Claims Submission Requirements
All participating providers and any provider who practices in our service area must submit their medical and dental claims electronically.
* Note to Washington-based providers: Electronic submission of medical claims will be required later this year. We encourage you to register now and begin submitting your medical claims to us electronically. We will notify you 90 days in advance of when this requirement will go into effect.
Paper claims are only accepted when they are submitted by:
- Providers who practice outside our service area and not subject to state or other local paperless claim mandates
ICD coding use
All International Classification of Disease (ICD) coding must be coded to the highest level of specificity that is known at the time of each health care encounter.
Specific diagnosis codes should be reported when they are supported by the available patient’s medical record documentation and clinical knowledge of the health condition, however, there are situations when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter as indicated below:
- It is appropriate to report codes for sign(s) and/or symptom(s) if a definitive diagnosis has not been established by the end of the patient encounter, in lieu of a definitive diagnosis.
- Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter.
Facility Revenue Codes
The Revenue Code Requirement (PDF) document outlines specific claim submission requirements.
Effective July 1, 2013, a taxonomy code is required on all claims submissions. Providers may have multiple taxonomy codes and should only include the taxonomy code that applies to the services performed and reported on the claim submission.
For electronic submission, report the taxonomy code for the service provided in the Health Insurance Portability and Accountability Act (HIPAA) v5010 837 P, I and D claims PRV segment. Please note:
Taxonomy codes are national specialty codes used by providers to indicate their specialty or provider type on a claim. When applying for a National Provider Identifier (NPI), you choose your provider taxonomy code(s). The Washington Publishing Company publishes the various provider specialty designations with their corresponding taxonomy codes.
- A taxonomy code must be valid
- If you send a rendering provider loop, include the PRV at the 2310B level. If no rendering provider loop, include the PRV at the 2000A level
Taxonomy codes indicated at the time of your NPI application are reflected on the confirmation notice document received from the National Plan and Provider Enumeration System (NPPES) along with the provider’s assigned NPI number. Current taxonomy code(s) registered with NPPES may be obtained on an inquiry basis by visiting the NPI Registry website.
View all the Health Care Provider Taxonomy Code sets.