The following information is provided to you and your staff to
aid in the process of submitting a Health Insurance Claim Form
(HCFA 1500) to Triad Healthcare Inc.
Please reference the patients plan information prior to
submitting claims to ensure Triad Healthcare inc. accepts claims
directly.
Please note: Claims for Oxford patients should continue to
be sent directly to Oxford Health Plans
Triad Healthcare Inc.
Claims Department
PO BOX
904
80 Spring Lane
Plainville, CT 06062 - 0904
The information requested in these data fields is required and
must be legibly provided on a HCFA 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. All claim
submissions received by Triad Healthcare Inc. will be reviewed in
accordance with a pre-certification (ICP/EOC). Only those services
that have been approved in advance will be reimbursed. Claims for
services rendered on the same date, or duplicates, will be
adjudicated based upon the authorization generated during the
pre-certification process.
Required Fields
Triad Healthcare Inc.
Claims Department
PO BOX
904
80 Spring Lane
Plainville, CT 06062 - 0904
The information requested in these data fields is required and
must be legibly provided on a HCFA 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. All claim
submissions received by Triad Healthcare Inc. will be reviewed in
accordance with a pre-certification (ICP/EOC). Only those services
that have been approved in advance will be reimbursed. Claims for
services rendered on the same date, or duplicates, will be
adjudicated based upon the authorization generated during the
pre-certification process.
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 |
| 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 |
| 33 |
Physician's, Supplier's Billing Name,
Address, Zip code & Phone # | |
* Please note field 9,9a-d are only required when field 11d is
filled out as YES
Please note: Triad Healthcare Inc. will accept the revised
(8/05) CMS 1500 claim form starting on 10/1/06. 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.
View manual online in pdf (Adobe Acrobat)
format or download the complete manual.
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