Fields marked “Required” in the claim form
instructions must be completed on all paper claim submissions. The
claim may be denied if a “required” field is incomplete.
Fields marked “Conditional” are required when they
apply to the claim. For example, Field 9a (marked “Conditional”)
must be populated with the policy or group number only when TPL
Fields marked “Recommended” are not required, but
will be returned with the provider’s remittance advice if supplied
on the claim. For example, if the provider’s in-house, patient
account number is provided in Field 26, it will be returned on the
remittance advice, thereby allowing billing staff to cross reference
the claim with the provider’s records if needed.
Fields marked “Not Required” are not used in
processing the claim, although the provider is free to populate the
field if desired.
Spaces, Dashes and Hyphens
Do not enter spaces, dashes, hyphens or any other
kind of punctuation within a provider’s NPI/API or 9-digit zip code,
a recipient’s ID, or any other identifier on the claim.