New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IX - Unfair Trade Practices › Part 217 - Processing Of Health Insurance Claims › Subpart 217-1 - Prompt Payment Of Health Insurance Claims › Section 217-1.2 - Health insurance claim submission guidelines

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A claim for payment of medical or
				  hospital services submitted on paper shall be deemed complete if it contains
				  the minimum data elements set forth in this Part. If the minimum data elements
				  set forth are not present or accurate, the payer may, but need not, adjudicate
				  the claim if the payer can determine, based on the information submitted,
				  whether such claim should be paid or denied. Even if the claim is deemed
				  complete, a payer may, pursuant to the provision of section 3224-a(b) of the
				  New York Insurance Law, request specific additional information, distinct from
				  information on the claim form, necessary to make a determination as to its
				  obligation to pay such claim.
(b)
(1) In the case of a medical claim submitted
				  on the national standard form known as a CMS 1500 (previously known as HCFA
				  1500 [New York State]) and its successors, attached as an appendix, (see
				  Appendix 26 of this Title), the claim shall contain at least the items in the
				  following fields of the claim form, except as provided in paragraph (2) of this
				  subdivision:
1a. Insured's I.D.
				  Number
2. Patient's Name
3. Patient's Date of Birth and
				  Gender
4. Insured's Name (Last
				  Name, First Name)
5. Patient's
				  Address
9. Other Insured's Name (if
				  appropriate)
9a. Other Insured's
				  Policy or Group Number (if appropriate)
9b. Other Insured's Date of Birth and Gender
				  (if appropriate)
9c. Employer's
				  Name or School Name (if appropriate)
9d. Insurance Plan Name or Program Name (if
				  appropriate)
10a. Is Patient's
				  Condition Related to Employment?
10b. Is Patient's Condition Related to Auto
				  Accident?
10c. Is Patient's
				  Condition Related to Other Accident?
11. Insured's Policy, Group or FECA Number
				  (if provided on ID Card)
11d. Is
				  There Another Health Benefit Plan?
12. Patient's or Authorized Person's
				  Signature (Can be completed by writing "signature on file" where
				  appropriate)
13. Insured's or
				  Authorized Person's Signature (if appropriate)
17. Name of Referring Physician or Other
				  Source (if appropriate)
17a. I.D.
				  Number of Referring Physician (if appropriate)
18. Hospitalization Dates Related to Current
				  Services (if appropriate)
21.
				  Diagnosis or Nature of Illness or Injury
23. Prior Authorization Number (to report ZIP
				  code for ambulance pick-up) (if appropriate)
24A. Dates of Service
24B. Place of Service
24D. Procedures, Services, or
				  Supplies
24E. Diagnosis Code (refer
				  to item 21)
24F. $
				  Charges
24G. Days or Units (if
				  appropriate)
25. Federal Tax I.D.
				  Number
28. Total Charge
29. Amount Paid (if appropriate)
30. Balance Due
31. Signature of Physician or Supplier
				  Including Degrees or Credentials (if not already on file, except as required by
				  applicable Federal and State laws)
33. Personal Identifying Number of the
				  particular practitioner rendering the care plus, if practicing in a group, the
				  Identifying Number of the group as well