Where is the secondary insurance information placed on a CMS-1500 claim form
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Health First Colorado(Colorado's Medicaid program), covers Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as described in this manual. Durable Medical Equipment (DME) is defined as equipment that can withstand repeated use and that generally would be of no value to the member in the absence of a disability, illness or injury. Prosthetics and Orthotics (P&O or O&P) are defined as replacement, corrective, or supportive devices that artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or support a weak or deformed portion of the body. Disposable Medical Supplies (Supplies) are defined as supplies that are specifically related to the active treatment or therapy for an illness or physical condition, they are non-durable, disposable, consumable and/or expendable. This manual gives a summary of the covered DMEPOS benefits. It is periodically modified as new billing or policy information is implemented, therefore, the information in this manual is subject to change. The DMEPOS benefit may also be referred to as 'DME' or 'Supply'. Show
The list of open Supply Healthcare Common Procedure Coding System (HCPCS) Codes is provided in this manual, which Health First Colorado updates and makes available to all enrolled DME providers at least annually. Providers should consult the current Supply HCPCS Codes included in this manual for updated benefit coverage, limitations, and prior authorization request (PAR) requirements. Providers may refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10 Section 8.590), for specific regulations and guidance on providing the DMEPOS benefit. Eligible ProvidersProviders must be enrolled as a Health First Colorado provider in order to:
Note: For members with primary insurance refer to the PAR submission instructions below.
Prescribing ProvidersDMEPOS must be prescribed by a physician, physician assistant, or nurse practitioner. The prescription must be within the scope of the prescribing provider's license. Over-the-counter rapid COVID tests may also be prescribed by a pharmacist. Breast pumps may also be prescribed by a certified nurse midwife. Billing ProvidersBilling Providers (the provider that bills/submits the claim) must acquire and retain Medicare DME accreditation and must be enrolled with the Department as a Supply Provider. At the time of enrollment, the Department requires proof of Medicare accreditation. The following exceptions apply:
Mail order and out of state pharmacies do not qualify to provide DMEPOS though they may separately enroll as a Supply provider.
Out of state DMEPOS providers may only provide services for crossover Medicare/Health First Colorado members or have a specialized product that cannot be obtained through an in-state DMEPOS provider. The Billing Provider must retain the member's prescription and related documentation for services for at least six (6) years and make it available for audit by the Department and its agents or representatives. Covered BenefitsDMEPOS must be medically necessary and prescribed by an authorized prescriptive authority for use by an eligible member. The following are categories of covered benefits and are further outlined in this section. Additional DMEPOS items are listed in the DMEPOS HCPCS table section of this manual. Durable Medical EquipmentDME refers to equipment and appliances that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable. DME may be rented or purchased. Purchase: These items are purchased for a member. Rental/Purchase: In general, these items are rented or purchased as follows:
Once rental is initiated on an item, a subsequent request for prior approval of purchase of that item must be accompanied by additional supporting documentation validating the need for purchase. Rental reimbursements may not exceed the purchase price of the item. Once the purchase price of the item is reached, the rental will be considered purchased and no additional reimbursement will be made.
Example: If the monthly rental for an item is $30 and the new purchase price is $200, Health First Colorado will pay six (6) full months of rental, plus no more than $20 in the seventh month of rental. At that time, the item becomes the property of the member, and no more rental payments are made.
Continuous Rental: Most rented equipment will convert to purchase when the purchase price is met. The following are exceptions to this policy and may be rented indefinitely as they require frequent and/or substantial servicing:
Transcutaneous or Neuromuscular Electrical Nerve Stimulators (TENS or NMES) A prior authorization request (PAR) that includes a completed Questionnaire #9 is required for rental and purchase. A TENS or NMES unit must be trialed for at least a two (2) month rental period before a request for purchase will be considered.
Speech Generating Devices (SGDs) For SGD specific coverage please refer to this policy. SGDs allow a member with an expressive communication disorder (e.g., severe dysarthria, apraxia, aphasia, a laryngectomy and any other conditions that severely inhibit expressive communication) to express thoughts or ideas through an alternative means. SGDs are classified as either Digitized or Synthesized (CCR 2505-10, § 8.590.1.S):
Tablet Computers are a benefit when they are primarily utilized as a Synthesized SGD.
Tablet Computer - A portable, integrated SGD, contained in a single panel, which utilizes touch screen technology. It is a device that has been manufactured by an entity that does not specialize in the production of SGDs or has not been re-branded specifically as an SGD. Accessories for SGDs, such as speech generating software, mounting systems, safety and protection accessories (cases, screen protectors, etc.), and alternate access or input methods (buttons, switches, eye gaze, etc.), may be covered. Communication Assessment The assessment must include documentation of:
Prior Authorization Request (PAR) Process Repair Replacement (10 CCR 2505-10, § 8.590.2.K)
Accessories
Limitations Cochlear Implant Processor/Bone-Anchored Hearing Aids (BAHA) ReplacementsFor lost/stolen Processors:
For Upgrades:
Oxygen Contents and Oxygen Delivery Systems Oxygen contents and delivery systems must be billed by the Supply provider. Continuous and Bilevel Positive Airway Pressure Devices (CPAP/BiPAP) CPAPs and BiPAPs require a trial (rental) period of 30-90 days, in which the member must demonstrate compliance, before a purchase request will be approved. Home sleep studies are accepted and Questionnaire #8 is required for adults 21 years of age and over. Compliance is defined as usage that is 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the approved trial/rental period.
Note: All related supplies are inclusive of the device's rental reimbursement and cannot be billed separately.
