CurrentAnthemPolicy G-06029

Claims Submission - Required Information for Professional Providers

Defines the information and form requirements professional providers must include when submitting CMS-1500 (or electronic equivalent) claims to Anthem New York Medicaid; applies to professional providers submitting claims for reimbursement.

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Professional Providers

Policy CodePolicy G-06029

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review DateN/A

Key ActionSubmit an original CMS-1500 or electronic equivalent with all required fields to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form requirement

≥20 itemsfields required

EDI preferredsubmission channel

Returned/Deniedalteration rule

No changesreview outcome

Required Claim Information

Required claim data elements

Claims must include the following required data elements; missing or incorrect information may result in denial, return, or recovery of payment.

Patient information: name; address including ZIP code; date of birth; gender; relationship to insured; 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; name of other health benefit plan (when applicable).

Coordination of Benefits/other insured information: other insured's name; policy or group number; name of insurance plan or program.

Referring physician/source: name of referring physician or source; NPI or other non‑NPI identifier for referring, ordering, or supervising provider.

Policy Summary

PayerAnthem

PolicyClaims Submission - Required Information for Professional Providers

Policy CodePolicy G-06029

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review DateN/A

Key ActionSubmit an original CMS-1500 or electronic equivalent with all required fields to avoid denial.

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.

Accepted Code Systems and Claim Format

Accepted code systemsmixed

CPT	Procedure codes must be reported using current CPT-4 codes
HCPCS	Services/supplies reported using HCPCS codes where applicable
ICD-10	Diagnosis codes must be ICD-10
NDC	National Drug Codes required with unit price, quantity, and composite measure per drug

Paper claim formatting — CMS-1500 requirements

Form requirementOriginal CMS-1500 form (or electronic equivalent) required for paper submission; paper claims accepted but EDI preferred.

Ink and printingPaper claims must be on original form with drop-out red ink; computer-printed or typed in a large, dark font readable by OCR.

Legibility ruleAll claims must be legible; altered or illegible claims will be returned, rejected, or denied.

Signature requirementIndication of signature on file (handwritten or computer-generated) and date signed must be provided.

Provider identifiersInclude individual rendering provider NPI and billing group NPI when applicable; NPI and other non-NPI identifier for referring/ordering/supervising provider.

Authorization and Submission Requirements

Prior Authorization

Authorization and Submission Requirements

Providers must obtain prior authorization when required by the member's benefit plan and the health plan's prior authorization rules. Submit an original CMS-1500 Health Insurance Claim Form or the electronic equivalent for all professional services unless otherwise directed by provider, state, federal, or CMS requirements. Claims must document medical necessity, include complete and accurate coding, and be supported by the medical record. Failure to follow authorization, documentation, or coding requirements may result in claim denial, payment recovery/recoupment, or adjusted reimbursement.

Prior authorization when required by member benefit plan and plan rules.
Submit original CMS-1500 or electronic equivalent unless contracts/regulations state otherwise.
Ensure medical necessity is documented and supported in the medical record and/or office notes.
Use correct, industry-standard CPT, HCPCS, and/or revenue codes and appropriate modifiers.
Include required CMS-1500 fields when applicable: patient and insured information, COB/other insured, referring physician, indication of outside lab, ICD-10 code(s), CLIA number (if applicable), date(s) and place of service, procedures/services/supplies with CPT/HCPCS and modifiers, charges, units/days, total charges and patient-paid amount, and Federal Tax Identification Number.
If required information is missing or incorrect, payment may be denied without interest/penalties per policy.

General Reimbursement Definitions

General reimbursement definitions

General reimbursement definitionsSee 'General Reimbursement Policy Definitions' in the policy for full definitions.

Required claim elements (summary)Claims must include patient, insured, coordination of benefits, referring physician, diagnosis, service details, payment info, provider identifiers, signature, and drug billing information.

Coding systemsAccepted code systems include CPT, HCPCS, ICD-10, and NDC as applicable (see coding section for details).

Submission preferenceElectronic Data Interchange (EDI) preferred; paper accepted with formatting and legibility requirements.