Peoples Health requires all claims to be submitted electronically, in accordance with the Medicare Claims Processing Manual 100-4, Chapter 24, and any other CMS guidance that governs claims handling and the filing of claims. All claims for covered services rendered must be submitted to us electronically via Change Healthcare EDI Systems, payer ID number 72126. Peoples Health reserves the right to use the claims procedures issued by CMS to adjudicate claims, specifically including the claims procedures contained in the Medicare Claims Processing Manual and all other CMS-issued payment guidance, and to avail itself of the reconciliation processes and other remedies contained therein.
If you are not currently submitting claims electronically and want to begin utilizing software to do so, please contact the provider services department.
All submitted claims must include the following information or we will deny the claim or the clearinghouse may reject it. Please be sure to complete all information on the claim as required by CMS, including the following:
- Patient’s name and date of birth
- Patient’s address and plan member ID, or “G,” number
- Referring physician’s name
- Referring physician’s DN qualifier
- Referring physician’s NPI number
- All claims for physical therapy, occupational therapy or speech-language pathology services, including those furnished incident to physician or non-physician practitioner (NPP) services, must have the name and NPI of the certifying physician or NPP for the therapy plan of care. For the purposes of processing professional claims, the certifying physician or NPP is considered a referring provider. Providers and suppliers filing electronic claims are required to comply with applicable HIPAA ASC X12 837 claim completion requirements for reporting a referring provider.
- Servicing provider’s NPI (as well as the group NPI if applicable)
- Home health agency certification number (if applicable)
- Submit ICD-10 diagnostic codes (volume 1, for institutional claims; include PCS codes if applicable)
- HCPCS codes with modifiers (if applicable)
- CPT procedure codes with modifiers (if applicable)
- CPT II codes for quality reporting (if applicable)
- Billed charges and totals
- NCD number and name of drug and dosage (if applicable)
- Information on other insurance coverage applicable to the covered person (i.e., primary coverage information if applicable)
- Date of service
- Place of service code (where services were rendered)
- Servicing provider’s tax ID number
- Servicing physician’s name and address
- Place of service, including name and address where services were rendered (including the patient’s home when used as a service location)
- Billing provider’s “pay to” name and address
- Condition codes, value codes and amounts, occurrence codes and amounts, admit type and point-of-origin codes, and discharge status codes (for institutional claims as applicable)
- DME claims must include the name, address and ZIP code of the location where the order was accepted
Providers are expected to follow CMS guidance and any special Peoples Health instructions when completing claim forms for payment consideration. Claims must be legible, accurate and completed in full. If filing a corrected claim, please mark the claim as such. For institutional claims filed on a UB04 form, the type of bill code should end in numeric value “7.”
For more detailed information about completing the UB04 claim form, also called the CMS-1450 claim form, reference Chapter 25 of the Medicare Claims Processing Manual (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c25.pdf).
For detailed information about completing the CMS-1500 claim form, reference Chapter 26 of the Medicare Claims Processing Manual (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf).