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MIF Claim Submission Guidance – Provider Claims

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Overview

Below are claim submission guidelines for providers submitting claims to the Medical Indemnity Fund (MIF). This guidance will be updated periodically to address common questions and concerns relating to MIF claim submission. The guidance below assumes all applicable authorizations have been obtained from Alicare.

If you have any questions about submitting claims, please contact us:
MIF@dfs.ny.gov or call 1-855-NYMIF33 (1-855-696-4333) and select the option for Claims.

If you have any questions about authorizations, please contact Alicare:
1-855-NYMIF33 (1-855-696-4333) and select the option for Enrollment and General Benefit Questions.

Overall Submission requirements

Due to the standardization of provider claims, it is preferable and more expedient if providers accept payment directly from the MIF and submit their claims directly to the MIF for reimbursement. If you are a member submitting a claim, please refer to the MIF Claim Submission Guidelines for Members available on the MIF website.

All completed claims are required to be received by the MIF within 90 days from the date services are rendered or purchased.

Provider Claims

Appendix A MIF Claims Requirements for 1500 Professional Form: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

1

Carrier Type

Optional

 

Type of Insurance

1a

Insured’s ID Number

Required

12 alpha numeric

Insured's MIF ID Number - Enter the member's MIF number as it appears on the ID card.

2

Patient’s Name

Required

 

Enter the member’s name as is indicated on the ID card.

3

Patient’s Date of Birth/Sex

Required

MMDDYYYY

F or M or U

Patient's Birth date - Enter member's date of birth and check the box for male or female.

4

Insured’s Name

Optional

 

Insured's Name

5

Patient’s Address

Required

 

Patient's Address - Enter member’s complete address and telephone number.

6

Patient’s Relationship to Insured

Optional

 

Patient's Relationship to Insured

7

Insured Address

Optional

 

Insured Address

8

Reserved

DO NOT USE

   

9

Other Insured’s Name

Required (if box 11d is Yes)

 

Other Insured's Information Name

9a

Other Insured’s Policy or Group Number

Required (if box 11d is Yes)

 

Other Insured's Information Policy/Group Number

9b

Reserved

DO NOT USE

   

9c

Reserved

DO NOT USE

   

9d

Insurance Plan Name or Program Name if Applicable

Required (if box 11d is Yes)

 

Other Insured's Information Employer/School Name, Insurance Plan/Program Name

10

Is Patient’s Condition Related to:

     

10a

Employment

Required
(if applicable)

 

Check Yes or No

10b

Auto Accident

Required
(if applicable)

 

Check Yes or No

10c

Other Accident

Required
(if applicable)

 

Check Yes or No

10d

Reserved

DO NOT USE

   

11

Insured’s Policy Group or FECA Number

Required
(if applicable)

 

Insured's Information - Policy/Group Number

11a

Insured’s Date of Birth

Required
(if applicable)

MMDDYYYY

Insured’s Date of Birth

11b

Other Claim ID designated by NUCC

Required
(if applicable)

   

11c

Insurance Plan Name or Program Name

Required
(if applicable)

 

Insured's Information - Plan/Program Name

11d

Is there Another Health Benefit Plan?

Required

 

Check Yes or No

12

Patient’s or Authorized Person’s Signature (Medical Records/Information Release) and Date

Required

 

Signature and Date

13

Insured’s or Authorized Person’s Signature (Assignment of Benefits)

Required

 

Insured's or Authorized Person's Signature

Appendix A MIF Claims Requirements for 1500 Professional Form Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

14

Date of Current Illness, Injury, Pregnancy, Qualifier

Optional

MMDDYY or MMDDCCYY

Date of Current - Illness (First Symptom) OR Injury OR Pregnancy (LMP) - Enter the date of onset of the member's illness, the date of accident/injury or the date of the last menstrual period.

15

Qualifier, First Date of Onset of Same/Similar Illness

Optional

 

If patient had same or similar illness give first date

16

Dates Unable to Work in Current Occupation

Optional

MMDDYY or MMDDCCYY

Dates Patient Unable to Work in Current Occupation

17

Qualifier/Name of Referring Physician

Required
(if applicable)

 

Name of Referring Provider or Other Source - Enter the full name of the Referring Provider. A referring/ordering provider is one who requests services for a member, such as provider consultation, diagnostic laboratory or radiological tests, physical or other therapies, pharmaceuticals or durable medical equipment.

17a

Legacy Referring

Required
(if applicable)

 

ID Number of Referring Physician - Enter State Medical License number.

17b

Referring Physician NPI#

Required
(if applicable)

10 digit number

Enter Referring Provider's NPI number.

18

Qualifier/Hospitalization Dates Related to Current Services

Optional

MMDDYY or MMDDCCYY

Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank.

19

Additional Claim Information designated by NUCC

Optional

MMDDYY or MMDDCCYY

Reserved for Local Use - Use this area for procedures that require additional information, justification or an Emergency Certification Statement.

  • This section may be used for an unlisted procedure code when explanation is required and clinical review is required.
  • If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be listed. • Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits.
  • All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.
  • Anesthesia start and stop times.
  • Itemization of miscellaneous supplies, etc.

20

Outside Laboratory?

Optional

 

Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory.

Appendix A MIF Claims Requirements for 1500 Professional Form Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

21

Diagnosis or Nature of Illness or Injury

Required

10 digit Alpha Numeric

Enter all letters and/or numbers of the ICD-10 code for each diagnosis, including fourth and fifth digits if present. The first diagnosis listed in section 21.1 indicates the primary reason for the service provided

22

Resubmission Code:

Required for correction or voiding of a claim only

 

Enter:

7 for a corrected claim 8 for a voided claim AND

Original Reference Code:

Enter the Claim ID number of the claim you are requesting to correct or void.

Both Data elements above are required.

23

Prior Authorization Number

Required
(if applicable)

 

Enter prior authorization or referral number.

24a

Date of Service, From and To

Required

MMDDYY or MMDDYYYY

Enter the date the service was rendered in the “from” and “to” boxes in the MMDDYY format. If services were provided on only one date, they will be indicated only in the “from” column. If the services were provided on multiple dates (i.e., DME rental, hemodialysis management, radiation therapy, etc), the range of dates and number of services should be indicated. “To” date should never be greater than the date the claim is received by the Health Plan.

24b

Place of Service

Required

2 digit number

Enter one code indicating where the service was rendered.

24c

Emergency Service

Optional

 

Check box and attach required documentation.

24d

Procedures, Services or Supply Code including modifiers if applicable NDC numbers

Required

 

Enter the applicable CPT and/or HCPCS National codes in this section. Modifiers, when applicable, are listed to the right of the primary code under the column marked “modifier”. If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code. Reminder: Payment modifiers should be in first position.

24e

Diagnosis Pointer

Required

 

Enter the diagnosis code number from box 21 that applies to the procedure code indicated in 24D.

24f

Charges

Required

 

Enter the charge for service in dollar amount format. If the item is a taxable medical supply, include the applicable state and county sales tax.

24g

Days or Units

Required

 

Enter the number of medical visits or procedures, units of anesthesia time, oxygen volume, items or units of service, etc. Do not enter a decimal point or leading zeroes. Do not leave blank as units should be at least 1.

Appendix A MIF Claims Requirements for 1500 Professional Form Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

24h

EPSDT Family Plan

Optional

 

Enter code “1” or “2” if the services rendered are related to family planning (FP). Enter code “3” if the services rendered are Child Health and Disability Prevention (CHDP) screening related

24i

ID Qualifier

Optional

 

Enter “X” if billing for emergency services.

24j

Provider ID Number Taxonomy Rendering Provider NPI Number

Optional Required

10 alpha numeric

10 digit number

Enter the Rendering Provider's NPI number

25

Federal Tax ID Number

Required

9 digit number

Enter the Federal Tax ID for the billing provider.

26

Patient’s Account Number

Required

Length 20 max.

Enter the patient’s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated.

27

Accept Assignment

Required

 

Check Yes or No

28

Total Charge

Required

 

Enter the total for all services in dollar and cents. Do not include decimals. Do not leave blank.

29

Amount Paid

Required
(if applicable)

 

Enter the amount of payment received from the Other Health Coverage or member. Enter the full dollar amount and cents. Do not enter Medicare payments in this box.

30

Reserved

DO NOT USE

   

31

Signature of Practitioner or Supplier and Date

Required

 

The claims must be signed and dated by the provider or a representative assigned by the provider in black pen. An original signature is preferred. Stamps are also acceptable. Initials and other facsimiles are not acceptable.

32

Service Facility Location/Location where services were rendered

Required

 

Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number of the facility where services were rendered, if other than home or office.

32a

Service Facility NPI if different from Billing Provider NPI

Required
(if applicable)

10 digit number

Enter the NPI of the facility where the services were rendered.

32b

Other ID

Optional

 

Enter the provider number for an atypical service facility.

33

Billing Provider/Supplier’s Name, Address, & Telephone Number as it appears on your W-9

Required

 

Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number.

33A

Billing Provider/Supplier’s NPI Number

Required

10 digit number

Enter the billing provider’s NPI.

33b

Other ID

Optional

 

Used for atypical providers only. Enter the provider number for the billing provider.

Appendix B MIF Claims Requirements for UB Institutional Forms: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

1

Provider Name, Address, and Phone

Required

Do not use P.O. boxes

Enter the provider name, address and zip code and telephone number this section.

2

Pay-to Name, address and Secondary Identification Fields

Required
(If different than 1)

 

Enter the provider name, address and zip code and telephone number this section.

3a

Patient Control Number

Required

Length 20 max.

This number is reflected on the Explanation of Benefits for reconciling payments if populated.

3b

Medical/Health Record Number

Optional

 

This number will not be reflected on EOB if populated.

4

Type of Bill

Required

4 digit code

Enter the appropriate four-character type of bill code.

5

Federal Tax Number

Pay-to-provider ≠ Billing Provider

Required

9 digit number.

Enter the Federal Tax ID for the billing facility.

6

Statement Covers Period (From-Through)

Required

MMDDYY

Enter the “From” and “Through” dates of services covered on the claim if claim is for inpatient services.

7

Not Used

DO NOT USE

   

8a

Patient’s Name

Required

 

Enter patient’s name in 8b

8b

Patient Identifier

Required

 

Enter patient’s last name, first name and middle initial if known.

9a-e

Patient’s Address, State, and Zip Code

Required

 

Enter Patient Address

10

Patient’s Date of Birth

Required

MMDDYYYY

Enter the patient’s date of birth in an eight digit format, Month, Date, Year (MMDDYYYY) format.

11

Patient’s Sex

Required

F or M

Use the capital letter “M” for male, or “F” for female.

12

Admission Date

Required
(if applicable)


MMDDYY

Enter in a six-digit format (MMDDYY), enter the date of hospital admission.

13

Admission Hour

Required
(if applicable)

Military Standard Time (00-23)

Enter hour of patient's admission.

14

Type of Admission

Required

Single digit code: 1-9

Enter the numeric code indicating the necessity for admission to the hospital. 1 - Emergency 2 – Elective

Appendix B MIF Claims Requirements for UB Institutional Forms Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

15

Source of Admission

Required

Single code: 1-9; A-Z

If the patient was transferred from another facility, enter the numeric code indicating the source of transfer.

1 - Non-Healthcare Facility Point of Origin 2

– Clinic 4 - Transfer from a Hospital (Different Facility) 5 - Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) 6 - Transfer from Another Healthcare Facility 7 - Emergency Room 8 - Court/Law Enforcement 9 - Information Not Available B - Transfer from Another Healthcare Facility C - Readmission to the same Home Health Agency D - Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in a separate claim to the payer E - Transfer from Ambulatory Surgery Center F - Transfer from Hospice and is under a hospice plan of care or enrolled in a hospice program

16

Discharge Hour

Required
(if applicable)

Military Standard Time (00-23)

Enter the discharge hour. For Inpatient only.

17

Patient Status

Required

 

Enter Patient Discharge Status

18-28

Condition Codes If Applicable Type of Admission

Required
(if applicable)

   

29

Accident State

Optional

2 alpha abbreviation

If visit or stay is related to an accident, enter in which state accident occurred.

30

Not Used

DO NOT USE

   

31-34

Occurrence Codes and Dates

Required
(if applicable)

MMDDYYYY

Enter the codes and associated dates that define the significant even related to the claim. Occurrence Codes covered by SFHP: 01 - Auto Accident 02 - No Fault Insurance Involvement - Including Auto Accident/Other 03 - Accident/Tort Liability 04 - Employment Related 05 - Other Accident 06 - Crime Victim

35-36

Occurrence Span Codes and Dates

Required
(if applicable)

MMDDYYYY

Enter Occurrence Span Codes and Dates

37

Not Used

DO NOT USE

   

38

Responsible Party Name and Address

Required
(if applicable)

 

Enter the name and address of the party responsible for payment if different from name in box 50

39-41

Value Codes and Amounts

Required
(if applicable)

 

Enter Value Codes and Amounts

42

Revenue Code

Required

4 digit code

Enter the four-digit revenue code for the services provided, e.g. room and board, obstetrics, etc.

Appendix B MIF Claims Requirements for UB Institutional Forms Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

43

Revenue Description

Required
(if applicable)

 

Enter the description of the particular revenue code in box 42 or HCPCS code in box

44. Include NDC/UPN Codes here, when applicable.

44

CPT/HCPCS only

Required
(if applicable)

 

Enter the applicable HCPCS codes and modifiers. For outpatient billing do not bill a combination of HCPCS and Revenue codes on the same claim form. When billing for professional services, use CMS 1500 form.