CPAP/BiPAP Replacement and Supplies
Mobility Equipment (Manual Wheelchairs, Power Wheelchairs and Scooters) For Wheelchair specific coverage policy please refer to this Wheelchair Benefit Coverage Benefit. All mobility equipment purchases require a PAR and must be accompanied by a signed letter of medical necessity from a physician, physician assistant or nurse practitioner. Customized items must be identified separately and included in the letter of medical necessity. Members who meet medical criteria guidelines may receive one (1) primary device and, when deemed necessary, one (1) secondary device within a five (5)-year time period. Replacement of stolen equipment requires a police report that conforms to criteria outlined in the Colorado Revised Statutes. Primary and secondary equipment cannot be duplicates. Billing
Note: Any time used equipment or parts are provided rather than new equipment or parts, the UE modifier should be used or used in place of the NU modifier. Please reference the Used and Refurbished DME and P&O section for additional information. Repair Prior Authorization for Repairs and Modifications
PARs for wheelchair repair no longer require a prescription or signature from the physician. The DME supplier must have either supplied the member with the initial equipment and have all corresponding medical documentation on file or must obtain a written order prior to delivery (WOPD) that has the make, model, and serial number of the equipment requiring repair. A new WOPD is not required for each repair as long as the above listed criteria is met. Note: Repairs for members residing in a nursing facility may be covered if the wheelchair was owned by the member prior to entering the facility. In this instance, the PAR must indicate that the member is residing in the nursing facility by checking "yes" in the appropriate field on the PA request. The PAR will not be processed without this disclosure.
Complex Rehabilitation Technology (CRT) Program Overview CRT Adaptive Seating SystemsThe following are considered Adaptive Seating Systems and are therefore considered CRT as stated above. Special bathing, toileting, showering, and or combination systems. Adaptive Car Seats Activity Chairs Eligible Providers Complex Rehabilitation Technology must be prescribed by a physician, physician assistant or a nurse practitioner. The prescription must be within the scope of the prescribing provider's license. Billing Providers Only providers enrolled as a CRT supplier may bill for CRT codes. In order to qualify as a CRT supplier, providers must:
Existing Health First Colorado DME providers that want to enroll as a CRT Supplier, need to request a letter of intent to enroll as a CRT supplier. Suppliers with multiple Health First Colorado provider ID numbers need to submit a letter of intent for each provider ID number that will bill CRT for Health First Colorado.
Billing for Repairs
Enclosed/Safety Bed CoverageEffective May 1, 2022, Questionnaire #19 will no longer be used for these Prior Authorization Requests (PARs). Bed RailsBed rails are a covered benefit for hospital beds only and must be from the same manufacturer as the bed they will be installed on. Vocational DMEDurable Medical Equipment is reviewed for medical necessity on an individual basis. Requests determined to be primarily for vocational purposes are not considered a medical benefit and will not be covered. Prosthetics and Orthotics (P&O)The benefit includes, but is not limited to, items such as breast prostheses, braces, artificial limbs, implants, and orthopedic shoes for diabetic members. Some services require prior authorization. SuppliesDisposable Supplies Disposable supplies are a benefit of Health First Colorado for use by the member in his/her home. With the exception of gloves, the Home Health agency is responsible for providing all supplies necessary to meet the universal precaution requirement during a visit. Beginning August 1, 2015, nasal atomizers (A4210) are a benefit when used in conjunction with the rescue medications Naloxone or Midazolam. For coverage information on Naloxone and Midazolam, refer to Appendix P found under the Appendices drop-down section on the Billing Manuals web page. Trans Anal Irrigation Systems Trans Anal Irrigation Systems HCPCS Item Description Unit Limits A4459
Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type. 4 units per year A4453Rectal catheter for use with the manual pump-operated enema system, replacement only1 unit of service = 1 catheterIrrigation SuppliesAs part of the 2022 new HCPCS procedure codes, A4397 has been discontinued and replaced by A4436 (reusable irrigation sleeve) and A4437 (disposable irrigation sleeve). A4437 has specific coverage criteria that providers will be asked to verify during the PAR process. At least one of the following must be true for A4437 to be medically necessary:
Enteral Nutrition Products Enteral nutrition (EN) refers to medical formula/solutions when ordered by a physician, physician assistant, or nurse practitioner and provided according to standards of practice. The allowance for all items includes delivery to a member's residence. Equipment, supplies, and nutrients for enteral feeding or food supplements are a benefit when prior authorized. Durable Medical Equipment providers should request that members participate in the Women, Infants & Children (WIC) program as a primary resource for medically necessary enteral nutrition products. Enteral nutrition products are a covered benefit when a member has been prescribed over the WIC limit and or WIC is unable to fulfill the prescription due to supply. Providers have the option of requesting a three (3) month PAR for members in the process of applying for WIC. After WIC determination is completed, provider may then submit a new PAR for one (1) year less one (1) day. Questionnaire #10 for Oral and Enteral Nutrition Formula is not a required form as of 2018. However, it is still accepted as a form of documentation when signed by a physician. For accessibility, the questionnaire is posted on the Provider Forms site. However, this form is optional and is still only acceptable when signed by a physician. Human Milk Fortifier products are a covered benefit. PARs and claims must identify the calculated number of units as specified in the current Supply HCPCS Codes section of this billing manual. Nutritional supplements are not for replacement of conventional foods or for use as a convenience item. Breast Pump CoverageEffective for dates of service June 8, 2022, or later, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers may bill Health First Colorado as the primary payer for manual and or single user electric breastfeeding pumps. This limited coverage policy ended on June 7, 2022. The WIC program has not changed. Members may acquire a breast pump from Health First Colorado or WIC.
