Corporate

Submitting Paper Claims

The Administrative Simplification Compliance Act (ASCA) requires that as of October 16, 2003, all initial Medicare claims be submitted electronically, except in limited situations. Medicare is prohibited from payment of claims submitted on a paper claim form that do not meet the limited exception criteria.

CMS has provided a listing of exceptions to electronic claim submission on its Administrative Simplification Compliance Act Self-AssessmentExternal Website Web page. Some of these include:

  • Small provider claims
  • Claims from providers that submit fewer than 10 claims per month on average during a calendar year
  • Claims for payment under a Medicare demonstration project that specifies paper submission

Prior to submitting any paper claims to CGS, providers should conduct a self-assessment to determine if they meet one of the exceptions for electronic claim submission by accessing the CMS Administrative Simplification Compliance Act Self-AssessmentExternal Website Web page.

When appropriate, paper claims should be mailed to:

J15 — Part B Claims
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202

NOTE: Part B claims, including Medicare Secondary Payer (MSP) claims, are accepted and processed as electronic claims through myCGS, our secure web portal. Electronic claims can be paid in as few as 14 days, compared to 29 days for paper claims. Submitting claims through myCGS is FREE! Check here to register.

Preparing the CMS-1500 Claim Form
CGS uses an optical character recognition (OCR) system to enter claim information from the CMS-1500 claim form into our processing system. Doing this automates the process and reduces the chance of human keying errors.  To ensure the OCR is able to capture all claims data correctly, it is important that the following be considered:

  • Follow the CMS-1500 claim form instructionsExternal PDF
  • An original CMS-1500 claim form is required
    • Version 02/12, OMB control number 0938-1197
  • Computerized or typed claims are preferred over handwritten claims
    • Laser printers are recommended
    • Remove the pin-feed perforated edges before mailing claims
  • Print claims using BLACK ink
    • Ink should be dark and legible
  • Courier or Arial in 10, 11 or 12 point font is preferred
  • Use capital letters when possible
  • Data should be inside the boxes of the claim form
  • Only one service may be entered per line
    • If additional line items are needed, please add them to a separate claim form
    • Complete the “Total” field (Item 28) on each page of the CMS-1500 claim form when multiple claim forms are submitted for the same patient
  • Avoid using liquid correction fluid or tape on claims
  • Do not use highlighter pens
  • Do not include stickers and/or notations in the margin of the claim form
  • Do not attach mailing labels to the claim
  • Narrative descriptions with procedure and/or diagnosis codes may cause scanning errors
  • Claims for multiple beneficiaries should not be folded separately
    • Multiple claims can be submitted in one envelope

When including documentation with the CMS-1500 claim form:

  • Additional documentation (i.e., operative reports, medical records, radiology/lab reports) are to be submitted only when the policy notes this information is needed to correctly adjudicate the claim
  • Do not staple or tape attachments to the claim
    • Attachments may be placed directly behind the CMS-1500 claim form
    • Paper clips are acceptable
  • Verify that all attachments include information pertinent to the patient
    • The patient’s name, Health Insurance Claim (HIC) number and the date of service should be identified on all pages of attachments
  • Attachments should be 8 ½ x 11 in size
    • When Medicare is the secondary payer (MSP), include a copy of the Explanation of Benefits (EOB) from the primary payer specific to the date of service.  NOTE:  MSP claims and EOB information may be submitted electronically for FREE using myCGS
    • Primary EOBs must include the name of the insurer, an explanation of how the claim was processed, and identifying information specific to the patient and date of service
  • Up to five attachments may be sent electronically through myCGS

Please see the following resources that are available on this topic:

Updated: 09.09.15


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