Important fields of the CMS 1500 Form during the claim submission

Claims submitted for payment should be in a HIPAA accepted 837 file format and filed electronically using the CarePlus Payer ID 95092 to Availity at www.availity.com. If all EDI methods have failed and the provider has contacted the CarePlus Claims Status team for assistance, the provider may then submit  their claim on a properly completed CMS 1500 form within the time frame specified in their contract.

**  Patient name
**  Patient ID number
**  Group number
**  Patient DOB
**  Patient address and telephone number
**  Other insurance information
–  Insured name
–  Insurance name
–  Policy/ Group number
**  Attach other insurance EOBs to show payment or denial
**  If patient’s condition is related to:
–  Employment (Worker’s Compensation)
–  Auto Accident
–  Other Accident
**  Referring Physician (when applicable)
**  Referring Physicians NPI #
**  Authorization number
**  ICD-9 Diagnosis Code(s)
**  Date(s) of Service
**  Place of Service & Type of Service
**  CPT-4 HCPC Procedure Codes and (modifiers when applicable)
**  Charges
**  Days or Units
**  CHCU-Family Planning
**  EMG
**  COB
**  Federal TID number
**  Patients account number
**  Accept assignment- Y or N
**  Total charges
**  Amount paid
**  Balance due
**  Name of Physician or supplier of service
**  NPI # of Physicians or supplier of service
**  Billing Providers NPI #
**  Name and address of facility where services were rendered (if other than home or office)
**  Physician name and address according to the contract
**  Plan assigned provider number