Home Intravenous (IV) Equipment Home Intravenous (IV) equipment is a benefit for administration of Total Parenteral Nutrition (TPN), administration of antibiotics, maintenance of electrolyte balances, hydration, or other medications. The home IV therapy solutions and medications in this manual that are indicated as a home mix are a pharmacy benefit. The following HCPCS codes must be provided by a pharmacy per pharmacy billing requirements using a rebatable National Drug Code (NDC) number: B4164, B4168, B4172, B4176, B4178, B4180, B4189, B4193, B4197, B4199, B4216, B5000, B5100, and B5200. These codes are only reimbursed as a supply benefit for crossover claims when provided as an inpatient therapy for full benefit Medicare-Health First Colorado members. Diabetic Supplies Most diabetic supplies, such as glucose testing meters, test strips and other related supplies are a benefit with a prescription from a physician, physician assistant or nurse practitioner. Diabetic supplies are available for insulin, and non-insulin dependent members. Diabetic supplies MUST be billed as DMEPOS. Pharmacies billing supplies must follow Supply billing procedures and will not be reimbursed if billed as a pharmacy claim using NDC codes. Continuous Glucose Monitor (CGM) Benefit Coverage CGMs and related supplies are covered by Health First Colorado when all of the following coverage criteria (1-5) are met:
CGM Prior Authorization Requests (PARs) must be submitted to the Department’s . PARs, including requests for CGM supplies, will be limited to a 6-month period. When requesting a CGM in the online PAR portal, providers will be asked whether the member has received or if there is documented plan to receive diabetes education specifically related to CGMs. CGM replacement policy per 8.590.2.J. Repairs and replacement parts are covered under the following conditions:
Initial Coverage Criteria
Reauthorization Criteria + Supplies
Covered Devices ManufacturerProductAbbottFreeStyle Libre 2AbbottFreeStyle Libre 3DexcomG6MedtronicGuardian Sensor 3InsuletOmnipod DASHInsuletOmnipod 5Billing for Omnipod®Procedure code A9274 with modifier U1 is a covered service and requires prior authorization for Omnipod® 5 and DASH® products. This code and modifier combination is manually priced. Claims must be submitted via the provider web portal with an invoice or manufacturer’s suggested retail price (MSRP) attached and the appropriate modifier for pricing. Over the Counter, At-Home COVID-19 TestsEffective January 15, 2022 OTC at-home COVID-19 rapid tests are a covered benefit for Health First Colorado Members. Providers should use HCPCS procedure code E1399+U1 to bill for these tests.
Incontinence Products or Briefs The prescribing practitioner's prescription must include incontinence as a condition of a primary or secondary diagnosis in order for the member to qualify for reimbursement by Health First Colorado. Diapers or briefs for children under four (4) years old are an expected childhood expense and are not a Health First Colorado benefit. COMBINATION LIMIT: Products are limited to 240 per calendar month in any combination of diapers, liners, and undergarments. Medically necessary usage above that amount requires prior authorization. Incontinence wipes are not a benefit. Medically necessary wipes are a benefit under EPSDT. Wipes for use by a Home Health provider are not a benefit. Prior Authorization Requests are not required. Effective July 1, 2021, providers must use HCPCS A9286 for this benefit. A4520 Incontinence garment, any type, (e.g. brief, diaper) each Special ConsiderationsRentalThere may be a financial cap on rental items. If the total cost for rental of an item reaches the cost of purchase, the item will be converted to a purchase unless otherwise specified. Rental amounts in excess of purchase amounts are subject to recovery. Modifier RR (rental) or KR (partial month rental) should be on all PARs (if required) and claims. One unit of a code with the RR modifier is the equivalent of a one-month rental. One unit of a code with the KR modifier is the equivalent of a one-day rental.
Accessories, supplies, maintenance, and repairs are inclusive in the reimbursement of rented equipment, unless otherwise specified.
For ventilator equipment that is considered a continuous rental, accessories and supplies may be billed separately. Continuous rental items (i.e. ventilators) do not require the KH (1st month rental) modifier. Additionally, if a member qualifies to have a back-up ventilator, two (2) units may be billed per month, otherwise, only one (1) unit is allowable. Continuous rental items require a Face-to-Face visit for both initial requests and renewals. See the section below. Related Medical SuppliesSupplies accompanying DME that has been prescribed and is owned by and currently being used by the member are covered. Used and Refurbished DME and P&OSupply providers have the option to request used and/or refurbished DME and P&O. Equipment may be donated, passed down from a sibling, or purchased from a DMEPOS provider post refurbishment. Used equipment also includes equipment that has not been previously rented or sold (e.g., equipment used for trial periods or as a demonstrator). All used and refurbished equipment requires a PAR. The DMEPOS provider must guarantee that the equipment provided to the member is in "like new" condition, and that any modifications are made prior to the delivery of the equipment. The cost of repairs or modifications must not exceed the cost of replacement equipment. The provider will maintain a one (1) year limited warranty that covers all necessary parts or repairs. Comparison pricing for new equipment must be included in the PAR documentation. PAR documentation must include the make, model, and serial number of equipment. The Used Equipment (UE) modifier must be included on all used and refurbished equipment PARs and claims. Examples of allowable used or refurbished equipment include but are not limited to:
If new equipment is rented to and subsequently purchased by the same member, it would not be considered used. Supplies (disposable items) may not be provided as used.
