CurrentAnthemPolicy G-06030

Claims Submission - Required Information for Facilities

Defines the required UB-04/CMS-1450 claim form data elements and submission requirements for institutional providers (facilities) billing New York Medicaid through Anthem; applies to facility providers submitting claims.

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Facilities

Policy CodePolicy G-06030

Change TypeClarification / Review

Effective Date05/06/2025

Next Review Date

Key ActionSubmit the original UB-04/CMS-1450 or electronic equivalent with all required data elements to avoid delays or denials.

SourceLink

POLICY UPDATE CHANGES

Added statement referencing provider manuals and state-specific guidelines; added electronic equivalent.

Review approved: no changes (05/06/2025).

1policy document for facility claims submission (UB-04/CMS-1450)

>30required UB-04 data elements listed

05/06/2025last approval date

NYjurisdiction

Coverage and Claims Determination

Claims submission and coverage linkage

Coverage is determined by the member's benefit plan. Reimbursement is contingent on proper claim submission, correct coding, and meeting authorization and medical necessity requirements.

ALL of the following

The determination that a service is covered under a member's benefit plan does not guarantee reimbursement; services must also meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence.
ALL of the following
- Institutional providers must submit the original UB-04/CMS-1450 or electronic equivalent with all required data elements; failure to provide required information may delay or deny payment.
- Required claim form elements (include applicable items)

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Facilities

Policy CodePolicy G-06030

Change TypeClarification / Review

Effective Date05/06/2025

Next Review Date

Key ActionSubmit the original UB-04/CMS-1450 or electronic equivalent with all required data elements to avoid delays or denials.

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.

Billing provider information (name, address, telephone), patient control number, medical record number, federal tax identification number, NPI, and attending/operating provider name and tax ID as applicable.

Type of bill; statement covers period (from–through); admission/start of care date; type of admission or visit; point of origin; patient discharge status; dates, units, total charges, and noncovered charges of services rendered; revenue codes and corresponding CPT/HCPCS codes where applicable.

Principal, admitting, and other ICD-10 diagnosis codes with POA indicators as applicable; diagnosis and procedure code qualifier (all seven digits where required) and date of principal inpatient procedure; patient reason for visit code.

CLIA certification number; insurance payer information including Coordination of Benefits (COB) secondary/tertiary payer details; prior payments and insureds' information; claim reporting data elements required by state compliance (e.g., admission source code, facility type code, birth weight with applicable codes); National Drug Code(s) with NDC number, unit price, quantity, and composite measure per drug.

ALL of the following

Use appropriate CPT, HCPCS, and ICD-10 codes; codes billed must be fully supported in the medical record.
Standard correct coding applies; claims not following appropriate coding/billing guidelines or current reimbursement policies may be rejected, denied, adjusted, or subject to recovery/recoupment.

ALL of the following

Paper claims must be original form, printed with dropout red ink, computer-printed or typed, and in a large, dark font readable by OCR; all claims must be legible and illegible fields may cause rejection or denial.
The health plan cannot accept claims with alterations to billing information; altered claims will be returned to the provider with an explanation.

ALL of the following

Providers should refer to their provider manuals and state-specific guidelines for details on claims submission requirements.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

ALL of the following

ANY of the following
- If appropriate coding/billing guidelines or current reimbursement policies are not followed, the claim may be rejected or denied.
- The health plan may recover and/or recoup claim payment or adjust reimbursement to reflect appropriate services performed.
- If required information is not provided on the UB-04/CMS-1450 or its electronic equivalent, payment can be delayed or denied without liability for interest or penalties.

Required Code Systems and Claim Legibility

Required code systemsmixedCovered

CPT	Use appropriate Current Procedural Terminology codes to denote services performed
HCPCS	Use appropriate Healthcare Common Procedure Coding System codes when applicable
ICD-10	Use principal, admitting, and other ICD-10 diagnosis codes with POA indicators as applicable (all seven digits for procedures where required)

Claim legibility requirement

Form typeOriginal UB-04/CMS-1450 or electronic equivalent

Paper claim form requirementsOriginal form with dropout red ink; computer-printed or typed; large, dark font readable by OCR

Legibility consequenceAll claims must be legible; any illegible field may cause the claim to be rejected or denied

Altered claimsClaims with alterations to billing information will be returned to the provider with an explanation

Preferred submission methodElectronic submission via EDI preferred; paper accepted if meeting form/legibility requirements

Claims Submission Requirements and Authorization

Billing Rule

Submit original UB-04/CMS-1450 or electronic equivalent with all required data elements

Submit the original UB-04/CMS-1450 or its electronic equivalent, fully completed with all required data elements (e.g., billing provider info, patient control and medical record numbers, type of bill, dates of service, revenue/CPT/HCPCS codes, ICD-10 diagnosis codes/POA indicators, NPI/tax IDs, CLIA number, payer coordination, and other listed elements). The health plan cannot accept altered claims; incomplete, altered, illegible, or missing required information may be delayed, denied, returned, or subject to recovery of payment.

Use the original UB-04/CMS-1450 form or electronic equivalent; paper claims must be original form with dropout red ink, computer-printed or typed, and large dark font readable by OCR.
Include all applicable required fields listed in the policy (billing provider, patient identifiers, dates, revenue codes with corresponding CPT/HCPCS, ICD-10 codes with POA, NPI, CLIA, payer/COB data, etc.).
Altered claims will be returned with an explanation; illegible fields may cause rejection/denial.

Prior Authorization

Services must meet authorization and medical necessity guidelines

Ensure services meet applicable authorization and medical necessity requirements for the specific procedure, diagnosis, and the member’s state of residence prior to billing; failure to meet these requirements may result in claim denial or recovery.

Confirm any required prior authorization per benefit plan and state-specific rules before submitting the claim.
Bill services with industry-standard compliant codes (CPT, HCPCS, revenue codes, ICD-10) fully supported by the medical record.

Definitions

Definitions — General Reimbursement Policy

Definitions referenceGeneral Reimbursement Policy Definitions (see policy for full list)

ScopeDefinitions apply across reimbursement policies guiding accurate claims submission and basis for reimbursement

Where to find full listSee the Definitions section of this policy document for complete term explanations