Claim Submission Guidelines
Effective 11/23/08
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.
Claims can be mailed to:
Triad Healthcare Inc.
Claims Department
PO BOX 904
80 Spring Lane
Plainville, CT 06062 - 0904
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.
Functionality:
View manual online in pdf (Adobe Acrobat)
format or download the complete manual.
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