Unless a part of the , the maximum allowable for used/refurbished equipment is 60% of the equipment's maximum allowable for purchase. Dates of Service after the Death of a Health First Colorado MemberHealth First Colorado will reimburse supply providers for durable medical rental equipment, oxygen, and bulk supplies that are drop-shipped to the member's home for services rendered during the month of the member's death, only if the claim’s date of service is before the member’s date of death. Health First Colorado will make recoveries for all DMEPOS services following the date of the member's death. The interChange operationalizes this policy in the following ways:
Span Billing for Certain Supplies The following items may have a date span of up to 30 calendar days on claims submitted to the Department:
Suppliers must span the dates of service using "From" and "To" dates on any claim for the items listed above. The "From" date is when the items were provided to the member. The "To" date is the last date the supplies are expected to be used. For example, if you are providing a 30-day supply of diabetic testing strips to a member, the "From" date on the claim would be "01/01/2021" and the "To" date would be "01/30/2021”. Shipped SuppliesSuppliers may not automatically dispense a quantity of supplies on a predetermined regular basis. Members must be contacted prior to shipping to ensure that member information is correct, there have been no changes to the prescription, and supplies/additional supplies are needed. Member contact consists of either a request from the member/caregiver that supplies are needed or a member/caregiver's response to an inquiry by the DMEPOS Provider that supplies are needed. Members may not be charged for costs associated with shipping and handling. Providers must use the date the supply was delivered to the member as the From Date on claim submissions for shipped supplies. Face-To-Face (F2F) Requirements A face-to-face (F2F) encounter is a federally required visit in which members must meet with a physician, or other allowed practitioner, within six months prior to the date the member receives the equipment. The F2F encounter documentation must demonstrate that the prescriber met F2F with the member specifically related to the member's primary clinical need for the prescribed DME item. Allowed Practitioners
Non-physicians (listed above) that perform a F2F, must communicate their clinical findings of that F2F encounter to the physician responsible for prescribing the related DME. These, and all F2F clinical findings, must be incorporated into a written or electronic document included and maintained in the member's medical record.
Medicare Coding To date, Medicare has chosen to not enforce their F2F requirements. As a result, the F2F code list has not been updated since 2016. Six Month Requirement The F2F encounter must happen within 6 months prior to the start of services and must be performed by the prescribing physician or other allowed practitioner. Start of Services As defined in 10 CCR 2505-10, § 8.590.1 the start of services means the date that the ordering practitioner signs the written order for durable medical equipment following the face-to-face encounter with the member. A F2F is only required for the initiation of the DME. The provision of the prescribed DME item does not require multiple F2F encounters for each related item, only documentation that the F2F occurred and is related to the main reason the DME item is needed. For items that are continuous rental, F2F within 6 months is a requirement on both initial requests as well as renewals. Repair and replacement do not require the F2F. Documentation
The member's medical need for the DME item should be clearly communicated in the F2F documentation. This will aid manufacturers in supplying the DME item without sending the member back multiple times for unnecessary F2F encounters.
Note: The prescriber's responsibility, concerning a F2F encounter, is to meet with the member and document the member's medical need for an item of DME, NOT to detail every DME item the member might need. Telehealth F2F encounters may be performed via telehealth if available. PricingThere are three (3) ways to determine the maximum allowable for DMEPOS: the fee schedule, the Manufacturer's Suggested Retail Price (MSRP), and By Invoice. Percentages noted below can be found in 10 CCR 2505-10, Section 8.590.7 of the Health First Colorado rules. Usual and Customary Charge (U&C): What a provider would charge the general public for the product/service. The Submitted Charge on a claim, regardless of how the maximum allowable is determined, should always be a provider's U&C. Fee ScheduleFor fee schedule items, reimbursement is the lower of the U&C or the fee schedule rate. No additional handling, shipping, or tax charges may be billed. For the majority of the DMEPOS codes, the fee schedule can be found on the Health First Colorado Fee Schedule. Federal Upper Payment Limit (UPL) requirement As of January 1, 2018, Health First Colorado is required to comply with the Consolidated Appropriations Act of 2016 (Section 503) which means Health First Colorado cannot pay more than what Medicare would have paid in the aggregate for certain DME services. The original effective date was January 1, 2019 but the Cures Act (Section 5002) changed the effective date to January 1, 2018.
Codes that fall within the scope of the UPL are indicated on the HCPCS Table in the Comments column with the following notation: *Code is subject to the 2019 DME UPL The fee schedule for the DME UPL codes can be found on the Rates and Fee Schedules web page under Durable Medical Equipment, Upper Payment Limit.
Manufacturer Suggested Retail Price (MSRP)Effective July 1, 2022, if the fee schedule states "Code is Manually Priced", reimbursement is the lower of (MSRP less 15.95%) or the provider's U&C.
By InvoiceEffective July 1, 2022, if the fee schedule states "Code is Manually Priced" and the product has no MSRP, reimbursement is the lower of the Actual Acquisition Cost plus 22.90% or the provider's U&C. Actual Acquisition Costs are defined as the manufacturer's list price for the item less any standard trade discount applied to lower the actual cost to the provider but excluding any time sensitive or otherwise conditional discounts available to the provider. The provider must keep a copy of the item's invoice. In order to receive the maximum allowable reimbursement for By Invoice items, one (1) unit of procedure code with the 'UB' modifier must be included on the claim. The Submitted Charge should reflect the provider's U&C minus the Actual Acquisition Cost. Effective July 1, 2018, A9901 will no longer be used for Manual Pricing by invoice. The percentage above the invoice cost will be calculated in line with the base code, similar to how MSRP works. Providers must attach a copy of the invoice on all PARs and claims. Line items that are reimbursed by invoice must:
The Submitted Charge should reflect the provider's U&C. The math for calculating the maximum allowable must be shown. It may be added to the invoice or a separate attachment. Using the above example:
After verifying the calculation, claims processors will price the claim at the lower of U&C or the actual invoice cost plus the percentage.
