DEPARTMENT OF SOCIAL AND HEALTH SERVICES HEALTH AND RECOVERY SERVICES ADMINISTRATION Olympia, Washington
To: All Providers Managed Care Organizations Memorandum No:
06-04 Issued: February 6, 2006
From: Douglas Porter, Assistant Secretary
Health and Recovery Services Administration (HRSA) For information, contact: 800.562.3022
Subject: Update HCFA-1500 Claim Form Instructions and page updates for the General Information Booklet.
The Health and Recovery Services Administration (HRSA) has updated the instructions for completing paper copies of the HCFA-1500/CMS-1500 and is adding a new section to the General Information booklet on How to Complete a HCFA .
Claim Form (HCFA-1500 or CMS-1500)
The Health Insurance Claim Form is now officially called -Providers can order and purchase --forms
on-line from many office supply stores.
Because HRSA billing instructions still refer to -, HRSA will continue to u- - until all of the billing instructions are updated.
HRSA uses Optical Character Recognition (OCR) equipment to process paper claim forms.
Use only the original pre-printed red and white CMS-1500 claim forms (version 12/90 or later, preferable on 20# paper).
The CMS-1500 form is designed specifically for OCR systems.
The scanner does not read black and white (copied, carbon, or laser-printer generated) CMS-1500 claim forms.
Most of HRSAs billing instructions include -section.
HRSA periodically revises this section according to ongoing system changes.
This memorandum introduces a number of updates to this section for certain fields on the claim form.
HRSA will incorporate these updates into specific program billing instructions as these billing instructions are reviewed and revised.
in addition to those below for completing the HCFA-1500 or CMS-1500 form for your specific program.Numbered Memorandum 06-04
February 6, 2006 Page 2
Updated Claim Form Fields
Field 17a ID Number of Referring Physician
If a referring provider does not have an HRSA-assigned ID number, enter 8900946 into Field 17a.
Use this standard number only for referring providers who are non-Medicaid referring providers.
Providers can find more information by visiting the Provider Number Reference web site: 19 Reserved for Local Use
Use Field 19 for comments that require a claims specialist to review a claim before payment is made.
Inappropriate comments in this field may result in delayed processing of claims.
Examples of appropriate comments include the following:
A or B;
A, triplet B, or C;
National Drug Codes); and
Field 24D Procedures, Services, or Supplies CPT/HCPCS
When appropriate, providers enter a modifier in this Field 24D
If there is more than one modifier, list them in descending numerical order.
For 24E Diagnosis Code
Enter the valid ICD-9-CM diagnosis code exactly as shown in the current volume of the ICD-9-CM manual, or relate each line item to Field 21 by entering a 1, 2, 3, or 4.
Enter the principal diagnosis as the first diagnosis code.
Providers must follow additional digital requirements found in the ICD-9-CM manual.Numbered Memorandum 06-04
January 30, 2006 Page 3
Field 26 - Patient Account Number
Providers create this number.
HRSA prints the characters entered in Field 26 on Remittance and Status Report (RA) under the heading Patient Account Number.
If providers use symbols in Field 26 (on paper or electronic claims) this may invalidate an electronic RA.
To ensure correct processing of an electronic RA, do not use spaces or the following characters in Field 26:
Field 30 Balance Due
Calculating the estimated payment due:
Results in faster adjudication and fewer rebilled claims; and
Aligns HRSA-party payers.
HRSA automatically calculates the estimated payment due for physician, dental, and institutional claims (excluding Medicare crossover claims).
HRSA calculates this amount on both electronic and paper claims.
This calculation takes place when the estimated payment due is either missing or not calculated correctly on the claim form and providers indicate one of the following:
Patient spenddown (if applicable); and
Noncovered charges on the claim form.
Providers must indicate the total charges on the claim and use the claim form specified in the nstructions.
Place only six detail lines on each claim form.
HRSA claim forms.
If more than six detail lines are needed, use additional claim forms.
Total each claim form separately.
Do not indicate the entire total (for all claims) on the
If the provider does not include or miscalculates the total charges on the claim form, HRSA will deny the claim.
Numbered Memorandum 06-04
January 30, 2006 Page 4
Field 33 - PIN #
HRSA assigns this 7-digit number to identify the performing individual (e.g., the physician or Advanced Registered Nurse Practitioner who performed the service) when the individual is part of a group, such as a clinic, which has its own assigned provider numbers for billing purposes.
General Information Booklet New Replacement Pages
Attached are updated and new General Information Booklet pages i - iv and H.11-H.18.
How do I conduct business electronically with HRSA?
You may conduct business electronically with HRSA by accessing the WAMedWeb at can I get HRSA provider issuances?
To obtain DSHS/HRSA provider numbered memoranda and billing instruction, go to the DSHS/HRSA website at http://hrsa.dshs.wa.gov (click the Billing Inst
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