CMS 1500

The CMS 1500 module is used to submit DDE (Direct Date Entry) professional claims to the MCO. In this module, providers will submit CMS 1500s if you as the provider do not submit claims through a Clearing House or upload 837 files via the Transactional Upload Queue.

To open the CMS 1500 module; click MenuClaimsCMS1500

NOTE: Regarding services H0010 and YP821; the admission date will be entered in box 18 (previously box 14). The discharge date must be entered in box 14 for the claim to process correctly. If not, the claim will deny for “123 Non-Covered days/Room charge adjustment.”

Module View

After launching the module, you will see 3 tiles which include the claim header, the service submitted and the adjudication results after processing. Like most modules, this module has a prominent tile which is the Base tile. Data displayed in the Service and Status tile is contingent on what CMS 1500 form header selected in the Base tile:

Note: It is best to Save your work and Save often as IT issues may occur that are out of the MCO and AlphaCM’s control. Issues such as ISP connectivity and internal network blips could cause you to lose your connection and be forced to log out, then back in.

Filter (TOP)

You can find saved and submitted claim forms by utilizing your Filter:

Base Tile

The Base tile is considered your form header for the claim. This is also the prominent tile meaning that the form selected in this tile will determine the data displayed in the surrounding tiles:

Claim #:Unique AlphaMCS form number assigned after creation

Provider ID:Unique AlphaMCS provider ID for your agency

Provider Name:Displays your agency name

Site ID:Unique AlphaMCS site ID for the site the form was submitted for

Site Name:Displays the site the form was submitted from

Patient ID:Unique AlphaMCS assigned patient ID the claim form is for

Patient Name:Displays the consumer’s name the claim form is for

Recd Date:Displays the submitted date of the form to the MCO

Insert User:Displays the provider staff who created the form

Insert Date:Displays the date the user first started the form

NPI:Displays the billing/provider NPI number submitted on the form

Last Update User:Displays the last staff member who updated the form

Last Update Date:Displays the last date the staff member updated the form

Service Tile (TOP)

The Service tile is used to quickly display the service(s) identified on the claim form:

Date From:Displays the first date of service for a treatment period

Date To:Displays the last date of service for a treatment period

Service:Displays the service code recorded on the claim form

Mods:If service submitted has a modifier, it will display here

POS:Displays the Place of Service for the service on the claim form

Charges:Displays the total claimed amount per claim line on the form

Units:Displays total units identified on the claim line

Diagnosis:Displays the field identifier number the service is billed for

EPSDT:Check box indicator if the service line is for EPSDT

Taxonomy:Displays the taxonomy submitted on the claim line

COBAmount:Displays the COB amount if identified on the claim line

RenderingNPI:Displays the rendering NPI number sent on the claim line

Status:Displays the current status of the claim line

COBReason:Displays the reason a COB was submitted on the claim line

Status Tile

The status tile simply gives you the adjudication results:

Creating a CMS 1500 Form (TOP)

To Create a CMS-1500 claim, simply lauch the module and click Create:

Boxes 1 – 1a

Boxes 5 – 8

Boxes 9 – 11d

Boxes 12 – 20

Boxes 21 – 23 (TOP)

The fields in box 21 are “populate as you type” fields. You can start entering the diagnosis by numerical identifier or by typing key words in the diagnosis description for the list to start populating and narrowing down the results. Once you see the diagnosis you are looking for in the list, you must select it from this list in order to register correctly:

Note: to accommodate the transition to DSMV, the DSMV codes will be marked with an asterisk next to the diagnosis description. The MCO requires at least one DSMV code to be submitted on the claim in order to transition all DX codes to DSMV.

Box 24

Boxes 25 – 33 (TOP)

The remaining boxes are populated for you contingent on the Site you selected at the top of the form. If you change your site at the top, then this is subject to change. If the prepopulated NPI number that is listed in box 32 can be changed if needed (SFL NPI):

  • Once complete, you can choose Update to save and return later, Submit to submit you claim form for payment or Print a hard copy of the claim form.
  • After Submission, you will receive a message stating “Submitted Successfully.” Choose OK and you’re done.

Note: Forms are processed and adjudicated the evening on the day of submission.

1 / AlphaCM, Inc.11/7/2018 5:08 AM