1. Review the claim file requirements listed below
2. Locate claims that will meet the requirements
3. Select previously submitted claim files that meet the basic claim file requirements
4. Run batch
5. Zip claim file

1. Claim files must be zipped before they are sent. This prevents possible data corruption. The zipped file should be named using your provider name (example lesnau.zip)
2. The batch file must contain a minimum of 50 claims to a maximum of 100 claims. Larger files will not be accepted.
3. Claims must contain a mixture of the payors.
4. The following HCFA Fields must have examples for each option for field.



• 6 - Pt. Relationship to insured
• 8 - Patient Status
• 10 - Patient condition related to Employment
• 11D - Other Insurance Indicator
• 20 - Outside Lab Charges


5. All fields utilized must be represented in the claim file. The Analysts can only map what is represented.
6. Test file must contain current claims, claims generated within the last 90 days.
7. All providers submitting claims must be included in the test claim file.
8. All facilities submitting claims should be represented in the file.
9. The test claim file must be batched using the same method that will be used once they are in production. Claims may not be cut and pasted into the file.

1. Physical Therapists and Podiatrists - Date Last Seen is required on all claims and must be placed in field (19). This would also require that a Referring Physician name and UPIN number be placed in fields (17) and (17a) respectively.
2. Chiropractors - Date of Last x-ray is required in field (14). Subluxation levels are required and should be placed in field (19). If they need to be line charge specific, they should then be placed in field (24k) instead of field (19). Whichever format you choose, it must always be consistent with what is represented in the test claim file.
3. Anesthesiologists - When giving anesthesia minutes, they must be in total minutes, i.e., 70 minutes, and not 1 hour 10 minutes.
4. If Payor specific procedure codes are used, these must be represented in the test claim file.
5. If you have not previously been filing claims electronically, please contact the Provider Relations Department at Medicaid, Medicare, BCBS and/or Champus (if you submit claims to any of these payors).

• Date of Birth missing for patient and/or insured (fields 3 and 11a)
• Only 1 sex represented for patient and/or insured (fields 3 and 11a)
• Insured's name represented (field 4) but no other information (field 7)
• Only 1 type of marital status represented (field 6)
• Other insured's information incomplete (i.e., name without policy/group number, date of birth, sex, and/or plan name - field 9a through 9d)
• Condition indicators always "No" on all claims even when some were due to Auto Accident, Workers' Comp or Other Injury (field 10)
• Signature on file (field 12 and/or 13) missing - field 13 is required if Accept assignment is "Yes", field 12 is always required
• Date of Current missing (field 14)
• Referring physician name and/or UPIN number missing (field 17)
• Third and Fourth diagnosis codes missing (field 21)
• Date of Service "to" missing (field 24a)
• Place of Service codes missing and/or Standard Codes not being used (field 4b)
• Type of Service codes missing and/or Standard Codes not being used (field 24c)
• Modifiers missing (field 24d)
• Test claim file doesn't contain a representation of all facilities provider utilizes - without this in the test claim file, proper set up of facilities cannot be done and auto population will not occur thus non matching facilities when loading claims will result in errors
• CLIA numbers not represented (if a physician doesn't have a CLIA number, we need to be informed of this) CPO ID (Care Plan Oversight ID) not represented

The claim file must contain complete addresses for all payors. PATIENT/INSURED DEMOGRAPHICS

1 Insured ID number required on all claims.

2 Patient name (LFM or FML required and must be same format for all patients).

3 DOB/Sex (DOB required MMDDYY or MMDDCCYY-as of October 1, 1998, must be in 8-digit format). Patient sex is required. If patient base consists of both sexes (M, F) claim file must have at least 2 claims with each sex represented.

4 Insured's name is not always required, but should be represented in the claim file as it is applicable in some cases. (LFM or FML format should be used and must be same whenever used.)

5 Patient Address, City, State, Zip and Phone with area code required.

6 Patient relationship to insured must be indicated. If claim files will ever contain more than one option (Self, Spouse, Child or Other), each of those relationships must be represented in test claim file.