45

Service Dates

Required

MMDDYYYY

Enter the service date in MMDDYY format for outpatient billing.

46

Units of Service

Required

 

Enter the actual number of times a single procedure or item was performed or provided for the date of service.

47

Total Charges

Required

 

Enter Total Charges (By Rev. Code)

48

Non-covered Charges

Optional

 

Enter Non-Covered Charges

n/a

Creation Date

Required

   

n/a

Totals

Required

   

49

Not Used

DO NOT USE

   

50a-c

Payer Name

Required

   

51a-c

National Health Plan Identifier

Optional

 

Enter Health Plan ID

52a-c

Release of Information Certification Indicator

Required

 

Check Yes or No

53a-c

Assignment of Benefits Certification Indicator

Required

 

Check Yes or No

54a-c

Prior Payments

Required if Applicable

 

Enter any prior payments received from Other Coverage in full dollar amount.

55a-c

Estimated Amount

Optional

 

Enter Estimated Amount Due

56

National Provider ID (NPI)

Required

10 digit number

Enter NPI number

57a-c

Other Provider ID

Optional

10 digit number

Enter Other Provider IDs

58a-c

Insured’s Name

Required

 

Enter the mother’s name if billing for an infant using the mother’s ID. If any other circumstance, leave blank.

59a-c

Patient’s Relationship to Insured

Required

 

Enter “03” (child) if billing for an infant using the mother’s Identification Number

60a-c

Insured’s Unique ID

Required

12 alpha numeric

Enter the patient’s 12-digit MIF ID number as it appears in the member’s ID card.

61a-c

Insurance Group Name

Optional

 

Enter Insured Group Name

62a-c

Insurance Group Number

Optional

 

Enter Insured Group Number

63a-c

Treatment Authorization Code

Optional

 

Enter any authorizations numbers in this section. It is not necessary to attach a copy of the authorization to the claim. Member information from the authorization must match the claim.

Appendix B MIF Claims Requirements for UB Institutional Forms Continued: claims received with missing required elements will be rejected

Field # Field Name Instruction Formatting Requirement Description

64

Document Control Number (DCN)

Required for correction or voiding of a claim only

 

When the Type of Bill in box 4 ends in a 7 or an 8 enter the Claim ID number of the claim you are requesting to correct or void. This can be found on your Remittance Advice

65

Employer Name

Optional

 

Enter Employer Name

66

Diagnosis and Procedure Code Qualifier ICD Indicator:

Required

10 digit alpha numeric

Enter:

0—ICD-10-CM Diagnosis

67

Principle Diagnosis Code

Required

10 digit alpha numeric

Enter all letters and/or numbers of the ICD-9 or 10 CM code for the primary diagnosis including the fourth and fifth digit if present

67A-Q

Other Diagnosis Code (including POA Codes)

Required
(if applicable)

10 digit alpha numeric

Enter all letters and/or numbers of the secondary ICD-9 or 10 CM code including fourth and fifth digits if present.

68

Not Used

DO NOT USE

   

69

Admitting Diagnosis

Required
(if applicable)

10 digit alpha numeric

Enter Admitting Diagnosis Code

70A-C

Patient’s Reason for Visit

Required
(if applicable)

10 digit alpha numeric

Enter Patient's Reason for Visit Code

71

Prospective Payment System (PPS) Code

Optional

 

Enter PPS Code

72

External Cause of Injury (ECI) Code

Optional

10 digit alpha numeric

Enter External Cause of Injury Code

73

Not Used

DO NOT USE

   

74

Principle Procedure Codes and Date

Required
(if applicable)

MMDDYYYY

Enter Principal Procedure Code/Date

74a-e

Other Procedure Codes and Dates

Required
(if applicable)

MMDDYYYY

Enter Other Procedure Code/Date

75

Not Used

DO NOT USE

   

76

Attending Provider Name and Identifiers (including NPI)

Required
(if applicable)

10 digit number

Enter Attending Name/ ID-Qualifier 1G

77

Operating Provider Name and Identifiers (including NPI)

Required
(if applicable)

10 digit number

Enter Operating ID

78-79

Other Provider Name and Identifiers (including NPI)

Required
(if applicable)

10 digit number

Enter Other ID

80

Remarks

Optional

 

Enter Remarks

81a-d

Code to Code Field

Optional

 

Enter Code-Code Field/Qualifiers

MIF@dfs.ny.gov | 1-855-NYMIF33 (1-855-696-4333)

Updated 01/25/2018

 

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