used, it must be initialed by the provider or authorized agent. If either the provider's signature or HMSA provider number is missing or illegible, the claim may be returned to you.
• Providers with more than one location or line of business should verify that they are billing under the correct provider number and that the provider number they use is active for the dates of service being billed.
• Always use the most current code books available. CPT, HCPCS and ICD-9-CM/ICD-10-CM are updated yearly; new codes are added and outdated codes are deleted. Be sure to validate that the codes were active on the date that the service was rendered.
• An ICD-9-CM/ICD-10-CM diagnosis code is required to indicate why specific services were rendered. When selecting a diagnosis code, use the most specific diagnosis available - through the fifth position when appropriate. (Note: Do not add zeros after the decimal to artificially create five positions.)
• When Motor Vehicle Insurance, Workers' Compensation, or other Third Party Liability issues are involved, please check the appropriate "Yes" box in Block 10 of the CMS 1500 claim form and list an "E" diagnosis code (describing the place of injury) as the final diagnosis in Block 21. You do not need to include any other information about the accident on the claim form; HMSA will ask the member for details. Note: a medical diagnosis code must accompany the "E" diagnosis code. Claims with only an "E" diagnosis code will be returned to you as an incomplete claim.
• Be sure to verify the codes entered on the claim form. A simple transposition error can delay the claim's processing or cause it to be processed incorrectly. In addition, it is necessary that the diagnosis referenced in Column 24E be the diagnosis that corresponds to the medical procedure code entered on that same line in Column 24D. If the diagnosis does not correspond to the medical procedure listed on the same line, payment will be denied for the procedure.
• When a patient is referred to you for service, please be sure to enter the name of the referring provider (in last name, first name, middle initial format) in Block 17 of the CMS 1500 claim form. Do not include the referring provider's title (e.g., M.D.). It is especially important to include the name of the referring provider on claims for consultations, physical therapy and speech therapy.
• For additional claims filing information specific to IV therapy services, refer to Claims Filing Highlights - IV Therapy.
• Service lines on the CMS claim form are designed to accommodate the service line itself as well as an informational area above each service line that is shaded in red. Enter only service line information as indicated by the column headers in the white shaded areas. All supplemental information must be contained in the red shaded areas above the service line or on an attachment to the claim itself.
• Do not skip service lines. Code service lines from the top down.
• Enter a start service date for all service lines, including the tax line.

Conditional Blocks

HMSA regards some blocks of the CMS 1500 claim form as conditional; they do not need to be completed on all claims, but must be completed under certain circumstances. For detailed information about the correct completion of each block on the CMS 1500 claim form, we encourage you to refer to CMS 1500 Claim Form - General Instructions.

We frequently receive claims that contain incorrect information in Blocks 17 or 18, or do not contain needed information in one of these blocks. Repeated below are instructions for completing these blocks. Please be sure to accurately complete the blocks, when applicable, or your claim may be rejected.

Block 17: Name of Referring (or ordering) Physician, is completed when a patient is referred by his or her physician to another physician for services. Block 17 must always be completed when lab, X-ray, physical therapy or speech therapy services are performed or durable medical equipment is provided. It must also be completed when a physician bills a consultation. This block should not be used to indicate a referral to a physician by a non-physician (e.g., a family friend has recommended that the patient seek your services). The correct format for completing this block is last name, first name, middle initial. Please omit titles or degrees (e.g., Dr., M.D. or Jr.) and punctuation.
This block should include an applicable Provider Qualifier Code to be entered to the left of the vertical dotted line. 

• DN = Referring Provider 
• DK = Ordering Provider 
• DQ = Supervising Provider

HMSA will reject the claim if the qualifier is missing.

An Ordering Provider pertains to a provider who is ordering non-physician items such as DMEPOS, imaging and clinical laboratory services. A Referring Provider pertains to a provider referring a patient to another provider.

Block 18: Hospitalization Dates Related to Current Services, must be used when a provider bills for services rendered to an inpatient (e.g., a major surgical procedure or an inpatient consultation). The dates should be entered in the following format: MMDDYY (070111 is preferred; 07 01 11 is also acceptable, but do not use slash marks). The date of service in Block 24A should fall within the range of dates for the inpatient stay. Be sure that you also enter the name and address of the hospital in Block 32. If you are treating a patient as an outpatient subsequent to his or her confinement, do not indicate the dates of the patient's hospital stay on the claim.

Claims Scanning

HMSA's claims scanner allows us to automatically enter clearly presented information from your claims into our claims processing system. When we utilize this equipment, we can process your claims promptly and avoid data processing errors. Claims that cannot be scanned must be manually entered into the claims processing system. You can facilitate the timely, accurate processing of your claims by:

• Typing or computer printing your claim.
• Using black or dark blue ink. Do not use red ink. Red ink is not preserved in the scanning process.
• Using an Arial or Times New Roman font with a font size of 8-10 that is bolded.
• Not obscuring any information with a highlighter.

Prompt Claims Filing

Please remember that it is important to file your claims on a timely basis. Claims that are not filed within one year of the date of service are not payable. This time frame also applies when HMSA is your patient's secondary insurance carrier.

Exceptions to the filing-time limitation

An exception may be made to the one-year filing-time limitation when HMSA is secondary to Medicare. In such a case, you must file your claim for secondary benefits within one year of the date Medicare paid or denied the claim. In addition, claims for members of the Federal Plan (coverage code 87) must be submitted by the end of the year following the year during which services were rendered (e.g., services rendered in July 2011 must be submitted before December 31, 2012). Even though filing limitations for the above-referenced plans may be extended beyond one year under certain conditions, it is to your advantage to file your claims in a timely manner.

Revision History