Claim Forms

• CMS 1500, formerly HCFA 1500 form — AMA universal claim form also known as the National Standard Format (NSF).
• CMS 1450, formerly UB92 form (for hospitals).
• For dental claims, please use the standard ADA dental claim form.

Paper claim forms can be handwritten, typed or computer generated. Electronic claims must be submitted using HIPAA-compliant transaction and code sets.

Information needed

All claims must include the following information:

• Patient (member) name
• Member’s CareSource ID number
• Member’s date of birth
• Place of service. Please use standard HCFA location codes.
• ICD-9 diagnosis code(s)
• HIPAA-compliant CPT or HCPCS code(s) and modifiers, where applicable
• Units, where applicable (Anesthesia claims require minutes)
• Date of service for each service rendered
• Prior authorization number, where applicable
• CareSource provider billing number. This is your tax ID number plus a location code. If you have multiple provider billing numbers, please include the number that corresponds to the organization and location from which you provided the service.
• Federal tax ID number
• Provider’s signature
• For prenatal or delivery services, the last menstrual period date is required on claims. Providers may estimate this date if necessary based on the gestational age of the child.

Please use your CareSource provider billing number on all claims. If you are unsure of your provider billing number, please contact your CareSource provider relations representative.

To see the information fields on a paper claim form, please click on the CMS 1500 Claim Form Sample.

Please send all paper claims to:

CareSource
P O Box 8730

Dayton , OH 45401

Attn: Claims Department