20:06:27:03Requirements

for use of HCFA Form 1500. The HCFA Form 1500 shall be used as follows: (1) Health care practitioners, other than dentists, shall use the HCFA Form 1500, adopted by HCFA, approved by AMA Council on Medical Service in August, 1988, and in effect in May of 1995, when filing claims for professional services with issuers. Health care practitioners that bill patients directly shall provide a completed HCFA Form 1500 in addition to any other explanatory information used to bill the patient if requested by the patient. Issuers may only require health care practitioners to use the following coding systems for the initial filing of claims for health care services: (a) HCPCS Level 1, Level 2, and Level 3 codes in effect as of June 30, 1995; and (b) ICD-9-CM codes in effect as of June 30, 1995; (2) Issuers may only require health care practitioners to use other explanations with a code or to furnish additional information with the initial submission of a HCFA Form 1500 under the following circumstances: (a) If the procedure code used describes a treatment or service that is not otherwise classified; (b) If the procedure code is followed by the CPT-4 modifier 22, 52, or 99, pursuant to the CPT-4 manual in effect as of June 30, 1995. Health care practitioners may use item 19 of the HCFA Form 1500 to explain multiple modifiers, unless box 19 is used for other purposes in accordance with the instructions for this form; or (c) If information contained in the code is insufficient to process the claim or, in the case of a public program, is necessary to administer the program; (3) Health care practitioners may use box 19 of the HCFA Form 1500 to indicate the form is an amended version of a form previously submitted to the issuer by inserting the word "amended" in the space provided; (4) Except as otherwise required through participation in Medicaid, health care practitioners billing for services based on the amount of time involved shall define on line 19 the time interval in item 24 G of the HCFA Form 1500, if the time interval is not already defined in the HCPCS code. If not defined by either HCPCS or in line 19, the issuer shall assume units to be days of treatment; (5) Except as otherwise required through participation in Medicaid, as authorized by Title XIX of the Social Security Act, 42 U.S.C. § 1396d, health care practitioners shall provide the unique physician identification number, as assigned by HCFA, in box 17a and the federal tax identification number or social security number to complete item 25 of the HCFA Form 1500.

Source: 22 SDR 97, effective December 18, 1995; 42 SDR 52, effective October 13, 2015.