N.Y. Comp. Codes R. & Regs. Tit. 11 § 217-1.2 - Health insurance claim submission guidelines

(a) A claim for payment of medical or hospital services submitted on paper shall be deemed complete if it contains the minimum data elements set forth in this Part. If the minimum data elements set forth are not present or accurate, the payer may, but need not, adjudicate the claim if the payer can determine, based on the information submitted, whether such claim should be paid or denied. Even if the claim is deemed complete, a payer may, pursuant to the provision of section 3224-a(b) of the New York Insurance Law, request specific additional information, distinct from information on the claim form, necessary to make a determination as to its obligation to pay such claim.

(b)

(1) In the case of a medical claim submitted on the national standard form known as a CMS 1500 (previously known as HCFA 1500 [New York State]) and its successors, attached as an appendix, (see Appendix 26 of this Title), the claim shall contain at least the items in the following fields of the claim form, except as provided in paragraph (2) of this subdivision:

1a. Insured's I.D. Number

2. Patient's Name

3. Patient's Date of Birth and Gender

4. Insured's Name (Last Name, First Name)

5. Patient's Address

9. Other Insured's Name (if appropriate)

9a. Other Insured's Policy or Group Number (if appropriate)

9b. Other Insured's Date of Birth and Gender (if appropriate)

9c. Employer's Name or School Name (if appropriate)

9d. Insurance Plan Name or Program Name (if appropriate)

10a. Is Patient's Condition Related to Employment?

10b. Is Patient's Condition Related to Auto Accident?

10c. Is Patient's Condition Related to Other Accident?

11. Insured's Policy, Group or FECA Number (if provided on ID Card)

11d. Is There Another Health Benefit Plan?

12. Patient's or Authorized Person's Signature (Can be completed by writing "signature on file" where appropriate)

13. Insured's or Authorized Person's Signature (if appropriate)

17. Name of Referring Physician or Other Source (if appropriate)

17a. I.D. Number of Referring Physician (if appropriate)

18. Hospitalization Dates Related to Current Services (if appropriate)

21. Diagnosis or Nature of Illness or Injury

23. Prior Authorization Number (to report ZIP code for ambulance pick-up) (if appropriate)

24A. Dates of Service

24B. Place of Service

24D. Procedures, Services, or Supplies

24E. Diagnosis Code (refer to item 21)

24F. $ Charges

24G. Days or Units (if appropriate)

25. Federal Tax I.D. Number

28. Total Charge

29. Amount Paid (if appropriate)

30. Balance Due

31. Signature of Physician or Supplier Including Degrees or Credentials (if not already on file, except as required by applicable Federal and State laws)

33. Personal Identifying Number of the particular practitioner rendering the care plus, if practicing in a group, the Identifying Number of the group as well

(2) For items listed in paragraph (1) of this subdivision with the notation "(if appropriate)", the generic nature of the standard claim form produces some instances when the information is not relevant in a particular instance. In those cases, the payer shall not insist upon completion of that item if the information is not relevant to the situation of that particular practitioner or patient or the information will not be used by the payer. If an item is not applicable at all, it should be left blank rather than inserting a notation that it is not applicable.

(c)

(1) In the case of a hospital claim submitted on the national standard form HCFA 1450 (also known as UB-92) and its successors, attached as an appendix (see Appendix 27 of this Title), the claim shall contain at least the items in the following fields of the claim form, except as provided in paragraph (2) of this subdivision:

1. Provider Name and Address

3. Patient Control Number

4. Type of Bill

5. Federal Tax Number

6. Statement Covers Period

7. Covered Days (if appropriate) (interim bill, etc.)

8. Non-Covered Days (if appropriate)

9. Coinsurance Days (if appropriate)

10. Lifetime Reserve Days (if appropriate)

11. Newborn Birthweight (if appropriate)

12. Patient Name

13. Patient Address

14. Patient Birthdate

15. Patient Sex

17. Admission Date

18. Admission Hour

19. Type of Admission

22. Discharge Status Code

42. Revenue Codes

43. Revenue Description

44. HCPCS/CPT4 Codes

45. Service Date

46. Service Units

47. Total Charges (by revenue code)

48. Non-Covered Charges

50. Payer Name

51. Provider ID

54. Other Insurance Payment (if appropriate)

55. Estimated Amount Due (if appropriate)

58. Insured's Name

59. Patient Relationship

60. Patient's Cert. SSN - HIC - ID No.

62. Insurance Group Number (if on card) (where appropriate)

67. Principal Diagnosis Code

68. Code

69. Code

70. Code

71. Code

72. Code

73. Code

74. Code

75. Code

76. Admitting Diagnosis Code

77. E-Code

78. DRG #

79. P.C.

80. Principal Procedure Code and Date

81. Other Procedures Code and Date

82. Attending Physician's ID Number

84. Remarks (to report ZIP code for ambulance pick-up) (if appropriate)

(2) For items listed in paragraph (1) of this subdivision with the notation "(if appropriate)", the generic nature of the standard claim form produces some instances when the information is not relevant in a particular instance. In those cases, the payer shall not insist upon completion of that item if the information is not relevant to the situation of that particular practitioner or patient or the information will not be used by the payer. If an item is not applicable at all, it should be left blank rather than inserting a notation that it is not applicable.

(d) Nothing in this Subpart shall prohibit a payer from electing to accept some or all claims with less information than that specified in the lists set forth in subdivisions (b) and (c) of this section.

Notes

N.Y. Comp. Codes R. & Regs. Tit. 11 § 217-1.2