NAC442.770. Submission and contents of claims.

     1. Except as otherwise provided in subsections 2 and 3, a provider shall submit a claim for the payment of services provided to a client to third-party payers before submitting the claim to the Division under the program.

     2. Except as otherwise provided in subsection 3, the provider may submit the claim directly to the Division under the program if:

     (a) The client does not have any third-party payers;

     (b) The provider has exhausted the resources of all third-party payers; or

     (c) All third-party payers deny the claim.

     3. A provider shall submit the claim of a client eligible for services pursuant to a program administered by the Indian Health Service to the Division before submitting the claim to the Indian Health Service.

     4. If a provider submits a claim to the Division under the program, he or she shall submit a single copy of each completed claim on billing forms acceptable to Medicaid within 120 days after the date:

     (a) Of service if the client does not have any third-party payers;

     (b) On which the provider exhausts the resources of all third-party payers; or

     (c) On which the final third-party payer denies the claim.

Ê All claims must be accompanied by legible medical reports and have all appropriate identification as required pursuant to this section or the claim will not be processed.

     5. A claim must not be a duplicate or reflect a balance from claims that the provider previously submitted.

     6. A claim must not be altered.

     7. A claim must include:

     (a) The full name, date of birth and address of the client.

     (b) The name and address of the provider submitting the claim.

     (c) The diagnosis, including the code number for the condition designated by the Division and whether the condition is presumptively covered under the program or is a confirmed eligible medical condition.

     (d) The date of service.

     (e) The type of service, using the code descriptors designated by the Division.

     (f) The usual and customary fee for each type of service.

     (g) The provider’s taxpayer identification number.

     (h) The signature of the provider or an authorized representative thereof.

     8. The primary surgeon’s claims and necessary reports must be submitted to the Division before payment can be made to the assistant surgeon, anesthesiologist or anesthetist or for other ancillary services.

     9. If the fee is claimed on the basis of time, the report of the examination must indicate the beginning and ending time of the procedure.

     10. Claims for tissue pathology must include the name of the ordering physician, the source of the specimen obtained and the date, and must be submitted with a description of the findings of each procedure performed.

     11. Claims for radiology must indicate the name of the ordering physician, the date on which each procedure was performed and the site of the procedure, according to current procedural terminology, and must indicate whether the fee was split.

     12. Laboratory and X-ray services ordered by the authorized physician and adjunctive to his or her services do not require separate prior authorization. Either the reports of such services or their mention in the physician’s progress notes or report must accompany the billing for such services.

     13. Claims for physical or psychological therapy must include the name of the ordering physician, the date of therapy and documentation of the therapy provided.

     (Added to NAC by Bd. of Health, eff. 11-27-89; A 1-18-94; R212-97, 7-23-98; R095-99, 11-29-99)