7 Insured Address, City, State, Zip, and Phone with area code is required if different than patient's. Use the same format as when completing patient information.

8 Patient Status - all three options (Single, Married or Other) should be represented in test claim file if these will ever possibly be on the claims.

9 These fields are not required, but if they will ever be present in claim files, there should be a representation of each of the fields in the test claim file.

9 Other insured's name (LFM or FML must be the same format whenever used).

9a Other insured's policy or group number may be required on some claims.

9b Other insured's DOB/Sex will be required if field (9) is populated on claim. Follow same format as indicated for field (3).

9c Employer's name or School name may be required on some claims.

9d Insurance plan name or program name may be required on some claims.

10 Patient condition related to Employment, Auto Accident or Other- Accident - "No" should be indicated on all three. If there will ever be claims when "Yes" would be indicated, include some claims with those indications in test claim file.

11 Insured's Policy/Group number is required and cannot be the same as Insured's ID in field (1a). If you file Medicare that requires the word "none" in this field that is acceptable.

12 Patient Release of Info required - recommend "Signature on File". Signature Date is required.

13 Assignment of Benefits signature required - recommend "Signature on File".

CLAIM CHARGE INFORMATION

14 Date of Current required if field (10) Is "Yes" or if ICD codes used range from 800.00-999-99.

15 Same Illness not usually required but if it is ever used, it must be represented in test claim file.

16 Unable to work dates To and From not required but if it is ever used, it must be represented in test claim file.

17 Referring Physician (LFM or FML and must be same format for all claims). At least one referring physician name should be represented in claim file if this field will ever be used.

17a UPIN number or provider number required if field (17) used.

1 8 Hospital To and From Dates not usually required but if it is ever used, it must be represented in test claim file.

19 Reserved for Local.

20 Outside Lab and charges - please indicate either "Yes" or "No"; if "Yes", a dollar amount needs to be indicated. If possibility exists that both options are used, both must be represented in test claim file.

21 Diagnosis codes (ICD-9) are required and should be most current codes and coded to the highest level of specificity.

22 Medicaid Resubmission Code/Reference Number not required.

23 Prior Authorization not required but if this field is ever used, at least one claim should contain number here.

23 CLIA number - if ever used on any claims (required by Medicare when lab work is done in office), it must be represented in test claim file. HCFA standard says to use field (23) for CLIA numbers.

24a Dates of Service From required (MMDDYY or MMDDCCYY format acceptable).

24a Dates of Service To required if units >1. Even if this only happens occasionally in your practice, it should be represented in test claim file. (MMDDYY or MMDDCCYY format acceptable.)

24b Place of Service required - standard codes should always be used. If a particular payor requires something different, HBOC will make the conversion prior to claim transmission. Claims.now will not allow the unusual Place of Service codes.

24c Type of Service required - standard codes should always be used. If a particular payor requires something different, HBOC will make the conversion prior to claim transmission. Claims.now will not allow the unusual Type of Service codes.

24d Procedure Codes are required.

24e Diagnosis Code Pointer required. The actual ICD codes can be placed here but if they were placed in field (21) and it must be consistently done one way or the other. Recommendation: ICD codes in field (21) and pointers only in field (24e).

24f Charges required. Claims.now cannot accept "zero" charge claims.

24g Units required (may also be anesthesia minute value).

25 Tax ID required. Either EIN or SSN must be indicated.

26 Patient Account Number required - must be unique to the patient.

27 Accept Assignment required. If both "Yes" and "No" will be used, both must be

represented in test claim file.

28 Total Charge required on claim. Claims.now will automatically add charges and

calculate Total Charge if not on claim.

29 Amount Paid - not required but must be represented in test claim file if you wish this information to be transmitted.

30 Balance Due not required.

31 Physician Name required (LFM, FML format must be consistent). Date of Signature required.

32 Facility Information required if services are ever rendered at a location other than the primary billing address (i.e., a different office location, nursing home, hospital, etc.).

33 Provider name, address, and telephone number required. This would be the name of the entity to whom payments are made and directly ties to Tax ID.