April 3, 2013
-Additional Paper CMS-1500 and UB-04 Field RequirementsDear Keystone Mercy Provider and Billing Staff:
Keystone Mercy is adopting the required HIPAA 5010 X12 electronic claims submission format
for both the CMS-1500 and UB-04 paper claim forms. Effective with claims received on July 1,
2013, paper claims that do not meet HIPAA 5010 X12 compliancy will be rejected.
Keystone Mercy must convert paper claims data into electronic claim information. All electronic
healthcare transactions are to be transmitted in compliance with standards set forth by The
Health Insurance Portability and Accountability Act (HIPAA) and the United States Department
of Health and Human Services (HHS). In addition, the federal mandate requires health plans,
clearinghouses and providers to use new standards when electronically submitting information.
Therefore, we are implementing this billing requirement to align the conversion of paper claims
to the mandated 5010 837 formats.
Please see the attached grids for both the CMS-1500 and UB-04 additional required fields
and billing guidelines that will make all provider claims submitted to Keystone Mercy
compliant with the 5010 837 Federal mandate.
Claims can be submitted now with these additional fields, but please note that effective
with claims received on July 1, 2013, additional data elements for the 837 format will be
required fields on all paper claims and will be rejected if missing.
If you have any questions, please contact Keystone Mercy Provider Services at 1-800-521-6007
or your Provider Account Executive.
Sincerely,
Paul L. Staudenmeier
Director, Provider Network Management
CMS-1500 Required Fields
CMS 1500 Field #
Field/Data Element
Required
Rejection
Billing Guidance
2
Patient Name
"Member name is missing or
illegible"
Claims wil be rejected if the first
and/or last name are missing or
illegible. SAME or SAME AS INSURED
is acceptable and will not reject.
3
Patient Birth Date
"Member DOB is missing"
Claims will be rejected if the month
and/or day and/or year is missing.
3
Patient Sex
"Member's sex is required"
One box must be checked.
"Insured name missing or illegible"
Claims will be rejected if first and/or
last name is missing or illegible.
SAME or SAME AS PATIENT is
acceptable and will not reject.
Claims will be rejected if any one of
the following are missing: street #,
street name, city, state, zip
4
Insured Name
5
Patient Address (#,
Street, city, state, zip)
phone
"Patient address missing"
6
Patient Relationship to
Insured
"Patient relationship to insured is
required"
7
Insured's Address (#,
street, city, state, zip)
phone
"Insured address missing"
Date of Service
"DOS is missing or illegible"
24a
One of the four boxes must be
checked
Claims will be rejected if any one of
the following are missing: street #,
street name, city, state, zip. SAME or
SAME AS PATIENT is acceptable and
will not reject.
Claims will be rejected if the if the
From and To date of service are
missing or illegible.
CMS-1500 Required Fields
CMS 1500 Field #
Field/Data Element
Required
Rejection
24E
Diagnosis Pointer
"Diagnosis Pointer is required on
Line(s) %Line%"
24F
Line Item Charge
Amount
"Line item charge amount is missing
on line(s) %Line%"
24G
Days/Units
"Days/units are required on line(s)
%Line%"
26
Patient acct #
27
Assignment #
"Patient Account/Control number is
missing or illegible"
"Assignment acceptance must be
indicated on the claim"
Billing Guidance
Each service line with a From date of
service, requires at least one (1)
diagnosis pointer.
Enter a value of greater than or equal
to zero on each valid service line.
Blank is not acceptable and will be
rejected.
Claims without a numeric value on
each valid service line will be
rejected.
Claim will be rejected if missing or
illegible.
Yes or No must be checked.
28
Total Claim Charge
Amount
"Total charge amount is required"
Claims will be rejected is a value
greater than or equal to zero is not
entered. Blank is not an acceptable
value. For multipage claims, the total
charge amount is only required on
the last page of the claim.
33
Billing Provider Info &
Ph#
"Billing Provider name and/or
address missing"
Claims will be rejected if any one of
the following are missing: name,
street #, street name, city, state, zip.
