Fields marked “Required” in the claim form instructions must be completed on all paper claim submissions. The claim may be denied if a “required” field is incomplete.

Fields marked “Conditional” are required when they apply to the claim. For example, Field 9a (marked “Conditional”) must be populated with the policy or group number only when TPL applies.

Fields marked “Recommended” are not required, but will be returned with the provider’s remittance advice if supplied on the claim. For example, if the provider’s in-house, patient account number is provided in Field 26, it will be returned on the remittance advice, thereby allowing billing staff to cross reference the claim with the provider’s records if needed.

Fields marked “Not Required” are not used in processing the claim, although the provider is free to populate the field if desired.

Do not enter spaces, dashes, hyphens or any other kind of punctuation within a provider’s NPI/API or 9-digit zip code, a recipient’s ID, or any other identifier on the claim.