CurrentAnthemPolicy G-06029

Claims Submission - Required Information for Professional Providers

Governs required information and form submission standards for professional providers submitting claims to Anthem Blue Cross and Blue Shield Medicaid in Ohio; applies to participating and non-participating professional providers unless superseded by contracts or state/federal requirements.

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Professional Providers

Policy CodePolicy G-06029

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review Date

Key ActionSubmit CMS-1500 claim form or electronic equivalent with required data elements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500required claim form

No papersubmission mode

No changespolicy history note

Enumeratedbilling elements

Claims submission requirements

Claims submission criteria

Claims must be submitted with the CMS-1500 form (or electronic equivalent) and include the listed data elements; failure to do so may result in denial or return of the claim.

Submit an original CMS-1500 Health Insurance Claim Form or its electronic equivalent for payment of healthcare services unless superseded by provider, state, federal, or CMS requirements.

ALL of the following

Patient information: Patient name; address including zip code; date of birth; gender; relationship to insured; and medical condition as related to employment or an accident.
Insured information: Member ID number; name; address including zip code; policy, group or FECA number; name of insurance plan or program; and name of other health benefit plan.

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Professional Providers

Policy CodePolicy G-06029

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review Date

Key ActionSubmit CMS-1500 claim form or electronic equivalent with required data elements.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required codes and data elements

Required code setsmixed

CPT/HCPCS/Revenue

Use industry-standard CPT, HCPCS, and revenue codes as applicable; codes must be supported in the medical record.

Drug codingNDC

NDC	When applicable, include National Drug Code number, unit price, quantity, and composite measure per drug.

Required claim data completeness — CMS-1500 elements and denial risk

Required claim formCMS-1500 Health Insurance Claim Form (or electronic equivalent)

Patient informationName; address including ZIP code; date of birth; gender; relationship to insured; medical condition related to employment or accident

Insured informationMember ID number; name; address including ZIP code; policy/group/FECA number; name of insurance plan; name of other health benefit plan

Claim coding and service detailsICD-10 diagnosis code(s); CPT/HCPCS procedure codes and appropriate modifiers; date(s) and place of service; charges; days/units

Provider and facility identifiersIndividual rendering provider NPI; group NPI when billing from a group; facility name and address; facility NPI; Federal Tax Identification Number

Other required elementsName of referring physician/source; indication of outside laboratory; CLIA number; coordination of benefits/other insured information; total charges and amount paid by patient

Required provider actions and prohibitions

Billing Rule

Claim submission and authorization — submit CMS-1500 or electronic equivalent with required data

The health plan requires providers to submit an original CMS-1500 Health Insurance Claim Form or its electronic equivalent for payment of professional services, unless provider, state, federal, or CMS contracts/requirements indicate otherwise. Submit a properly completed CMS-1500 (or electronic equivalent) that includes, as applicable: patient and insured information (names, addresses, DOB, gender, relationship to insured, member ID, policy/group/FECA number, other plan name), coordination of benefits/other insured data, referring physician/source, indication of outside laboratory, ICD-10 diagnosis code(s), CLIA certification number, date(s) and place of service, CPT/HCPCS procedure codes and appropriate modifiers, charges, units/days, total charges and patient payment, federal tax ID, facility name/address and facility NPI, individual and group NPI reporting rules (rendering provider NPI for individual servicing provider; group's NPI for group billing), NPI and other identifiers for referring/ordering/supervising providers, billing provider contact info, indication of signature on file and date, and NDC details when applicable (NDC number, unit price, quantity, composite measure). If required information is not submitted, payment may be denied and the plan may recover/recoup payment. Follow authorization and medical necessity guidelines where applicable.

Patient and insured demographics, policy and COB data
ICD-10 diagnosis code(s) and CLIA number when applicable
Dates/place of service, CPT/HCPCS codes with modifiers, unit/day counts
Individual rendering provider NPI and billing group NPI rules
NDC information: number, unit price, quantity, composite measure
Signature on file and date

Denial Risk

Prohibited submissions

Do not submit paper claims. The health plan will not accept paper claims; submit electronically or on an original CMS-1500 as required. The health plan cannot accept claims with alterations to billing information — altered claims will be returned to the provider with an explanation and may be denied or subject to recovery/recoupment.

Paper claims are not accepted — submit electronically or on an original CMS-1500
Altered claims will be returned and may be denied and/or subject to recovery

Policy context and definitions

Reimbursement policy guidance

Purpose of reimbursement policiesGuides to assist in accurate claims submissions and to outline the basis for reimbursement when a service is covered by a member's benefit plan.

Not a guarantee of paymentCoverage under a member's benefit plan does not guarantee reimbursement; services must also meet authorization and medical necessity requirements.

Coding and billing expectationsUse industry-standard CPT, HCPCS, and/or revenue codes; billed codes must be fully supported in the medical record and office notes.

Consequences of noncomplianceFailure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection/denial and recovery/recoupment of payments.