Maximum Allowable for RentalFee schedule: With the exception of oxygen and items noted as continuous rental, rental reimbursement caps at the item's purchase price. MSRP or By Invoice Pricing: Fee schedule items that require manual pricing for rental, excluding oxygen, are reimbursed using the MSRP or Invoice methodology, divided by 13, for one month of rental. If for a partial month rental, divide again by 30 for the daily maximum allowable. Total rental reimbursement cannot exceed the maximum allowable purchase price. RebatesIf a rebate is available, the provider must reflect U&C minus the rebate received or anticipated from the manufacturer. Prior Authorization Requests (PARs)Some supply items and most DME items require prior authorization. A member may be required to receive an occupational therapy evaluation to determine appropriateness of prescribed equipment such as motorized chairs. This manual contains a detailed list of prior authorization requirements as well as the correct form and mailing address for each PAR. Prior Authorization Requests must be submitted and approved before services are rendered. The service must be rendered by the identified supplier on the approved PAR. Services rendered must match the approved services exactly. Approval of a PAR does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is a medical necessity and is considered a benefit of Health First Colorado. In reviewing for medical necessity, the Utilization Management Vendor may deny an item that has been deemed unsafe for the member. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, detailed provider information, detailed description of medical necessity, all required attachments included, etc.) before payment can be made. PAR SubmissionAll PARs must be submitted by the supply provider that intends to submit the claim for the service and have an attached prescription from the prescribing authority and any other required documentation. Each PAR must include the name and phone number of the member's Primary Care Physician (if applicable). PAR requests for members with a non-Health First Colorado primary care physician must include the primary care provider's National Provider Identifier (NPI), contact information and note in the "comment" section stating that the referring provider is not a Health First Colorado provider and prescriptive authority has been verified. Providers shall not charge a member for items covered as a Health First Colorado benefit. This includes but is not limited to blood pressure monitors, blood glucose monitors, walkers, canes, nutritional supplements, and incontinence products. Prior Authorization Request dates typically have a date span for one (1) year less one (1) day. Exceptions for decreased span dates less than one (1) year are allowed in certain circumstances such as short-term rental or WIC application period. Dates must not exceed one (1) year and must match the dates on individual line items or the PAR will be denied. All PARs and revisions processed by the ColoradoPAR Program must be submitted through the PAR portal. Prior Authorization Requests submitted via fax or mail will not be processed by the ColoradoPAR Program and subsequently not reviewed for medical necessity. These PARs will be returned to providers via mail. This requirement only impacts PARs submitted to the ColoradoPAR Program. The electronic PAR format will be required unless an exception is granted by the ColoradoPAR Program. Exceptions may be granted for providers who submit five (5) or less PARs per month. To request an exception, more information on electronic submission, or any other questions regarding PARs submitted to the ColoradoPAR Program, please contact the ColoradoPAR Program at 888-801-9355 or refer to the Department's Colorado PAR Program webpage. PAR Review and NotificationThe actual number of units approved for any item may be reduced or increased by the reviewer evaluating the PAR. Once review is complete, the status of a PAR (approved, partially approved or denied) is available through the Health First Colorado Secure Web Portal (Web Portal). In addition, both the provider and the member receive a letter indicating whether or not the services were authorized. The letter will include a PAR number that must be included on the claim. DME Safety Equipment PolicyAs part of the Prior Authorization Request (PAR) process, Health First Colorado’s PAR vendor reviews requests for safety of the member. It is the member’s responsibility to ensure safe installation of any safety equipment that modifies the home and or their environment. This would refer to items such as rails that attach to a wall, toilet, or other part of the home. The department refers to these items as permanently affixed safety equipment. Due to substantial risk of safety for the member, the department will not approve of safety items that are not permanently affixed. This includes but is not limited to items attached by means of a suction cup or tension mechanism. However, PARs are still reviewed for safety on an individual basis and this policy should not be used to assume that all permanently affixed items are safe for every member. DME most commonly impacted by this policy: Submitting Claims after PAR ApprovalProviders must receive an approval for all items/services that require a prior authorization before submitting a claim. Once prior authorization is received, claims should only include the approved PAR number and, if applicable, the serial number of the approved equipment. In most cases, it is not necessary to submit a copy of the approved PAR. Providers will be notified if a copy of the approved PAR is needed. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)8.280.4.E Other EPSDT Benefits Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:
QuestionnairesAll questionnaires are located in the Provider Services Forms web page of the Department's website, under DMEPOS Questionnaires. Complex Rehabilitation Technology (CRT)There are two (2) levels of documentation requirements associated with PARs for CRT:
Specialty evaluation is required for:
NOTE: Specialty evaluation is not required for CRT repair and replacement.
Record KeepingSupply providers must maintain the records described below for all items provided to member. Supply providers must keep the information for seven (7) years, and provide a copy of any documentation to the Department and member or his/her representative upon request.
