Laboratory Services Billing Manual

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Laboratory Services

Providers must be enrolled as a Health First Colorado provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

A certified clinical laboratory means a provider who possesses a certificate of waiver or a certificate of registration from the Centers for Medicare and Medicaid Services (CMS) or its designated agency as meeting CMS guidelines and whose personnel and director are qualified to perform laboratory services.

An independent laboratory means a certified clinical laboratory that performs diagnostic tests and is independent both of the attending or consulting physician's office and of a hospital.

All clinical laboratory providers must furnish their Clinical Laboratory Improvement Amendment (CLIA) certification numbers to the Health First Colorado fiscal agent at the time of enrollment.

Medically necessary, physician-ordered laboratory services are a benefit of the Health First Colorado.

Providers should refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10), for specific information when providing laboratory services.

Important: Laboratory services for Emergency Medicaid (EMS) clients must include the emergency indicator on the claim for the claim to be paid.

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General Billing Information

Refer to the General Provider Information manual for general billing information.

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General Prior Authorization Requirements

Please consult the General Provider Information Manual on the Department's Billing Manual web page for information about Prior Authorization requirements. More information can be found on the ColoradoPAR website, and contact information can be found on the Department's Provider Contact web page.

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Laboratory Prior Authorized Procedure Codes

Below is a list of prior authorized procedure codes for Laboratory billing. Reference the current Fee Schedule for rates.

Note: this table serves only as a reference guide and not a guarantee of payment or coverage. Definitive coverage of a specific procedure code is found on the Fee Schedule.

Last table update: 01/10/2020

Procedure Code Notes Procedure Code Notes
81162 PAR required as of 1/1/2016 81295 PAR required as of 2/10/2020
81163 PAR required as of 1/1/2019 81296 PAR required as of 2/10/2020
81164 PAR required as of 1/1/2019 81297 PAR required as of 2/10/2020
81165 PAR required as of 1/1/2019 81298 PAR required as of 2/10/2020
81166 PAR required as of 1/1/2019 81299 PAR required as of 2/10/2020
81167 PAR required as of 1/1/2019 81300 PAR required as of 2/10/2020
81200 PAR required as of 2/10/2020 81306 PAR required as of 1/1/2019
81201 PAR required as of 7/1/2019 81307 PAR required as of 1/1/2020
81209 PAR required as of 2/10/2020 81308 PAR required as of 1/1/2020
81211 Coverage terminated 12/31/2018 81309 PAR required as of 1/1/2020
81212 PAR required as of 7/1/2015 81312 PAR required as of 1/1/2019
81213 Coverage terminated 12/31/2018 81317 PAR required as of 7/1/2019
81214 Coverage terminated 12/31/2018 81318 PAR required as of 2/10/2020
81215 PAR required as of 7/1/2015 81319 PAR required as of 2/10/2020
81216 PAR required as of 7/1/2015 81321 PAR required as of 7/1/2019
81217 PAR required as of 7/1/2015 81323 PAR required as of 2/10/2020
81220 PAR required as of 2/10/2020 81327 PAR required as of 2/10/2020
81241 PAR required as of 2/10/2020 81380 PAR required as of 2/10/2020
81242 PAR required as of 7/1/2019 81400 PAR required as of 2/10/2020
81243 PAR required as of 2/10/2020 81401 PAR required as of 2/10/2020
81251 PAR required as of 2/10/2020 81402 PAR required as of 2/10/2020
81255 PAR required as of 2/10/2020 81403 PAR required as of 7/1/2019
81256 PAR required as of 2/10/2020 81404 PAR required as of 7/1/2019
81257 PAR required as of 2/10/2020 81405 PAR required as of 7/1/2019
81260 PAR required as of 2/10/2020 81406 PAR required as of 2/10/2020
81277 PAR required as of 1/1/2020 81407 PAR required as of 2/10/2020
81283 PAR required as of 2/10/2020 81408 PAR required as of 7/1/2019
81290 PAR required as of 2/10/2020 81420 PAR required as of 2/10/2020
81292 PAR required as of 7/1/2019 81432 PAR required as of 2/10/2020
81293 PAR required as of 2/10/2020 81522 PAR required as of 1/1/2020
81294 PAR required as of 2/10/2020 81542 PAR required as of 1/1/2020

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Clinical Laboratory Improvement Amendments (CLIA) Claims

Laboratory providers submitting procedures covered by CLIA must have a CLIA number of the laboratory where the procedure was done on the claim or claim line. Pass-through billing is not allowed per the Laboratory and X-ray rule found at 10 CCR 2505-10 8.660.

  • Providers billing on the 837P format should refer to the updated 837P Companion Guide which is posted in the Provider Services EDI Support section of the Department's website. Providers billing on the 837P format and billing agents should update their billing systems for 837P transactions.
  • Providers billing an 837P through the Health First Colorado Online Portal (Online Portal) are able to enter CLIA numbers on the Detail Line Item tab (claim line).
  • Providers billing on the CMS 1500 paper claim form should enter their valid CLIA number in the REMARKS field (# 23). Enter "CLIA" before the CLIA number.

