In order for ambulance claims to adjudicate and price, the ZIP Code of the point of pick-up must be included in the designated field on the CMS-1500 form (Item/Box 23). Here is a brief outline of the CMS guidelines that were put into effect January 1, 2001.
Guidelines:
- Per CMS Medicare Claims Processing Manual (Chapter 15, Section 30.1.2) effective January 1, 2001:
- Where the CMS-1500 Form is used the ZIP Code is reported in item 23. Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pick-up have the same ZIP Code. Suppliers must prepare a separate paper claim for each trip if the points of pick-up are located in different ZIP Codes.
- Claims without a ZIP Code in item 23 on the CMS-1500 Form box 23, or with multiple ZIP Codes in item 23, must be returned as un-processable.
Billing Inaccurately:
- If billed incorrectly, Wellcare will be unable to adjudicate and price the claim which will result in the denial of the claim. These claims can be identified on your remittance advise with denial reason “DNAMB: denied missing address and/or ZIP Code of the pick-up location.
- A corrected claim would need to be submitted to remediate this denial with the accurate point of pick-up in Item/Box 23
Staying Complaint:
Providers must ensure that they are billing according to CMS billing guidelines as outlined in the Medicare Claims Processing Manual (PDF)
Questions:
Please reach out to Provider Customer Service at 1-855-538-0454 or your specific Provider Relations contact with any additional questions or concerns.
