Billing Manual for Community Care Network Providers

43 Description Not required44 HCPCS & Modifier / Rates/HIPPS Required – IfAuthorized45 Service Date RequiredNOTE – Not requiredif confinement claim(determined byreferencing Type ofBill info)46 Service Units Required47 Total Charges Required48 Non-Covered Charges Not required49 Unlabeled Not required50A Payor Name – Primary Required50B Payor Name – Secondary Required50C Payor Name – Tertiary Required51A Plan ID – Primary Required51B Plan ID - Secondary Required51C Plan ID - Tertiary Required52 Release Information Not required53 Assignment of Benefits Not required54 Prior Payments Not required55 Est. Amt. Due Not required56 NPI # Required57 Other Provider ID Not required58a Insured’s First Name Required58a Insured’s Last Name Required58a Insured’s Name Required58b Insured’s First Name Not required58b Insured’s Last Name Not required58b Insured’s Name Not required59a P. Rel. Not required60a Member’s Unique ID (13-Digit MedicaidRequiredRecipient ID for primary HealthChoices claims)60b Cert. SSN HIC ID No. Not required61 Group Name Not required62 Ins Group No. Not required63 Treatment Authorization Code Not required64 Doc Control Number- Required when submitting a Requiredcorrected claim.65 Employer Name Not required66 Diagnosis Version Qualifier Not required67 Principal Diagnosis Code ICD-9-CM BHDiagnosis Range 290 – 319.RequiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 111