National Uniform Billing Committee's UB-04 Data Specifications Manual is available here.Ĭorrect coding is key to submitting valid claims. Health Net uses the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual as the standard source for codes and code descriptions to be entered in the various form locators (FL). IMPORTANT NOTE: We require that all facility claims be billed on the UB-04 form. Medicare CMS-1500 and CMS-1450 completion and coding instructions, are available on the Centers for Medicare & Medicaid Services (CMS) website.Īll paper claims and supporting information must be submitted to: Line of Business These claims will not be returned to the provider. 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. The form must be completed in accordance with the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2018. Providers billing for institutional services must complete the CMS-1450 (UB-04) 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. Providers billing for professional services and medical suppliers must complete the CMS-1500 (02/12) form. Providers should purchase these forms from a supplier of their choice. Health Net does not supply claim forms to providers. Copies of the form cannot be used for submission of claims, since a copy may not accurately replicate the scale and OCR color of the form. To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions. 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. 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. Health Net only accepts standard claim forms printed in Flint OCR Red, J6983 (or exact match) ink. Requirements for paper forms are described below. Refer to electronic claims submission for more information.įor providers unable to send claims electronically, paper claims are accepted if on the proper type of form. Health Net prefers that all claims be submitted electronically. Note: where contract terms apply, not all of this information may be applicable to claims submitted by Health Net participating providers. This information pertains to claims for services rendered by providers to Health Net members in all products offered by Health Net. HMO/POS/HSP, PPO, Centene Corporation Employee Self-Insured PPO PLAN, & MediConnect – Los Angeles MediConnect – San Diego Settlement and Dispute Resolution Mechanism
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