Claims Submission Requirements
Provider Type
- Physicians
- Hospitals
- Participating Physician Groups (PPG)
- Ancillary
Health Net encourages providers to submit claims electronically. Paper submissions are subject to the same edits as electronic and web submissions.
All paper claims sent to the claims office must first pass specific edits prior to acceptance. Claim records that do not pass these edits are invalid and will be rejected or denied. Claims missing the necessary requirements are not considered clean claims and will be returned to providers with a written notice describing the reason for return. Nonstandard forms include any that have been downloaded from the Internet or photocopied, which do not have the same measurements, margins, and colors as commercially available printed forms.
Refer to un-clean claims for more information.
Acceptable Forms
For paper claims, Health Net only accepts the Centers for Medicare & Medicaid Services (CMS) most current:
- CMS-1500 form - complete in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual, updated each July.
- CMS-1450 (UB-04) form - complete in accordance to UB-04 Data Specifications Manual, updated each July.
Other claim form types will be upfront rejected and returned to the provider. Providers should adhere to the claims submission requirements below to ensure that submitted claims have all required information, which results in timely claims processing.
Electronic Claims
For fastest delivery and processing, claims can be submitted electronically using the HIPAA 5010 standard 837I (005010X223A2) and 837P (005010X222A1) transaction. Each claim submitted must include all mandatory elements and situational elements, where applicable. Secondary COB claims can be sent electronically with all appropriate other payer information and paid amounts.
Paper Claims
Paper claim forms must be typed in black ink with either 10 or 12 point Times New Roman font, and on the required original red and white version to ensure clean acceptance and processing. Claims submitted on black and white, handwritten or nonstandard forms will be rejected and a letter will be sent to the provider indicating the reason for rejection. To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions. Copies of the form cannot be used for submission of claims, since a copy may not accurately replicate the scale and optical character recognition (OCR) color of the form.
Health Net only accepts claim forms printed in Flint OCR Red, J6983 (or exact match) ink and does not supply claim forms to providers. Providers should purchase these forms from a supplier of their choice.
Professional Claims
Providers billing for professional services and medical suppliers must complete the CMS-1500 (02/12) form. The form must be completed in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17 at www.nucc.org. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant.
Institutional Claims
Providers billing for institutional services must complete the CMS-1450 (UB-04) form. The form must be completed in accordance with the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2018 at www.nubc.org. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant.
Medicare Billing Instructions
Medicare CMS-1500 and completion and coding instructions, are available on the CMS website at www.cms.gov.
Mandatory Items for Claims Submission
Refer to CMS-1500 Billing instructions or UB-04 Billing Instructions as applicable for complete description and required or conditional fields.
Form Fields | Electronic | CMS-1500 | UB-04 |
|---|---|---|---|
Billing provider tax ID | Loop 2010AA REF segment with TJ qualifier | Box 25 | Box 5 |
Billing provider name, address and NPI | Loop NM109 with XX qualifier | Box 33 | Box 1 |
Subscriber (name, address, DOB, sex, and member ID required) | 2000B and 2010BA | Subscriber box 1a, 4, 7, 11 | Box 58 and 60 |
Provider taxonomy | Box 33B and Box 24 | Box 57 | |
Patient (name, address, DOB, sex, relationship to subscriber, status, and member ID) | 2000C and 2010CA | Patient box 2, 3, 5, 6, 8 | Box 8, 9, 10, 11 |
Principal diagnosis and additional diagnoses | Loop 2300 HI segment qualifier BK (ICD9) or ABK (ICD10) | Box 21 | Box 66 |
Diagnosis pointers (up to 4) | Loop 2410 SV107 | Box 24E (A-L) | N/A |
Referring provider with NPI | Loop 2300 NM1 with DN qualifier | Box 17 | N/A |
Attending provider with NPI | Loop 2300 NM1with DN qualifier | N/A | Box 76 |
Rendering provider | Loop 2300 NM1 with 82 qualifier (if differs from billing provider) | NPI in Box 24J | N/A |
Service facility information | Loop 2310C or 2310E NM1 with 77 qualifier (if differs from billing provider) | Box 32 | N/A |
Procedure code | Loop 2400 SV segment | Box 24D | Box 44 if applicable |
NDC code | Loop 2410 LIN segment with N4 qualifier. Must include mandatory CTP segment. | Box 24D shaded | Box 43 |
UPN | Loop 2410 LIN segment with appropriate UP, UK, UN qualifier. Must include mandatory CTP segment. | Box 24D shaded | Box 43 |
Value codes (for accommodation codes, share of cost, etc.) | Loop 2300 HI segment with qualifier BE | N/A | Box 39, 40, 41 |
Condition codes | Loop 2300 HI segment with qualifier BG | N/A | Box 18-28 |
COB-other subscriber or third party liability | Loop 2320, 2330A and 2330 B | Box 9, if applicable (requires paper EOB from other payer), 10, 11 | Box 50-62 (requires paper EOB from other payer) |
Claim DOS | Loop 2400 DTP segment with 472 qualifier | Box 24A | Box 45 for outpatient when required |
Claim statement date | Loop 2300 with 434 qualifier | N/A | Box 6 from and through |
Claims Rejection Reasons and Resolutions
The following are some claims rejection reasons, challenges and possible resolutions.
