Audiology Benefit Billing and Policy Manual

1. Insurance Type

Required

Place an "X" in the box marked as Medicaid.

1a. Insured's ID Number

Required

Enter the member's seven-digit Health First Colorado ID number as it appears on the Health First Colorado identification card. Example: A123456.

2. Patient's Name

Required

Enter the member's last name, first name, and middle initial.

3. Patient's Date of Birth/Sex

Required

Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.

4. Insured's Name

Conditional

Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.

5. Patient's Address

Not Required

6. Patient's Relationship to Insured

Conditional

Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.

7. Insured's Address

Not Required

8. Reserved for NUCC Use

Not Required

9. Other Insured's Name

Conditional

If field 11d is marked "YES", enter the insured's last name, first name and middle initial.

9a. Other Insured's Policy or Group Number

Conditional

If field 11d is marked "YES", enter the policy or group number.

9b. Reserved for NUCC Use

9c. Reserved for NUCC Use

9d. Insurance Plan or Program Name

Conditional

If field 11D is marked "YES", enter the insurance plan or program name.

10a-c. Is patient's condition related to?

Conditional

When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.

10d. Reserved for Local Use

11. Insured's Policy, Group or FECA Number

Conditional

Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.

11a. Insured's Date of Birth, Sex

Conditional

Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.

11b. Other Claim ID

Not Required

11c. Insurance Plan Name or Program Name

Not Required

11d. Is there another Health Benefit Plan?

Conditional

When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.

12. Patient's or Authorized Person's signature

Required

Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.

13. Insured's or Authorized Person's Signature

Not Required

14. Date of Current Illness Injury or Pregnancy

Conditional

Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period

15. Other Date Not

Not Required

16. Date Patient Unable to Work in Current Occupation

Not Required

17. Name of Referring Physician

Required

17b. NPI of Referring Physician

Required

Required in accordance with Program Rule 8.125.8.A

18. Hospitalization Dates Related to Current Service

Conditional

Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.

19. Additional Claim Information

Conditional

20. Outside Lab?
$ Charges

Not Required

21. Diagnosis or Nature of Illness or Injury

Required

Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.

22. Medicaid Resubmission Code

Conditional

List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.

23. Prior Authorization

Not Required

24. Claim Line Detail

Information

The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).

24A. Dates of Service

The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.

or

Span dates of service

Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: Permissible if the same service (same procedure code) is provided on consecutive dates.
Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
N4 - National Drug Codes

• Enter NDC qualifier N4 (left-justified), immediately followed by the 11-digit NDC numeric code.
• Enter one space for separation.
• Enter the appropriate qualifier for the correct dispensing NDC unit of measure (UN - Units, ML - Milliliter, GR - Gram, or F2 - International Unit), immediately followed by the quantity (number of NDC units).

VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth and Areas of Oral Cavity

24B. Place of Service

Required

Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.

Refer to the Allowed Place of Service Codes section in the Speech Therapy Billing Manual.

Effective May 3, 2024, place of service 03 is an allowed place of service for all fee-for-service benefits. In order for community providers to bill fee-for-service to children in a school setting, the provider must follow school district policy. Please reference the Community Providers in a School Setting Policy memo.

24C. EMG

Conditional

Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.

24D. Procedures, Services, or Supplies

Required

Enter the procedure code that specifically describes the service for which payment is requested.

24D. Modifier

Conditional

Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

Refer to the Allowed Place of Service Codes section in the Speech Therapy Billing Manual.

24E. Diagnosis Pointer

Required

Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.

24F. $ Charges

Required

Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.

24G. Days or Units

Required

Enter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.

24G. Days or Units

General Instructions

A unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

24H. EPSDT/Family Plan

Conditional

EPSDT (shaded area)
For Early and Periodic Screening, Diagnosis and Treatment-related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
Not Required

24I. ID Qualifier

Not Required

24J. Rendering Provider ID #

Required

In the shaded portion of the field, enter the NPI of the Health First Colorado provider assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.

25. Federal Tax ID Number

Not Required

26. Patient's Account Number

Optional

Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).

27. Accept Assignment?

Required

The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.

28. Total Charge

Required

Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

29. Amount Paid

Conditional

Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

30. Rsvd for NUCC Use

31. Signature of Physician or Supplier Including Degrees or Credentials

Required

Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

32. Service Facility Location Information
32a- NPI Number
32b- Other ID #

Required

Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

33. Billing Provider
Info & Ph #

Required

Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code

33a- NPI Number

Required

33b- Other ID #

If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.