31.10.11.03

.03 Requirements for Use of HCFA Form 1500.

A. Except as provided in Regulation .10 of this chapter, third-party payors shall accept the HCFA Form 1500 and instructions provided by CMS for use of the HCFA 1500 as the sole instrument for filing claims with third-party payors for professional services.

B. The requirement set forth in §A of this regulation does not apply to:

(1) Dental services which are billed by dentists using the J512 Form, or its equivalent, and CDT-1 Codes; or

(2) Pharmacists or pharmacies which are filing claims for prescription drugs.

C. Except for parties to a global contract, a third-party payor may not require a health care practitioner or other person entitled to reimbursement to use any code or modifier for the filing of claims for health care services that is different from, or in addition to, what is required under the applicable standard code set for the professional services provided.

D. Except as provided in Regulation .10 of this chapter, a third-party payor may not use, and may not require a health care practitioner or other person entitled to reimbursement to use, any other descriptor with a code or to furnish additional information with the initial submission of a HCFA Form 1500 that is different from, or in addition to, the applicable standard code set for the professional services provided.

E. A health care practitioner or other person entitled to reimbursement whose billing is based on the amount of time involved shall indicate the start and stop time or number of minutes in field 24G, currently titled Days or Units, of the HCFA Form 1500 if it is not used to specify the number of days of treatment.