33
Billing Provider Info &
Ph#
"P.O. Box is not permitted as a billing Claims will be rejected that are
address"
submitted with a P.O. Box
UB-04 Required Fields
UB04 Field #
1
1
3a
8b
Field/Data Element Required
Billing Provider Name, Address and Telephone
Number
Billing Provider Name, Address and Telephone
Number
Patient Control No.
Patient Name
Rejection
"Billing Provider name and/or address missing"
"P.O. Box is not permitted as a billing address"
"Patient Account/Control number is missing or
illegible"
Claims will be rejected if a P.O. Box is submitted.
Claim will be rejected for missing or illegible
patient account/control number.
"Member name is missing or illegible"
Claims will be rejected if first and/or last name
are missing or illegible; however SAME or "SAME
AS INSURED" is acceptable.
Patient Address
"Patient address missing"
10
11
Patient Birth Date
Patient Sex
"Member DOB is missing"
"Member's sex is required"
12
Admission Date
"Admission Date is missing or illegible"
9a-e
Billing Guidance
Claims will be rejected if any one of the following
are missing: name, street #, street name, city,
state, zip.
13
Admission Hour
"Admission Hour is required"
14
Admission Type
"Admission Type is required"
15
Source of Referral for Admission or Visit
"Source of Referral for Admission or Visit missing"
Claims will be rejected if any one of the following
are missing: street #, street name, city, state, zip.
Claim will be rejected if missing month and/or day
and/or year.
Claim will be rejected if missing.
Inpatient claims will be rejected when a valid date
is missing or illegible.
Inpatient claims (other than bill type 21X) will be
rejected when a valid numeric value is missing or
illegible.
Claims will be rejected if a numeric value in
missing.
Claims will be rejected (other than bill type 14X)
when the field is blank.
16
17
Discharge Hour
Patient Discharge Status
"Discharge Hour is required"
"Patient discharge status is required"
45
Serv. Date
"DOS is missing or illegible"
Inpatient claims (other than bill type 21X) with
frequency codes 1 or 4 will be rejected if a
discharge hour is missing.
Claims will be rejected if missing.
Outpatient claims will be rejected if the field is
blank on any service line.
45
Creation Date
"Creation date is missing or illegible"
Claims will be rejected when missing or illegible.
"Days/units are required on line(s) %Line%"
Claims will be rejected for each line with a from
date of service that is missing a numerice value. A
zero or negative value is not allowed and will be
rejected.
46
Serv. Units
UB-04 Required Fields
UB04 Field #
47
Field/Data Element Required
Line Item Charges
47
50
Total Charges
Payer
52
Rel. Info
53
Asg. Ben.
Rejection
"Line item charge amount is missing on line(s)
%Line%"
"Total charge amount is missing"
"Payer name is required"
"Release of Information Certification Indicator is
required"
"Assignment of Benefits Certification Indicator is
required"
Billing Guidance
Claims will be rejected if a value greater than or
equal to zero is not present. Blank is not an
acceptable value. For multipage claims, the total
charge amount is only required on the last page of
the claim.
Claims will be rejected if a value greater than or
equal to zero is not present. Blank is not an
acceptable value. For multipage claims, the total
charge amount is only required on the last page of
the claim.
Claims will be rejected if missing.
Claims will be rejected if missing
Claims will be rejected if missing
Claims will be rejected if first and/or lst name is
missing or illegible; however SAME or "SAME AS
PATIENT" is acceptable.
58
Insured's Name
59
P. Rel
"Member name is missing or illegible"
"Patient's relationship to insured is required" (If blank,
reject claim)
Claims will be rejected if missing.
69
Admitting Diagnosis Code
"Admitting diagnosis code is missing or illegible"
Inpatient claims will be rejected when the
admitting diagnosis code is missing or illegible.
70
Patient’s Reason for Visit
"Patient’s Reason for Visit is missing"
Required for all outpatient visits. If reason is
missing claims will be rejected.
"Attending Provider Qualifier is missing/ invalid"
If other provider ID is present, two (2) character
qualifier is required or claim will be rejected.
"Attending Provider Other ID# Missing"
If other provider ID qualifer is present, and other
provider ID is blank, claim will be rejected.
Attending Provider Qualifier
76
Attending Provider Other ID#
76