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GENERAL REQUIREMENTS
■
Use original claim forms (red and
white) CMS 1500.
■
Don’t use copies of claim forms.
■
Detach claims at perforated lines
before mailing.
■
Don’t fold claim forms, corrected
claims, appeals or correspondence.
■
Don’t use labels, stickers or stamps
on the claim form.
■
Don’t send duplicate copies of
information.
■
Don’t mail claims with correspon-
dence for other departments, such as
Complaints and Appeals.
■
Use 8½-by-11 inch paper. Don’t use
paper smaller or larger than 8½-by-11.
DATA FIELDS
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Print claim data within defined boxes
on the claim form.
■
Use black ink, but not a black marker.
Don’t use red ink or highlighters.
■
Use all capital letters.
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Use a laser printer for best results.
■
Print using 10-pitch (12-point) Cou-
rier font, 10 point.
■
Don’t use proportional fonts, such as
Arial or Times Roman.
■
Don’t use a dot matrix printer, if
possible.
■
Don’t use dashes or slashes in data
fields.
ATTACHMENTS
■
Use paper clips or staple claims or ap-
peals if they include attachments. Don’t
use glue or tape.
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Place the claim form on top when
sending new claims, followed by
any medical records or other
attachments.
■
Ensure that all remittance advice
from primary carriers is attached and
include the denial descriptions.
■
Submit claim-correct claims with a
corrected claim form located on the El
Paso First website,
www.epfirst.com/forms/
corrected_claim_form.pdf
.
MULTIPLE CLAIM
SUBMISSION
■
Paper-clip or staple multiple claims.
■
Number the pages when sending
PO Box 971100
El Paso, TX 79997-1100
CHANGE SERVICE REQUESTED
Health
Quarterly
HEALTH QUARTERLY is published as a service for members
of the EL PASO FIRST HEALTH PLANS provider network. EL
PASO FIRST HEALTH PLANS Executive Offices are located at
1145 Westmoreland Drive, El Paso, TX 79925, 915-532-3778 or
877-532-3778,
www.epfirst.com
.
Information in HEALTH QUARTERLY comes from a wide range
of medical experts. If you have any concerns or questions
about specific content in this newsletter, call 915-532-3778 or
877-532-3778.
Models may be used in photos and illustrations.
Member services 877-532-3778
Copyright © 2012 Coffey Communications, Inc.
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Nonprofit Org.
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Walla Walla, WA
Permit No. 44
Filing claims
23. PRIOR AUTHORIZATION NUMBER
19. RESERVED FOR LOCAL USE
21. DIAGNOSES OR NATURE OF ILLNESS OR INJURY
(relate items 1, 2, 3 or 4 to form 24E by line)
1.
3.
2.
4.
22. MEDICAID RESUBMISSION
CODE
20. OUTSIDE LAB?
YES
NO
$ CHARGES
ORIGINAL REF. NO.
The authorization number should be 10 characters long with
a prefix of zeros (Example: 0000123456). All other characters
submitted in the authorization field will cause your claim to deny
with “Denial reason: Invalid authorization.” The authorization
number should be in
box 23
of the CMS1500 form.
Do not send:
■
CLIA numbers
(45D0123456).
■
Authorization
NOT needed.
■
Not first visit.
■
Expired.
■
117044.
attachments or multiple claims for
the same client (e.g., 1 of 2, 2 of 2).
■
The authorization number should
be 10 characters with a prefix of
zeros. Example: 0000123456.
All other characters submitted
in the authorization field will cause
denial of your claim for the reason:
“Invalid authorization.”
■
The authorization number
should be in box 23 of the
CMS1500 Form. Do not leave the
field blank if an authorization is
required.
■
Do not send:
CLIA numbers (45D0123456).
Authorization NOT Needed.
Not first visit.
Expired.
117044.