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Claims that are submitted with incomplete or incorrect information can influence repricing turn-a-round time that may result in a delay in payment. The following are some trends that have been identified by Midlands Choice concerning claims submission. Addressing these issues will assist offices in submitting claims successfully the first time.

Physical Billing Address

Healthcare providers are required to use a street address as the billing provider address under the Version 5010 transactions. The billing provider address is reported in the billing provider loop of the 837 claim transaction. Providers wanting payments to be sent to a PO box or lock box should report this address in the “pay-to” loop in the EDI transaction, not in the billing loop. 

9-Digit Zip Code

HIPAA requires that all 5010 transactions be billed with extended zip codes (ZIP+4) in the billing provider loop. Midlands Choice also requires all transactions to include this information. Since claims submitted on paper to Midlands Choice are converted into an electronic file, addresses must contain a 9-digit zip code.

Group Information

Since Midlands Choice works with nearly 60 payers, unless the correct group information from the patient’s member identification card is populated on the claim, there is no way to determine where the claim should be forwarded.

• Always include the group number from the patient's member identification card on the claim. Claims submitted without a group number are returned to the provider.
• Claims submitted with "NGN" (no group number) will also be returned to the provider.
• Look for the Midlands Choice logo on the patient identification card to determine if the patient is a member of a group that accesses the Midlands Choice network.
• Contact the payer or claims administrator for eligibility information. Contact information for the payer can be found on the patient's member identification card. Midlands Choice does not have access to member eligibility or benefit information.
• If a group has terminated with Midlands Choice, contact the patient for the current insurance information.

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