Reject code | Reject reason | Requirements | CMS-1500 or UB-04 | ECM and Community Supports Invoice Claim Form |
|---|---|---|---|---|
01 | Member's DOB is missing or invalid | Enter the member’s 8-digit date of birth (MM/DD/YYYY) | CMS-1500 box 3 UB-04 box 10 | Section 2 1Non-standard submission or equivalent |
02 | Incomplete or invalid member information | Enter the member’s Health Plan member identification (ID) for Commercial and Medicare or Client Identification Number (CIN) for Medi-Cal. Social Security number (SSN) should not be used. Check eligibility online, electronically, or refer to the member’s current ID card to determine ID numbers | CMS-1500 box 1a UB-04 box 60 | Section 2 1Non-standard submission or equivalent |
06 | Missing/invalid tax ID | Include complete 9-character tax identification number (TIN) | CMS-1500 box 25 UB-04 box 5 | Section 1a 1Non-standard submission or equivalent |
17 | Diagnosis indicator is missing POA indicator is not valid DRG code is not valid | Ensure 9/0 (“9” for ICD-9 or “0” for ICD-10) appears in field 66 for all claims. Ensure present on admission (POA) indicators are valid when billed. Ensure a valid DRG code is used in field 71. POA valid values are: Y – Diagnosis was present at time of inpatient admission. N – Diagnosis was not present at time of inpatient admission. Leave blank if cannot be determined | UB-04 box 66-70 UB-04 box 71 | Section 3 1Non-standard submission or equivalent |
75 | The claim(s) submitted has missing, illegible or invalid value for anesthesia minutes | When box 24 is completed, then box 24G must be completed as well | CMS-1500 box 24D and 24G | N/A |
76 | Original claim number and frequency code required | When submitting a corrected claim, for UB-04 box 64 and CMS-1500 box 22, you must reference the original claim. Claim numbers can be found on your Remittance Advice (RA)/Explanation of Payment (EOP) or check claims status online. Do not include punctuation, words or special characters before or after the claim number. Submission ID from a reject letter is not a valid claim number. If not using frequency codes 7 or 8 leave boxes 64 and 22 blank. Submit contested claims to Medi-Cal Provider Contested Claims. | CMS-1500 box 22 UB-04 box 4 and 64 | Section 4 1Non-standard submission or equivalent |
77 | Type of bill or place of service invalid or missing | Enter the appropriate type of bill (TOB) code as specified by the NUBC UB-04 Uniform Billing Manual minus the leading “0” (zero). A leading “0” is not needed. Digits should be reflected as follows: 1st digit – Indicating the type of facility 2nd digit – Indicating the type of care 3rd digit – Indicating the bill sequence (frequency code) | UB-04 box 4 | N/A |
87 | One or more of the REV codes submitted is invalid or missing | Include complete 4-digit revenue code | UB-04 box 42 | N/A |
92 | Missing or invalid NPI | Enter provider’s 10-character National Provider Identifier (NPI) ID | CMS-1500 box 24J and 33A UB-04 box 56 | Section 1b 1Non-standard submission or equivalent |
A5 | NDC or UPIN information missing/invalid | Providers must bill the UPIN qualifier, number, quantity, and type or National Drug Code (NDC) qualifier, number, quantity, and unit/basis of measure. If any of these elements are missing, the claim will reject | CMS-1500 box 24D UB-04 box 43 | N/A |
A7 | Invalid/missing ambulance point of pick- up ZIP Code | When box 24 D is completed, include the pickup/drop off address in attachments | CMS-1500 box 24 or box 32. Medicare claims require a point of pickup (POP) ZIP in box 23 in addition to the addresses in 24 shaded area or box 32 | N/A |
A9 | Provider name and address required at all levels | Include complete provider billing address including city, state and ZIP Code | CMS-1500 box 33 UB-04 box 1 | Section 1a 1Non-standard submission or equivalent |
AK | Original claim number sent when the claim is not an adjustment | When submitting an initial claim, leave CMS 1500 box 22 and UB-04 box 64 blank. Any values entered in these boxes will cause a claim to reject. | CMS-1500 box 22 UB-04 box 64 | Section 4 1Non-standard submission or equivalent |
C8 | Valid POA required for all DX fields | Do not include the POA of 1. The valid values for this field are Y or N or blank. (for description see Reject code 17) | UB-04 box 67– 67Q and 72A– 72C | N/A |
B7 | Review NUCC guidelines for proper billing of the CMS-1500 versions (08/05) and (02/12). Claims will be rejected if data is not submitted and/or formatted appropriately | Only CMS-1500 02/12 version is accepted | N/A | N/A |
C6 | Other Insurance fields 9, 9a, 9d, and 11d are missing appropriate data | If the member has other health insurance, box 9, 9a and 9d must be populated, and box 11d must be marked as yes. If this is not provided, the claim will be rejected | CMS-1500 box 9, 9a, 9d and 11d | N/A |
AV | Patient's reason for visit should not be used when claim does not involve outpatient visits | Include patient reason for visit for bill type 013x, 078x, and 085x (outpatient) when Type of Admission/Visit (Box 14) is 1 (emergency), 2 (urgent) or 5 (trauma) and revenue code 045x, 0516 or 0762 are reported. Otherwise, do not populate | UB-04 box 70a, b, c | N/A |
HP | ICD-10 is mandated for this date of service | Submit with the ICD indicator of 9/0 on both UB-04 and CMS-1500 claim forms according to the 5010 Guidelines requirement to bill this information. (for description see Reject code 17) | CMS-1500 box 21 UB-04 box 66 | N/A |
RE | Black/white, handwriting or nonstandard format | Use proper CMS-1500 or UB-04 form typed in black ink in 10 or 12 point Times New Roman font | N/A | N/A |
1This is not a standard claim form like the CMS-1500 or the UB-04 claim forms; used to bill ECM and Community Supports services only.