Blue Cross scans all paper claims to eliminate the need to manually enter the claims data into our system. Please follow the guidelines below to ensure that your claims are scanned properly, which will allow you to benefit from faster, more accurate claims processing:
• Blue Cross does not accept black and white hardcopy claim forms. Do not submit black and white copies, as data recoginition can be affected and may delay the processing of claim payments. Black and white claims are less legible after they are scanned.
• Laser printed claims produce the best scanning results. If you use a dot-matrix printer, please use a standard 10 or 12 font ribbon when the type begins to fade.
• Use CMS-1500 forms that are printed on good quality paper. When the paper is too thin, the claim cannot be scanned properly.
• Type or computer print all information within the appropriate blocks on the CMS-1500 claim form. Information should not overlap from one block into another.
• Type or computer print Block 14. This information cannot be handwritten because only typed information can be scanned and converted to text file for our system to process.
• If there is a signature in Block 31, it should not overlap into Block 25 (Federal Tax ID number) because the Tax ID number cannot be read.
• Do not use any stamps or stickers on your claim forms. The scanning equipment has a lamp that distorts stamps with black ink and completely removes any information with red ink. Therefore, stamps with pertinent information in red ink, such as “Benefits Assigned” or “Corrected Copy,” will be lost if the claim is scanned.
Health Insurance Claim Form (CMS-1500 Version 02-12) Explanation
Block 1 Type(s) of Health Insurance - Indicate coverage applicable to this claim by checking the appropriate block(s).
Block 1A Insured’s I.D. Number - Enter the member’s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card.
Block 2 Patient’s Name - Enter the full name of the individual treated.
Block 3 Patient’s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block.
Block 4 Insured’s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word “same” may be entered.
Block 5 Patient’s Address - Enter the patient’s complete, current mailing address and phone number.
Block 6 Patient’s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the member. Spouse - Patient is the member’s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren).
Other - Patient is the member’s grandchild, adult-sponsored dependent or of a relationship not covered previously.
Block 7 Insured’s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient’s address and the insured’s address are the same, enter “same” in this field.
Block 8 Reserved for NUCC USE - This section is reserved for NUCC use. Deleted “Patient Status” and content of field.
Block 9 Other Insured’s Name - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known).
Block 10 Is patient’s condition related to: a. Employment (current or previous)?; b. Auto Accident?;
c. Other Accident?. Check appropriate block if applicable.
Block 10D When applicable, use to report appropriate claim codes. Applicable claim codes are designated by the NUCC. Please refer to the most current instructions from the public or private payer regarding the need to report claim codes. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field. The Condition Codes approved for use on the CMS-1500 Claim Form are available at www.nucc.org under Code Sets. When reporting more than one code, enter three blank spaces and then the next code.
Block 11 Not required.
Block 11D When appropriate, enter an X in the correct box. If marked “YES,” complete 9, 9A, and 9D.
Only mark one box.
Block 12 Patient’s or Authorized Person’s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or “Signature on File” and date required. “Signature on File” indicates that the
signature of the patient is contained in the provider’s records.
Block 13 Insured’s or Authorized Person’s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from members who do not have a copayment benefit and having the payments sent to
the patients. To receive payment for office services when the copayment benefit is not applicable,
Block 13 must be completed. Acceptable language is:
a. Signature in block d. Benefits assigned
b. Signature on file e. Assigned
c. On file f. Pay provider
Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment.
Block 14 Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the present illness, injury or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.
Block 15 Enter another date related to the patient’s condition or treatment. Enter the date in the date in the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) format. Enter the applicable qualifier to identify which date is being reported.
Block 16 Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable.
Block 17 Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported to the left of the vertical, dotted line.
Block 17A Other ID#. The non-NPI ID number of the referring physician, when listed in Block 17.
Block 17B NPI – Required. Enter the national provider identifier (NPI) for the referring physician, when listed in Block 17.
Block 18 For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital.
Block 19 Additional Claim information to be completed by NUCC.
Block 20 Laboratory Work Performed Outside Your Office - Enter, if applicable.
Block 21 Diagnosis or Nature of Illness or Injury - Enter the applicable ICD indicator to identify which version of ICD codes is being reported: “0” for ICD-10-CM codes- Note:
All transactions, electronic or paper-based, for services on and after October, 1, 2015, must contain ICD-10 codes or they will be rejected. Blue Cross will not accept ICD-9 codes with dates of services on or after October 1, 2015. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. Use the most specific diagnosis codes when reporting codes. List no more than 12 ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
Block 23 Prior Authorization Number - Enter the authorization number obtained from Blue Cross HMO Louisiana, if applicable.
Block 24A Date(s) of Service - Enter the “from” and “to” date(s) for service(s) rendered. Report the NDC in the shaded area.
We follow CMS billing requirements for CMS1500 claims when billing the NDC codes: (CMS Claims Processing Manual, chapter 26, section 10.4) states the following:
Item 24 - The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.
When required to submit NDC drug and quantity information submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g. N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space-fill the remaining positions (e.g., UN2 or F2999999).
Block 24B Place of Service - Enter the appropriate place of service code. Common place of service codes are: Inpatient - 21 Outpatient - 22 Office - 11
Block 24C EMG - Enter the Type of Service code that represents the services rendered.
Block 24D Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate.
Block 24E Diagnosis Pointer - Enter the diagnosis code reference letter (pointer) as shown in Block 21 to relate the date of service and procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in Block 21 only.
Do not enter them in 24E.
Block 24F Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges.
Block 24G Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Base units value should never be entered in the “units” field of the claim form.
Block 24J Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians’ services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians,
Diagnostic Radiology Center, Laboratory and Diagnostic Services and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32A and 33A as instructed.
*Rural health clinics and Federally Qualified Health Centers are required to enter the rendering provider NPI.
Block 25 Federal Tax I.D. Number - Enter the provider’s/clinic’s federal tax identification number to which payment should be reported to the Internal Revenue Service.
Block 26 Patient’s Account Number - Enter the patient account number in this field. As many as nine characters may be entered to identify records used by the provider. The patient account number will appear on the Provider Payment Register/Remittance Advice only if it
is indicated on the claim form.
Block 27 Accept Assignment - Not applicable - Used for government claims only.
Block 28 Total Charge - Total of all charges in Item F.
Block 29 Amount Paid - Not required.
Block 30 Not required.
Block 31 Signature of Provider - Provider’s signature required, including degrees and credentials.
Rubber stamp is acceptable.
Block 32 Name and Address of Facility - Required, if services were provided at a facility other than the physician’s office.
Block 32A NPI - Enter the NPI for the facility listed in Block 32.
Block 32B Other ID. The non-NPI number of the facility refers to the payer-assigned unique identifier of the facility.
Block 33 Billing Provider Info & Ph# - Enter complete name, address, telephone number for the billing provider.
Block 33B Other ID#. The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional.
Block 33A NPI - Enter the NPI for the billing provider listed in Block 33.