Please note: Only one CLIA number can be included on each paper claim form. It is applied to all CLIA covered procedures on the claim. Procedures covered by different CLIA numbers need to be submitted on separate claims. Enter the CLIA number in the REMARKS field only.

The tax ID (TID) on record with the Centers for Medicare and Medicaid Services (CMS) for the CLIA number must correspond to the TID on record with the Department. Questions regarding claims processing or responses should be directed to DXC Technology (DXC) at 844-235-2387 (toll-free).

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Handling, Collection and Conveyance Charges

Specimen collection (including venipuncture) is considered to be an integral part of the laboratory testing procedure when performed by a hospital laboratory and is not reimbursable as a separate or additional charge.

Transfer of a specimen from one clinical laboratory to another is a benefit only if the first laboratory's equipment is not functioning or the laboratory is not certified to perform the ordered tests. Modifier -KX used with procedure code 99001 verifies that the lab's equipment is not functioning or that the laboratory is not certified to perform the ordered test.

Specimen collection, handling, and conveyance from the member's home, a nursing facility, or a facility other than the physician's office or place of service is a benefit only if the member is homebound, bedfast, or otherwise non-ambulatory and the specimen cannot reasonably be conveyed by mail. A physician's statement explaining the circumstances and medical necessity is required.

Each laboratory will be reimbursed only for those tests performed in the specialties or subspecialties for which it is certified.

Papanicolaou (Pap) Smears

Health First Colorado allows one pap smear screening/examination per 12-month period in women under 40 years of age. Benefit for more than one Pap smear in a 12-month period is allowed for women ages 40 and over; women with a history of diethylstilbestrol exposure in utero; women with malignancy of the cervix, vagina, uterus, fallopian tubes or ovaries; women with cervical polyps, cervicitis, neoplastic disease of the pelvic organs, vaginal discharge or bleeding of unknown origin, postmenopausal bleeding, or vaginitis; or if the physician determines that more frequent testing is needed and is medically necessary. Claims will deny if the diagnosis code entered on the claim does not support the testing frequency.

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Drug Testing Unit Limitations and Documentation Requirements

Current Procedural Terminology (CPT) codes 80305, 80306 and 80307 have a unit limit of four (4) per month per client for each code. This unit limit applies to all provider types.

As of January 2020, substance-specific confirmatory tests, CPT codes 80320 – 80377, no longer require a positive or inconclusive presumptive test or medical necessity documentation attached to the claim to be considered for reimbursement.

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Newborn Metabolic Screening

Costs associated with Newborn Metabolic Screening (NMS) are included in the inpatient hospital diagnosis-related grouper (DRG) calculation and the birthing center facility payment and may not be billed separately by the hospital or birth center. Billing S3620 while receiving a DRG or facility payment for the delivery is duplicative.

S3620 may only be billed by providers, not reimbursed for the delivery, who submit a second-specimen screen and are charged for an initial-specimen screen by Colorado Department of Public Health and Environment (CDPHE) because the second-specimen could not be linked to an initial-specimen. S3620 does not require a CLIA certification.

Because the NMS are performed by CDPHE's laboratory and not the provider collecting and submitting the specimen, unbundling the NMS and billing for the individual tests performed by CDPHE's laboratory is not allowed per the Laboratory and X-ray rule found at 10 CCR 2505-10 8.660.

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BRCA Screening and Testing

Per the Women's Health Services rule found at 10 CCR 2505-10 8.731, the following are requirements for BRCA screening and testing:

  • BRCA screening, genetic counseling, and testing is only covered for clients over the age of 18.
  • BRCA screening is covered and must be conducted prior to any BRCA-related genetic testing.
  • The provider shall make genetic counseling available to clients with a positive screening both before and after genetic testing, if the provider is able, and genetic counseling is within the provider’s scope of practice. If the provider is unable to provide genetic counseling, the provider shall refer the client to a genetic counselor*.
  • Genetic testing for breast cancer susceptibility genes BRCA1 and BRCA2 is covered for clients with a positive screening

*Genetic Counselors cannot be directly reimbursed for services. A supervising physician may be reimbursed. The services require direct supervision if done by a genetic counselor, with the supervisor on site.

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Prenatal Testing

Per the Maternity Services rule at 10 CCR 2505-10 8.732.4.E. prenatal genetic screening tests are available for women carrying a singleton gestation who meet one or more of the following conditions:

  • Maternal age 35 years or older at delivery;
  • Fetal ultrasonographic findings indicated an increased risk of aneuploidy;
  • History of a prior pregnancy with a trisomy;
  • Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or a quadruple screen; or
  • Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or 21.

