The following information is provided to you and your staff to
aid in the process of submitting a Health Insurance Claim Form
(CMS1500) to Triad Healthcare Inc.
Triad Healthcare Inc.
Claims Department
80 Spring Lane
Plainville, CT 06062
Please refer to the plan specific addendum of the provider manual
for client specific requirements regarding claim submission.
The information requested in these data fields is required and
must be legibly provided on a CMS 1500 Form. If any required field
on this form is omitted, or otherwise illegible, you will receive
notice that you have failed to follow the proper procedure for
filing a claim. Such notice shall be provided to you within
statutory time frames and shall include a description of the failure
and the proper procedures to follow in order to rectify and
re-submit the request.
All claims must include the following information in order to be
considered clean and processed in a timely manner.
Required Fields
| Field# |
Description |
| 1 |
Check off one - Medicare/Medicaid/CHAMPUS/CHAMPVA/Group Health Plan/FECA/other |
| 1a |
Insured's ID Number |
| 2 |
Patient's Name |
| 3 |
Patient's DOB/Gender |
| 4 |
Insured's Name |
| 5 |
Patient's Address/City/State/Zip
Code/Phone# |
| 6 |
Patient Relationship to Insured
(Self/Spouse/Child/Other) |
| 8 |
Patient Status - Check either-
Single/Married/Other/Employed/FT/PT |
| 9,9a-d* |
Other Insured's Name/Other Insured's
Policy #/ DOB/Gender/Employer's Name/Insurance
Plan |
| 10a-c |
Is the patient's condition related to:
Employment, Auto or Other? Place? |
| 11 |
Insured's Policy Group or FECA
Number |
| 11d |
Is there another Health Benefit
Plan? |
| 12 |
Patient's or authorized person's
signature |
| 13 |
Insured's or authorized person's
signature |
| 21 |
Diagnosis Codes |
| 24a |
Date of Service |
| 24b |
Place of Service |
| 24d |
Procedure Codes |
| 24e |
Diagnosis Code |
| 24f |
Charge Amounts |
| 24g |
Days or Units |
| 24i |
ID. Quality |
| 24j |
Rendering Provider ID.# |
| 24k |
Rendering Provider's ID as assigned by
payer |
| 25 |
Federal Tax ID Number, SSN/EIN |
| 26 |
Patient's Account # |
| 27 |
Accept Assignments |
| 28 |
Total Charge |
| 29 |
Amount Paid |
| 30 |
Balance Due |
| 31 |
Signature of Physician or supplier and
Date |
| 32 |
Name and Address of Facility where
services were rendered |
| 32a |
NPI |
| 33 |
Physician's, Supplier's Billing Name,
Address, Zip code & Phone # |
| 33a |
NPI | |
* Please note field 9,9a-d are only required when field 11d is
filled out as YES
Please note: Required fields - 24J (shaded area) Rendering
Provider's ID as assigned by payer 24J (white area) Rendering
Provider's NPI if one has been assigned. All other CMS-1500 fields
are required per HCFA-1500 requirements above.
ARCHIVE PROCESS
Click
here to see the archived process.
View manual online in pdf (Adobe Acrobat)
format or download the complete manual.
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