10A NCAC 27A .0303. CLEAN CLAIM FORMAT REQUIREMENTS

(a)  A provider of a service that is payable from funds administered by an LME shall submit a claim for payment to the authorizing LME.  The provider shall submit the claim in one of the formats listed as follows:

(1)           HIPAA compliant 837;

(2)           CMS-1500;

(3)           the standardized billing format provided by the DMH/DD/SAS; or

(4)           a single web based direct data entry system.

The provider shall complete each element contained in the selected format.

(b)  The billing format provided by the DMH/DD/SAS shall contain standardized elements including:

(1)           date of claim;

(2)           provider information including:

(A)          name; and

(B)          number.

(3)           client information including:

(A)          name;

(B)          identification number;

(C)          target population code; and

(D)          ICD-9 diagnosis code.

(4)           service information including:

(A)          name;

(B)          date;

(C)          units delivered;

(D)          billing code; and

(E)           authorization number.

 

History Note:        Authority G.S. 122C-112.1(a)(32); S.L. 2006-142;

Eff. May 1, 2008.