CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS
CLAIM SUBMISSION CHECKLIST
Prior to submitting your claims to the Kidney Disease Program, use the following checklist:
�� Is your copy legible? Did you type or print your form? Although not required, typing the form will speed up the process.
�� Did you follow the Billing Instructions?
�� Do you have the correct address for submitting your claims? Correct address for submission is listed on page 1 of these billing instructions.
CLAIM TROUBLESHOOTING
This section provides information about the most common billing errors encountered when
providers submit claims to the Kidney Disease Program. Preventing errors on the claim is
the most efficient way to ensure that your claims are paid in a timely manner.
Claims commonly reject for the following reasons:1. The appropriate provider and/or recipient identification is missing or inaccurate.
�� Verify that the 6 digit Kidney Disease Program Patient Identification number is entered in Block 10D. This ID number must be entered or claim will reject for invalid KDP recipient.
�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.
�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.
�� Verify that the recipient’s name is entered in Block #2, last name first.
2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.
�� Verify that you did not bill for services provided prior to or after your provider enrollment dates.
�� Verify that you entered the correct dates of service in the Block #24a of the claim form.
�� Verify Medical Assistance eligibility. If patient has full Medical Assistance coverage, do not bill KDP.
3. The medical services are not covered or authorized for the provider and/or recipient.
�� There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.
�� A valid 2-digit place of service code is required.
�� Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.
�� Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.
�� Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.
�� Primary diagnosis must be ESRD (end stage renal disease) related. Our program only reimburses for the primary diagnosis, which must be directly related to a recipients ESRD or a condition that is a direct result of their ESRD.
4. The claim is a duplicate, has previously been paid or should be paid by another party.
�� KDP edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.
�� If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.
Finally, some errors occur simply because the data entry operators have incorrectly keyed or were unable to read data on the claim. In order to avoid errors when a claim is keyed, please ensure that this information is either typed or printed clearly. When a claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying error, resubmit the claim.
CLAIM SUBMISSION CHECKLIST
Prior to submitting your claims to the Kidney Disease Program, use the following checklist:
�� Is your copy legible? Did you type or print your form? Although not required, typing the form will speed up the process.
�� Did you follow the Billing Instructions?
�� Do you have the correct address for submitting your claims? Correct address for submission is listed on page 1 of these billing instructions.
CLAIM TROUBLESHOOTING
This section provides information about the most common billing errors encountered when
providers submit claims to the Kidney Disease Program. Preventing errors on the claim is
the most efficient way to ensure that your claims are paid in a timely manner.
Claims commonly reject for the following reasons:1. The appropriate provider and/or recipient identification is missing or inaccurate.
�� Verify that the 6 digit Kidney Disease Program Patient Identification number is entered in Block 10D. This ID number must be entered or claim will reject for invalid KDP recipient.
�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.
�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.
�� Verify that the recipient’s name is entered in Block #2, last name first.
2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.
�� Verify that you did not bill for services provided prior to or after your provider enrollment dates.
�� Verify that you entered the correct dates of service in the Block #24a of the claim form.
�� Verify Medical Assistance eligibility. If patient has full Medical Assistance coverage, do not bill KDP.
3. The medical services are not covered or authorized for the provider and/or recipient.
�� There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.
�� A valid 2-digit place of service code is required.
�� Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.
�� Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.
�� Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.
�� Primary diagnosis must be ESRD (end stage renal disease) related. Our program only reimburses for the primary diagnosis, which must be directly related to a recipients ESRD or a condition that is a direct result of their ESRD.
4. The claim is a duplicate, has previously been paid or should be paid by another party.
�� KDP edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.
�� If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.
Finally, some errors occur simply because the data entry operators have incorrectly keyed or were unable to read data on the claim. In order to avoid errors when a claim is keyed, please ensure that this information is either typed or printed clearly. When a claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying error, resubmit the claim.