Ambulatory Surgery Centers (ASC) Billing Manual | Colorado Department of Health Care Policy & Financing

1. Insurance Type
Required
Place an “X” in the box marked as Medicaid.
1a. Insured’s ID Number
Required
Enter the member’s Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient’s Name
Required
Enter the member’s last name, first name, and middle initial.
3. Patient’s Date of Birth/Sex
Required
Enter the member’s birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an “X” in the appropriate box to indicate the sex of the member.
4. Insured’s Name
Conditional
Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient’s Address
Not Required
 
6. Patient’s Relationship to Insured
Conditional
Complete if the member is covered by a commercial health insurance policy. Place an “X” in the box that identifies the member’s relationship to the policyholder.
7. Insured’s Address
Not Required
 
8. Reserved for NUCC Use
Not Required
 
9. Other Insured’s Name
Conditional
If field 11d is marked “YES”, enter the insured’s last name, first name and middle initial.
9a. Other Insured’s Policy or Group Number
Conditional
If field 11d is marked “YES”, enter the policy or group number.
9b. Reserved for NUCC Use
 
 
9c. Reserved for NUCC Use
 
 
9d. Insurance Plan or Program Name
Conditional
If field 11D is marked “YES”, enter the insurance plan or program name.
10a-c. Is patient’s condition related to?
Conditional
When appropriate, place an “X” in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use
 
 
11. Insured’s Policy, Group or FECA Number
Conditional
Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured’s Date of Birth, Sex
Conditional
Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an “X” in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID
Not Required
 
11c. Insurance Plan Name or Program Name
Not Required
 
11d. Is there another Health Benefit Plan?
Conditional
When appropriate, place an “X” in the correct box. If marked “YES”, complete 9, 9a and 9d.
12. Patient’s or Authorized Person’s signature
Required
Enter “Signature on File”, “SOF”, or legal signature. If there is no signature on file, leave blank or enter “No Signature on File”.

Enter the date the claim form was signed.
13. Insured’s or Authorized Person’s Signature
Not Required
 
14. Date of Current Illness Injury or Pregnancy
Conditional
Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 – Onset of Current Symptoms or Illness
484 – Last Menstrual Period
15. Other Date Not
Not Required
 
16. Date Patient Unable to Work in Current Occupation
Not Required
 
17. Name of Referring Physician
Conditional
 
17b. NPI of Referring Physician
Required
Required in accordance with Program Rule 8.125.8.A
18. Hospitalization Dates Related to Current Service
Not required
 
19. Additional Claim Information
Conditional
 
20. Outside Lab?
$ Charges
Conditional
Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury
Required
Enter at least one but no more than twelve diagnosis codes based on the member’s diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code
Conditional
List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 – Replacement of prior claim
8 – Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization
Not Required
 
24. Claim Line Detail
Information
The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service
Required
The field accommodates the entry of two dates: a “From” date of services and a “To” date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From
To
01
01
19
 
 
 

or

From
To
01
01
19
01
01
19

Span dates of service

From
To
01
01
19
01
31
19

Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the “From” field. Completion of the “To” field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ – Narrative description of unspecified code
N4 – National Drug Codes

• Enter NDC qualifier N4 (left-justified), immediately followed by the 11-digit NDC numeric code.
• Enter one space for separation.
• Enter the appropriate qualifier for the correct dispensing NDC unit of measure (UN – Units, ML – Milliliter, GR – Gram, or F2 – International Unit), immediately followed by the quantity (number of NDC units).

VP – Vendor Product Number
OZ – Product Number
CTR – Contract Rate
JP – Universal/National Tooth Designation
JO – Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service
Required
Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
24 – ASC
24C. EMG
Conditional
Enter a “Y” for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a “Y” for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Procedures, Services, or Supplies
Required
Enter the procedure code that specifically describes the service for which payment is requested.
24D.
Required
Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.

Telemedicine
For originating provider use procedure code Q3014.

For distant provider use procedure code + modifier GT.
24D. Modifier
Not Required
 
24E. Diagnosis Pointer
Required
Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges
Required
Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.
24G. Days or Units
Required
Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family Plan
Conditional
EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment-related services, enter the response in the shaded portion of the field as follows:
AV – Available- Not Used
S2 – Under Treatment
ST – New Service Requested
NU – Not Used

Family Planning (unshaded area)
If the service is Family Planning, enter “Y” for YES or “N” for NO in the bottom, unshaded area of the field.
24I. ID Qualifier
Not Required
 
24J. Rendering Provider ID #
Not Required
 
25. Federal Tax ID Number
Not Required
 
26. Patient’s Account Number
Optional
Enter information that identifies the member or claim in the provider’s billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?
Required
The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer’s program.
28. Total Charge
Required
Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid
Conditional
Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use
 
 
31. Signature of Physician or Supplier Including Degrees or Credentials
Required
Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider’s name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
“Signature on file” notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required
Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required
Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number
Required
 
33b- Other ID #
 
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.