Billing InformationRefer to the General Provider Information manual for general billing information. Using ModifiersModifiers are used with HCPCS codes to describe circumstances that may change or alter payment or provide additional information. Refer to the approved modifiers for use with DME procedure codes in field locator 19c in the . The following modifiers are approved for use with DME procedure codes and must be used when applicable: AVItem furnished in conjunction with a prosthetic device, prosthetic or orthoticBOOrally administered nutrition, not by feeding tubeKHDMEPOS item, initial claim, purchase or first month rentalKIDMEPOS item, second or third month rental.KRRental item, billing for partial monthMSSix (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warrantyRRRental (use the RR modifier when DME is to be rented)SCMedically Necessary Service or Supply - To be used with MSRP priced codes onlyTTIndividualized service provided to more than one (1) member in same settingTWSecondary or back-up equipmentUBInvoice cost - To be used with "By Invoice" priced codes onlyNUNew EquipmentUEUsed EquipmentEffective July 1, 2017RAReplacement of a DME, orthotic or prosthetic itemRBReplacement of part of a DME, orthotic or prosthetic item furnished as part of a repairEffective June 1, 2018:KFItem designated by the FDA as a Class III deviceProcedure/HCPCS Codes OverviewThe Colorado Department of Health Care Policy and Financing develops procedure codes that are approved by the Centers for Medicare & Medicaid Services (CMS). The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled certified Health First Colorado providers. The Healthcare Common Procedural Coding System (HCPCS) is divided into two (2) principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by four (4) numeric digits, while CPT codes are identified using five (5) numeric digits. National Correct Coding InitiativePlease note that Medically Unlikely Edits (MUEs) may apply for some codes, please see National Correct Coding Initiative (NCCI) web page. Paper PAR Instructional ReferenceField LabelCompletion FormatInstructionsThe upper margin of the PAR form must be left blank. This area is for authorizing agency use only.Invoice/Pat Account NumberTextOptionalEnter up to 12 characters (numbers, letters, hyphens) that help the provider identify the claim or member.1. Member NameTextRequired Enter the member's last name, first name, and middle initial exactly as it appears on the eligibility verification. Example: Adams, Mary A.2. Member Identification Number7 charactersRequired This number consists of a letter prefix followed by six (6) numbers. Example: A1234563. SexCheck box MFRequired Enter an "X" in the appropriate box.4. Date of Birth6 digitsRequired Enter the member's birth date using a MMDDYY format. Example: January 1, 2015 = 0101155. Member AddressCharacters: numbers and lettersRequired Enter the member's full address: Street, city, state, and zip code.6. Member Telephone NumberTextOptional Enter the member's telephone number.7. Prior Authorization NumberNoneLeave Blank This field is automatically system assigned8. Dates Covered by This Request6 digits for From date and 6 digits for Through dateOptional Enter the date(s) within which service(s) will be provided. If left blank, dates are entered by the authorizing agent. Authorized services must be provided within these dates. Use the MMDDYY format. Example: January 1, 2016 - January 31, 2016 = From 010116 Through 0131169. Does Member Reside in a Nursing Facility?Check Box Yes/NoRequired Check the appropriate box.10.Group Home Name if Member Resides in a Group HomeTextConditional Complete if member resides in a group home. Enter the name of the group home or residence.11.DiagnosisTextRequired Enter the diagnosis code and sufficient relevant diagnostic information to justify the request. Include the prognosis. Provide relevant clinical information, other drugs or alternative therapies tried in treating the condition, results of tests, etc., to justify a Health First Colorado determination of medical necessity. Approval of the PAR is based on documented medical necessity. Attach documents as required.12.Requesting Authorization for RepairsTextConditional Complete if requesting repairs for equipment owned by the member. Enter the serial number of the equipment.13.Indicate Length of NecessityTextConditional Complete if renting equipment. Provide best estimate of how long equipment will be needed.14.Estimated Cost of EquipmentDigitsConditional Complete if purchasing, replacing, or repairing equipment. Provide best estimate of cost for labor and replacement part(s) for repair or cost for purchases.15.Services To Be AuthorizedNonePreprinted Do not alter preprinted lines. No more than five (5) items can be requested on one (1) form.16.Describe Procedure, Supply, or Drug to be ProvidedTextRequired Enter the description of the service/procedure to be provided. Include model number for DME purchase or serial number for repair.17.Procedure, Supply or Drug Code5 digitsRequired Enter the appropriate HCPCS code for each item that will be billed on the claim form. The authorizing agent may change any code. The approved code(s) on the PAR form must be used on the claim form.18.Number of ServicesDigitsRequired Enter the number of units for supplies, services or equipment requested. If this field is blank, the authorizing agent will complete with one (1) unit.19.Authorized No. of ServicesNoneLeave Blank The authorizing agent indicates the number of services authorized which may or may not equal the number requested in Field 18 (Number Of Services).20.A=Approved D=DeniedNoneLeave Blank Providers should check the PAR on-line or refer to the PAR letter.21.Primary Care Physician (PCP) NameTextConditional Complete if member has a PCP. Enter the PCP's name as it appears on the current eligibility verification.Telephone NumberTextOptional Enter the PCP's telephone number.22.Primary Care Physician AddressTextConditional Complete if member has a PCP. Enter the PCP's complete address.23.PCP Provider Number8 DigitsConditional Complete if member has a PCP. Enter the PCP's eight-digit Colorado Medical Assistance provider number. This number must be obtained by contacting the PCP for the necessary authorization.24.Name and Address of Provider Requesting Prior AuthorizationTextRequired Enter the complete name and address of the physician requesting prior authorization (the physician ordering/writing the prescription).25.Name of Provider Who will Render ServiceTextRequired Enter the name and telephone number of the supplier who will render the service.26.SignatureTextRequired The prescribing authority must sign the PAR or the prescription must be attached. If prescription is attached notate "see attached." Do not send the original prescription, send a photocopy on an 8¬Ω x 11 sheet. The written diagnosis must be entered in Field 11 (Diagnosis), even if a prescription form is attached. A rubber stamp facsimile signature is not acceptable on the PAR.Telephone NumberTextRequired Enter the telephone number of the requesting provider.27. Date Signed6 DigitsRequired Enter the date the PAR form is signed by the requesting provider.28. Requesting Provider Number8 DigitsRequired Enter the eight-digit Health First Colorado provider number of the