4/1/2014 Introduction text changed N/A N/A Please Note: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the Provider Online Service Center (POSC) or on paper. Please Note: Effective January 1, 2012, MassHealth adopted an claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the Provider Online Service Center (POSC) or on paper. 4/1/2014 The sample CMS-1500 form was replaced with the updated form. N/A N/A- N/A N/A 4/1/2014 Member identification (ID) number is required in all cases. 1a Insured’s I.D. Number Enter the complete 12-character member identification (ID) number that is printed on the MassHealth card. If the Medicare box is checked in Field 1 (and if this is a crossover claim), enter the member’s HIC (health insurance claim) number. Enter the complete 12-character member identification (ID) number that is printed on the MassHealth card. 4/1/2014 Field name changed. 8 Reserved for NUCC Use N/A N/A 4/1/2014 Changes to instructions for completing the field. 9 Insured’s Name If Field 11d has an entry, complete Fields 9 and 9a through 9d, as applicable. When additional group health coverage exists, enter the name of the other insured in the following order: last name, first name, middle initial. If Field 11d has an entry, complete Fields 9, 9a, and 9d, as applicable. When additional group health coverage exists, enter the name of the other insured in the following order: last name, first name, middle initial. 4/1/2014 Field now reserved for NUCC use. 9b Reserved for NUCC Use Enter the eight-digit date of birth of the other insured in MM/DD/YYYY format. Enter an X in the applicable box to indicate the gender of the other insured. Only one box can Not required
and orthotics. Unshaded/lower area: date of current illness, injury, or pregnancy; place of service; emergency status; procedures, services, or supplies; diagnosis pointer; charges; days/units; etc. 4/1/2014 Clarifications to field name and description. 24A Date(s) of Service (for lower, unshaded area) Enter the date the service was provided in MMDDYYYY format. the date the service was provided in MMDDYYYY format in the unshaded area. 4/1/2014 Changed references to pointers from numeric to alphabetic. 24E Diagnosis Pointer If applicable, enter the diagnosis code reference number (pointer) as shown in Field 21 to relate the date of service and the procedures performed to the primary diagnosis. (ICD-9-CM diagnosis codes must be entered in Field 21 only. Do not enter them in Field 24E.) When multiple services are performed, enter the primary reference number for each service first, followed by other applicable services. The reference number should be a 1, 2, 3, 4, or multiple numbers as explained in the previous sentence. Enter numbers left-justified in the field. Do not use commas between the numbers. If applicable, the diagnosis code reference letter (pointer) as shown in Field 21 to relate the date of service and the procedures performed to the primary diagnosis. (ICD-CM diagnosis codes must be entered in Field 21 only. Do not enter them in Field 24E.) When multiple services are performed, enter the primary reference letter for each service first, followed by other applicable services. The reference number should be a letter A through L or multiple letters as explained in the previous sentence. Enter letters left-justified in the field. Do not use commas between the letters. 4/1/2014 Field now reserved for NUCC use 30 Rsvd for NUCC Use N/A Not required 4/1/2014 Appendix A: TPL Supplemental Instructions for Submitting Claims on the CMS-1500 for N/A N/A N/A Removed references to fields 1a, 9b, 10d, and changed TPL Required information for field 11d to reflect changes to these fields.