Claims Submission Information

Claims Submission Information

When submitting claims all providers must include, at a minimum, all of the following required information:

  • Patient’s ID number
  • Patient’s name and date of birth
  • Employer group number
  • Submitting provider’s tax ID number or Social Security number
  • State license number of attending provider
  • Submitting provider’s name and address
  • ICD-9 diagnosis code
  • Service date
  • Billed charge
  • Current year CPT or HCPCS procedure code (physician) or UB-92 revenue code with narrative description (hospital)
  • Submitting provider’s name and address
  • CMS place of service code (professional claims only)
  • CMS type of service code (professional claims only)
  • Number of days or units for each service line (professional claims only)
  • When authorization is required include authorization number and all necessary information

General Billing Requirements

Patient ID number: Enter the corresponding identification (ID) number as noted below:

  • Member ID number (Medi-Cal): Currently, the 11-digit number found on patient’s health plan ID card. Include all numbers including the last two digits, which indicate the relationship of the patient to the subscriber.
  • Subscriber ID number (Commercial HMO, AIM, Healthy Families, Senior HMO): The nine-character (the letter “R” followed by eight digits) ID found on patient’s health plan ID card.

Employer group number: The number assigned to the subscriber’s employer group located on the member’s ID card.

UPIN or state license number: Six-digit universal provider identification number (UPIN) or state license number of all attending providers.

  • When billing for more then one attending provider, indicate the UPIN on the appropriate detail line
  • For physicians, the state license number should be entered as a seven-digit number A0nnnnn. When “a” is the alpha character shown on the state license (A, C, G), “0” is the filler zero and “nnnnn” are the five numeric characters in the state license number
  • All other providers use their state-assigned license number without modifications

Specific Billing Requirements

Ambulance Claim: Trip reports are not needed for the following claims:

  • 911 referral
  • Law enforcement or fire department involvement
  • Mental health hold (5150/5350)
  • Motor vehicle accident (MVA)

Anesthesia Claim: Include surgeon’s name and license number instead of the referring physician’s name. For a Caesarean section performed after epidural anesthesia, indicate administration time for the general anesthetic and the epidural separately on the claim. The unit field should contain the number of time units (not minutes) being charged. Do not include base value or modifier units.

Assistant Surgeon: Include surgeon’s name in Box 17 of the CMS-1500. Use -80 modifier after CPT code.

By Report: Include the operative report or chart notes for report procedures, including high level exams or consults.

Coordination of Benefits (COB): When Serra Community Medical Clinic, Inc is the secondary payor, the provider must submit the claim and a copy of the Explanation of Medical Benefits/Explanation of Benefits (EOMB/EOB) from the primary carrier to Serra Community Medical Clinic, Inc for payment consideration.

Eye Exams: Claims for exams related to diseases or injuries of the eye must include diagnosis.

Injectable Medications: When billing for injectable medications, list appropriate HCPCS code identifying medication name, NDC number, strength, dosage and method of administration.

Itemized OB Care: State reason why a global maternity fee is not being billed.

Medical Supplies: List and describe all supplies used. Include a copy of the invoice for all charges in excess of $35. Use HCPCS codes for supplies when possible.

Multiple Diagnoses: Indicate specific diagnosis for each procedure billed.

Multiple Visits: If billing for three or more office visits within 30 days, include chart notes. If billing for two visits for the same patient on the same day, include chart or hospital notes.

Trauma: When billing a claim or itemization that is stamped trauma or with revenue code 208, an emergency room (ER) and Trauma Team Activation sheet/report must be attached to the claim.

Unusual Services: When billing modifier 22, (unusual services) include report or chart notes except for sigmoidoscopy over 35 centimeters.

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