requesting provider.Telephone NumberTextRequired Enter the telephone number of the requesting provider.29. Billing Provider Number8 DigitsRequired Enter the eight (8)-digit Health First Colorado provider number of the billing provider. The billing provider must be enrolled in Health First Colorado.30. Comments or Reasons For Denial of BenefitsNoneLeave Blank Refer to the PAR response for comments submitted by the authorizing agency.31. PA Number Being RevisedTextLeave Blank This field is completed by the authorizing agency. Paper Claim Reference TableSupply and DME claims are submitted on the CMS 1500 claim form or as an 837P transaction. The following paper claim form reference table shows required fields and detailed field completion instructions. Instructions for completing and submitting electronic claims are available through the X12N Technical Report 3 (TR3) for the 837P (wpc-edi.com), 837P Companion Guide (in the EDI Support section of the Department's Web site), and in the Web Portal User Guide (via within the portal). CMS Field Number & LabelField is?Instructions1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.1a. Insured's ID NumberRequiredEnter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.2. Patient's NameRequiredEnter the member's last name, first name, and middle initial.3. Patient's Date of Birth/SexRequiredEnter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.Place an "X" in the appropriate box to indicate the sex of the member.4. Insured's NameConditionalComplete if the member is covered by a Medicare health insurance policy. Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.5. Patient's AddressNot Required 6. Client Relationship to InsuredConditionalComplete if the member is covered by a commercial health care insurance policy.7. Insured's AddressNot Required 8. Reserved for NUCC Use 9. Other Insured's NameConditionalIf field 11d is marked "yes", enter the insured's last name, first name, and middle initial.9a. Other Insured's Policy or Group NumberConditionalIf field 11d is marked "yes", enter the policy or group number.9b. Reserved for NUCC Use 9c. Reserved for NUCC Use 9d. Insurance Plan or Program NameConditionalIf field 11d is marked "yes", enter the insurance plan or program name.10a-c. Is patient's condition related to?ConditionalWhen appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.10d. Reserved for Local Use 11. Insured's Policy, Group or FECA NumberConditionalComplete if the member is covered by a Medicare health insurance policy. Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.11a. Insured's Date of Birth, SexConditionalComplete if the member is covered by a Medicare health insurance policy. Enter the insured's birth date using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070115 for July 1, 2015. Place an "X" in the appropriate box to indicate the sex of the insured.11b. Other Claim IDNot Required 11c. Insurance Plan Name or Program NameNot Required 11d. Is there another Health Benefit Plan?ConditionalWhen appropriate, place an "X" in the correct box. If marked YES, complete 9, 9a and 9d12. Patient's or Authorized Person's signatureRequiredEnter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File". Enter the date the claim form was signed.13. Insured's or Authorized Person's SignatureNot Required 14. Date of Current Illness Injury or PregnancyConditionalComplete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070116 for July 1, 2016. Enter the applicable qualifier to identify which date is being reported 431 Onset of Current Symptoms or Illness 484 Last Menstrual Period15. Other Date NotNot Required 16. Date Patient Unable to Work in Current OccupationNot Required 17. Name of Referring PhysicianRequired 18. Hospitalization Dates Related to Current ServiceConditionalComplete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.19. Additional Claim InformationConditionalDurable Medical Equipment Complete for DME purchases, repairs, and labor. Enter the make, model and serial number of the equipment.20. Outside Lab? $ ChargesNot Required 21. Diagnosis or Nature of Illness or InjuryRequiredEnter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition. Enter applicable ICD-10 indicator.22. Medicaid Resubmission CodeConditionalList the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field. 7 - Replacement of prior claim 8 - Void/Cancel of prior claim This field is not intended for use for original claim submissions.23. Prior AuthorizationConditionalComplete for medical equipment and supplies that require prior authorization. If the procedure code requires prior authorization, enter the prior authorization from the approved Prior Authorization Request (PAR). Do not combine services from more than one (1) approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agency or the fiscal agent.24. Claim Line DetailInformationThe paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line. Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing. Each claim form must be fully completed (totaled). Do not file continuation claims (e.g., Page 1 of 2).24A. Dates of ServiceRequiredThe field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.FromTo010119 orFromTo010119010119Span dates of serviceFromTo010119013119Practitioner claims must be consecutive days. Single Date of Service: Enter the six digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields. Span billing: permissible if the same service (same procedure code) is provided on consecutive dates. Durable Medical Equipment Rental The "To" date of service must represent the last date of the rental period.24B. Place of ServiceRequiredEnter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.04Homeless Shelter11Office12Home15Mobile Unit20Urgent Care Facility21Inpatient Hospital22Outpatient Hospital23Emergency Room Hospital25Birthing Center26Military Treatment Center31Skilled Nursing Facility32Nursing Facility33Custodial Care Facility34Hospice41Transportation - Land52Psychiatric Facility Partial Hospitalization53Community Mental Health Center54Intermediate Care Facility - MR60Mass Immunization Center61Comprehensive IP Rehab Facility62Comprehensive OP Rehab Facility65End Stage Renal Dialysis Treatment Facility71State - Local Public Health Clinic99Other Unlisted24C. EMGNot Required 24D. Procedures, Services, or SuppliesRequiredEnter the HCPCS procedure code that specifically describes the service for which payment is requested. All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually. HCPCS Level II Codes The current Medicare coding publication (for Medicare crossover claims only). Only approved codes from the current CPT or HCPCS publications will be accepted.24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.BOOrally administered nutrition, not by feeding tubeKHDMEPOS item, initial claim, purchase or first month rental KI DMEPOS item, second or third month rental.KRRental item, billing for partial monthMSSix (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warrantyRRRental (use the RR modifier when DME is to be rented)SCMedically Necessary Service or Supply - To be used with MSRP priced codes onlyTTIndividualized service provided to more than one (1) member in same setting TW Secondary or back-up equipmentUBInvoice cost - To be used with "By Invoice" priced codes onlyNUNew EquipmentUEUsed EquipmentEffective July 1, 2017RAReplacement of a DME, orthotic or prosthetic itemRBReplacement of part of a DME, orthotic or prosthetic item furnished as part of a repairEffective June 1, 2018:KFItem designated by the FDA as a Class III device24E. Diagnosis PointerRequiredEnter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis. At least one diagnosis code reference letter must be entered. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. This field allows for the entry of 4 characters in the unshaded area.24F. $ ChargesRequiredEnter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number. Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply. The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed. Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service. Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.24G. Days or UnitsRequiredEnter the number of services provided for each procedure code. Enter whole numbers only- do not enter fractions or decimals.24H. EPSDT/Family PlanConditionalEPSDT (shaded area) For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:AVAvailable- Not UsedS2Under TreatmentSTNew Service Requested NU Not UsedFamily Planning (unshaded area) Not Required24I. ID QualifierNot Required 24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the ,strong>individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.25. Federal Tax ID NumberNot Required 26. Patient's Account NumberOptionalEnter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).27. Accept Assignment?RequiredThe accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.28. Total ChargeRequiredEnter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.29. Amount PaidConditionalEnter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.30. Rsvd for NUCC Use 31. Signature of Physician or Supplier Including Degrees or CredentialsRequiredEach claim must bear the signature of the enrolled provider or the signature of a registered authorized agent. Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.32. 32- Service Facility Location Information 32a- NPI Number 32b- Other ID #RequiredEnter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and ZIP Code If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.33. Billing Provider Info & Ph #RequiredEnter the name of the individual or organization that will receive payment for the billed services in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and ZIP Code33a- NPI NumberRequired 33b- Other ID # If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization. Timely FilingFor more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual. Column Instructions forCode ColumnHCPCS codes consist of a letter followed by four (4) numbers. Read the entire entry to determine the benefit status of the item. Providers are instructed to submit the HCPCS code most closely describing the item being requested on the PAR form. Health First Colorado reserves the right to amend the coding for any approved item. Description ColumnA description of the item as provided by Centers for Medicare and Medicaid Services (CMS) is listed. When possible and appropriate, the description of the item includes a notation of the billing unit. For disposable supplies, one (1) billing unit represents one (1) item unless otherwise noted. PAR ColumnThis column is used to identify if prior authorization is required for the item identified and to identify which reviewing agency to send the PAR to for review. YesPARs for these items are reviewed by the Colorado PAR Program.NoThe identified item does not require prior authorization when provided to an eligible member. If there is a unit limit and the member needs to exceed that limit, a PAR may be submitted.Con(Conditional) The item requires prior authorization under certain circumstances. See the comments section next to the item or the subheading description for an explanation of the circumstances.Unit Limit ColumnUnit limits are displayed with the maximum unit allowable and the minimum time between requests. Some items may have special provisions for unit limits with more detail in the Comment Column.
**This column is being updated on a continual basis, further updates will be made to complete this column. No changes are being made to unit limits, they are only being identified in an easily accessible column. Unit limits may be identified in the comment column until changes are made.**
Comment ColumnThe comment section outlines specific or special instructions as well as more detailed information on unit limits where applicable. Comments expand on the description and identify any required special PAR or billing instructions. The notation "DELETED" means that the code is invalid effective the day following the date shown in the "COMMENTS" column. Newly added codes become effective on the date shown. For example, procedure codes deleted effective 12/31/17 can be used only for non-prior authorized services provided prior to 1/1/18 or on PARs approved prior to 1/1/18. Questionnaires: Some codes require a questionnaire to be filled out to be sent in with the PAR. The questionnaires can be found on the Department's website on the Forms web page under Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Forms. In the code table, a questionnaire is indicated by 'Q' and the number associated with the questionnaire (I.e. Q1, Q2, Q15, etc.). F2F: (Face-to-face) Codes that fall under the face-to-face regulation are indicated by the notation 'F2F'. Please refer to the Face-To-Face section of this manual for details of the regulation. This opens a new web page, there are links back to this section of this manual. CRT HCPCS Code TableThe following codes are pure CRT codes. Only qualified CRT suppliers may bill for these codes. For the purpose of the table below only, please note the following definitions. Pursuant to HB22-1290 Changes to Medicaid for Wheelchair Repairs, the department will no longer require prior authorization requests (PARs) for repairs of Complex Rehabilitative Technology (CRT) equipment. Effective July 1, 2022 claims related to the repair of CRT will not require a PAR when billed with modifiers RB. Please note, the PAR column in the table below is for purchase only and not repair. New
CRT HCPCS Code Table*The Specialty Eval column represents when the eval is required and is not intended to limit or restrict access to Specialty Evals. What should be entered in field 24E of the CMS 1500 claim?Item 24E - This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter Page 17 per line item.
What is in Box 21 of the CMS 1500 claim form?Box 21 is used to indicate the diagnosis codes for the symptom, complaint, or condition of the patient.
When completing the CMS 1500 form which section contains information?When completing the CMS-1500 Form, which section contains information about the patient and the insured? Both A and B; Social Security Number (SSN). Employer Identification Number (EIN).
What are loops and segments?A block or section of an EDI file is called a Loop. Each loop contains several different Segments, which are comprised of Elements and Sub-Elements. Although Loops are the biggest component in an EDI, they are often the hardest to distinguish. They will typically begin with an HL or NM1 Segment.
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