EDI CMS 1500

EDI CMS 1500 Instructions (The Security Health Plan)

EDI CMS 1500 can be processed by the Security Health Plan Processing System that is designed to process standard health insurance claim forms (CMS 1500) using CPT-4 Procedure Codes or Health Care Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-10-CM Diagnosis Codes. Security Health Plan Processing Systems require that a compliant red form be used. If the form is not red, it will be returned with a request for a red form.

EDI CMS must be submitted with national provider identifier (NPI) only in all primary and secondary fields. Claims containing legacy numbers will be rejected.

Required information must be filled in completely, accurately, and legibly. If the information is inaccurate or incomplete, the claim cannot be processed and will be rejected with a note explaining the rejection.

A complete claim is considered to have the following data elements (numbered as shown on claim form):

1. Type of health insurance coverage applicable to this claim – check appropriate box

2. Patient’s name (last name, first, middle initial)

3. Patient’s eight-digit date of birth (MM/DD/CCYY) and sex

4. Insured’s name (last name, first, middle initial)

5. Patient’s address (street, city, state, and ZIP code)

6. Patient’s relationship to insured

7. Subscriber’s address (street, city, state, and ZIP code) and phone number

8. Patient’s marital status

9. Other insured’s name (last name, first name, middle initial) if applicable. Please include the actual insurance carrier name if available, not the name of a repricing company

10a–c. If patient’s condition is related to:

  • employment
  • auto accident
  • other accident

11. Insured’s policy group number

11a. Insured’s eight-digit date of birth (MM/DD/CCYY) and sex

11b. Employer’s name or school name

11c. Insurance plan name or program

12. The patient or authorized representative must sign and date

13. Insured’s or authorized person’s signature

14. Date of current illness, injury pregnancy (if applicable)

15. Not required

16. Not required

17. Name of referring physician or other source

17a. Leave blank

17b. Enter NPI of the referring/ordering physician listed in item 17

18. Hospitalization dates related to current services

19. Not required

20. Outside lab

21. Diagnosis (ICD-10-CM) or nature of illness or injury

22. Not applicable

23. Not required

24a. Date of service

24b. Place of service

24c. Type of service

24d. CPT/HCPCS/modifier

24e. Diagnosis code pointer

24f. Charge amount (for each service)

24g. Days or units

24h. Not required

24i – ID Qual (Medicaid only) If the rendering provider’s NPI is different than the billing provider number in Element 33A, enter a qualifier of “PXC” indicating provider taxonomy, in the shaded area of the detail line.

24j. Rendering provider’s NPI. (Medicaid only-If the rendering provider’s NPI is different than the billing provider number in Element 33A, enter the 10-digit taxonomy code in the shaded area of this element and enter the rendering provider’s NPI in the white area provided for the NPI.)

25. Tax Identification Number (TIN)

26. Patient’s account number

27. Check appropriate box to indicate whether the provider of service or supplier accepts assignment of Medicare benefits

28. Total charge

29. Amount paid by other insurance carrier. Do not include discounts, only actual payments

30. Balance due

31. Signature of physician or supplier

32. Name and address of facility where services were rendered (if other than home or office)

33. Physician’s supplier’s billing name, address, zip code, phone number and NPI

33a. NPI of service facility

33b. Qualifier “PXC” plus 10-digit provider taxonomy code (Medicaid only)

If there are any questions regarding claims submission, please, contact the Claims Processing Department at 1-800-548-1224.

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