20:06:27:04Requirements

for use of HCFA Form 1450. The HCFA Form 1450 shall be used as follows: (1) Institutional care practitioners shall use the HCFA Form UB-92 HCFA-1450, adopted by HCFA and in effect as of June 30, 1995, when filing claims for health care services with issuers. When requested by the patient, institutional care providers that bill patients directly shall provide a completed HCFA Form 1450 in addition to any other explanation or information used to bill the patient; (2) Issuers may require institutional care practitioners to use only the following coding system for the initial filing of claims for health care services: (a) ICD-9-CM codes, in effect as of June 30, 1995; (b) Revenue codes, in effect as of June 30, 1995; (c) HCPCS Level 1, Level 2, and Level 3 codes, in effect as of June 30, 1995; and (d) The information outlined in subdivision 20:06:27:03(3), if the charges include direct service furnished by a health care practitioner and the direct service is not covered by the instructions for the HCFA Form 1450; (3) Hospitals may use the HCFA Form 1500 to supplement a HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with issuers for outpatient services.

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