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General Requirements

  • Fees for blood drawing, specimen collection, or handling are not reimbursable to laboratories.
  • The provider who actually performs the laboratory procedure is the only one who is eligible to bill and receive payment. Physicians may only bill for tests actually performed in their office or clinic. Tests performed by laboratories or hospital outpatient laboratories must be billed by the performing laboratory.
  • CPT identifies tests that can be and are frequently done as groups and combinations ("profiles") on automated multi-channel equipment. For any combination of tests among those listed, use the appropriate Level 1 or Level 2 CMS codes.
  • For organ or disease-oriented panels (check CPT narrative), use the appropriate Level 1 CMS codes. These tests are not to be performed or billed separately when ordered in a group/combination and must be billed with one unit of service.

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Procedure/HCPCS Codes Overview

The Department accepts procedure codes that are approved by the Centers for Medicare & Medicaid Services (CMS). The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled certified Health First Colorado providers.

The Healthcare Common Procedural Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.

HIPAA requires providers to comply with the coding guidelines of the AMA CPT Procedure Codes and the International Classification of Disease, Clinical Modification Diagnosis Codes. If there is no time designated in the official descriptor, the code represents one unit or session. Providers should regularly consult monthly bulletins located in the Provider Services Provider Bulletins section. To receive electronic provider bulletin notifications, an email address can be entered into the Online Portal in the (MMIS) Provider Data Maintenance area or by completing and submitting a Publication Email Preference Form in the Provider Services Forms section. Bulletins include updates on approved procedures codes as well as the maximum allowable units billed per procedure.

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Procedure Codes

Services must be reported using HCPCS procedure codes.

Use procedure codes listed in the most recent Practitioner HCPCS bulletin located in the Provider Services Provider Bulletins section.

The fiscal agent updates and revises CMS codes through Health First Colorado bulletins.

CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Client Relationship to Insured Conditional Complete if the member is covered by a commercial health care insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19

Practitioner claims must be consecutive days.

Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.
81 Lab
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life- threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
26 Professional component
Use with diagnostic codes to report professional component services (reading and interpretation) billed separately from technical component services.
Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure.
Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.
KX Specific required documentation on file
Use with laboratory codes to certify that the laboratory's equipment is not functioning, or the laboratory is not certified to perform the ordered test. The -KX modifier takes the place of the provider's certification, "I certify that the necessary laboratory equipment was not functioning to perform the requested test", or "I certify that this laboratory is not certified to perform the requested test."
TC Technical Component
Use with diagnostic codes to report technical component services or procedures and includes the cost of equipment and supplies to perform that service or procedure. This modifier corresponds to the equipment/facility part of a given service or procedure. Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure.

Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units General Instructions A unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV Available- Not Used
S2 Under Treatment
ST New Service Requested
NU Not Used
Family Planning (unshaded area)
Not Required
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 Laboratory Services Claim Example with CLIA Number

CMS 1500 Laboratory Services Claim Example with CLIA Number

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CMS 1500 Laboratory Services Claim Example with CLIA Number

CMS 1500 Laboratory Services Claim Example with CLIA Number

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Client Relationship to Insured Conditional Complete if the member is covered by a commercial health care insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19

Practitioner claims must be consecutive days.

Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.
81 Lab
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life- threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
26 Professional component
Use with diagnostic codes to report professional component services (reading and interpretation) billed separately from technical component services.
Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure.
Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.
KX Specific required documentation on file
Use with laboratory codes to certify that the laboratory's equipment is not functioning, or the laboratory is not certified to perform the ordered test. The -KX modifier takes the place of the provider's certification, "I certify that the necessary laboratory equipment was not functioning to perform the requested test", or "I certify that this laboratory is not certified to perform the requested test."
TC Technical Component
Use with diagnostic codes to report technical component services or procedures and includes the cost of equipment and supplies to perform that service or procedure. This modifier corresponds to the equipment/facility part of a given service or procedure. Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure.

Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units General Instructions A unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV Available- Not Used
S2 Under Treatment
ST New Service Requested
NU Not Used
Family Planning (unshaded area)
Not Required
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 Laboratory Services Claim Example with CLIA Number

CMS 1500 Laboratory Services Claim Example with CLIA Number

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CMS 1500 Laboratory Services Crossover Claim Example with CLIA Number

CMS 1500 Laboratory Services Claim Example with CLIA Number

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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Laboratory Services Revision Log

Revision Date Section/Action Made by
12/01/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manuals Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
2/9/2018 Removed NDC supplemental qualifier - not relevant for independent laboratory providers DXC
6/25/2018 Updated general billing and timely to point to general manual HCPF
12/21/2018 Clarification to signature requirements HCPF
2/22/19 Add Section on Drug Testing Unit Limitations and Documentation Requirements
Added term dates and new codes to PAR table
HCPF
3/18/2019 Clarification to signature requirements HCPF
5/6/19 Add Section on Newborn Metabolic Screening
Update Title to Laboratory Services
HCPF
5/22/19 Add Codes to Prior Authorization Table HCPF
9/16/19 Updated Drug Limitations section HCPF
12/27/19 Converted to web page HCPF
1/10/2020 Added BRCA/Prenatal section, added codes to PAR table HCPF
1/14/2020 Update Drug Limitations section HCPF
9/10/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF