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The document provides detailed descriptions of the fields required for the CMS-1500 professional claims form, including electronic segment examples and their corresponding information. It serves as a guide for business and technical staff to ensure clean claim submissions to Group Health, outlining specific data requirements such as patient and insured details, service information, diagnosis codes, and billing provider information.

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What is a 837 professional claim?

Box 23 - TITLE: Prior Authorization Number (this field is also used for CLIA numbers) INSTRUCTIONS: Enter any of the following: prior authorization number, referral number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

What is considered a professional claim?

The claims that are generated for the work done by suppliers, physicians, and other non-institutional providers are considered professional billing. These professional charges are billed on the standard CMS-1500, which is a red ink on white paper claim form that both suppliers and physicians use for claim billing.

What is a 837 transaction type?

The ANSI 837 Professional transaction is primarily used for professional healthcare services rendered by individual providers. This transaction type encompasses services such as office visits, consultations, and diagnostic procedures.

What is a 837 EDI claim?

An EDI 837 file is a standardized electronic format used for submitting healthcare claims to insurance providers and government agencies. It ensures accurate and efficient transmission of patient care, procedures, and cost details for processing and reimbursement.

What is field 23 in CMS 1500 claim form?

On the CMS 1500 claim form, the billing provider name, address, and phone number from Healthie will populate in Box 33. You can add the Type 2/NPI 2 or Organizational NPI that appears in Box 33 by going to Organization Settings.

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Is CMS 1500 a professional claim?

The 837P is the standard format health care professionals and suppliers use to submit health care claims electronically. The ANSI ASC X12N 837P Version 5010A1 is the current electronic claim version. Find more information on the ASC X12 website.

What is a claim professional?

Claims adjusters, appraisers, examiners, and investigators typically do the following: Investigate, evaluate, and settle insurance claims. Determine whether the insurance policy covers the loss claimed. Decide the appropriate amount the insurance company should pay. Ensure that claims are not fraudulent.

Cms 1500 professional claim-2025

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