Professional Claim Form

Professional Claim Form Basics

Professional Claim Form may be electronically submitted to a Medicare carrier, Durable Medical Equipment Medicare Administrative Contractor (DMEMAC), or A/B MAC from a provider’s office using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements contained in the provider enrollment & certification category area and the EDI Enrollment requirements. Providers that bill an A/B MAC are also permitted to submit claims electronically via direct data entry screens.

How Professional Claim Form Submission Works: The Professional Claim Form is electronically transmitted in data “packets” from the provider’s computer modem to the Medicare contractor’s modem over a telephone line. Medicare contractors perform a series of edits. The initial edits are to determine if the claims in a batch meet the basic requirements of the HIPAA standard. If errors are detected at this level, the entire batch of claims would be rejected for correction and resubmission. Professional Claim Form that passes these initial edits, commonly known as front-end edits or pre-edits, is then edited against implementation guide requirements in those HIPAA claim standards. If errors are detected at this level, only the individual claims that included those errors would be rejected for correction and resubmission.

Once the first two levels of edits are passed, each claim is edited for compliance with Medicare coverage and payment policy requirements. Edits at this level could result in rejection of individual claims for correction, or denial of individual claims. In each case, the submitter of the batch or of the individual claims is sent a response that indicates the error to be corrected or the reason for the denial. After successful transmission, an acknowledgement report is generated and is either transmitted back to the submitter of each claim, or placed in an electronic mailbox for downloading by that submitter.

Professional Claim Form must meet the requirements in the following claim implementation guides adopted as national standard under HIPAA:

  • Providers billing a A/B MAC must comply with the ASC X12 837 Institutional Guide (005010X223A2).
  • Providers billing a Carrier or DMEMAC (for other than prescription drugs furnished by retail pharmacies) must comply with the ASC X12 837 Professional guide (005010X222A1).
  • Providers billing a B DMEMAC for prescription drugs furnished by a retail pharmacy must comply with the National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard D.0 and Batch Standard Version 1.2.


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