Medical Indemnity Fund
- Guidance is also available in Portable Document Format (PDF)
MIF Claim Submission Guidance - Provider Claims
Overview
Below are claim submission guidelines for providers submitting claims to the Medical Indemnity Fund (MIF). This guidance will be updated periodically to address common questions and concerns relating to MIF claim submission. The guidance below assumes all applicable authorizations have been obtained.
If you have any questions about obtaining authorizations or submitting claims, please contact us: NY_DOH_MIF@pcgus.com or call 1-855-NYMIF33 (1-855-696-4333).
Overall Submission requirements
Due to the standardization of provider claims, it is preferable and more expedient if providers accept payment directly from the MIF and submit their claims directly to the MIF for reimbursement. If you are a member submitting a claim, please refer to the MIF Claim Submission Guidelines for Members available on the MIF website.
All completed claims are required to be received by the MIF within 90 days from the date services are rendered or purchased.
Provider Claims
- You are required to submit an IRS Form W9 and a list of providers who will be billing with the TIN/SSN listed on the W9 before payment can be made.
- You can submit your claims electronically or by mail.
- Electronically: The Fund offers two options for submitting Electronic Data Interchange (EDI) claims. With the appropriate option in place for your electronic workflow, electronic billing results in fewer errors, lower costs and increased efficiency for businesses on both ends of the transaction. These options are detailed below:
- Clearinghouse Submitters: Standard 837 file submission through a clearinghouse using the Fund´s receiver ID, NYDFS. This PIN is the identifier at the Clearinghouse to route claims directly to the Claims Operation Department.
- Direct Submitters: This option is for providers who choose to create their own 837 file and submit that file directly to the MIF portal. If you wish to request online access, you can send a request via email with your Tax ID and group NPI to NY_DOH_MIF@pcgus.com
- Mail: Claims that are mailed must be submitted on completed CMS1500 or CMS1450 (also known as a UB04). Mail to:
Medical Indemnity Fund
c/o Public Consulting Group, Inc.
P.O. Box 784
Greenland, NH 03840-0784
Phone: (855) NYMIF33 | (855) 696-4333 - For Claims submitted via certified mail, mail to:
Medical Indemnity Fund
c/o Public Consulting Group, Inc.
609 Portsmouth Ave.
P.O. Box 784
Greenland, NH 03840-0784Note: Photographs and faxes of claims are not acceptable and will not be processed.
- Electronically: The Fund offers two options for submitting Electronic Data Interchange (EDI) claims. With the appropriate option in place for your electronic workflow, electronic billing results in fewer errors, lower costs and increased efficiency for businesses on both ends of the transaction. These options are detailed below:
- Legible, handwritten claims are acceptable; however, typed claims are preferred for more accurate and expedient processing.
- Correct usage of CPT and HCPC procedure codes (and when applicable Revenue and DRG codes) and ICD10 diagnosis codes. Using miscellaneous codes when there is a specific code available for the service or item being billed will result in a denial and a corrected claim will be required.
- Anesthesia claims require the start and end times of the procedure.
- Ambulance and Non Emergency Transportation claims require address of origin and destination.
- Please see Appendix A below for further MIF claims requirements for 1500 Professional Forms and Appendix B below for MIF Claims Requirements for UB Institutional Forms.
- Supporting documentation must accompany claims:
- Durable Medical Equipment (DME) claims for items that don´t have a specific procedure code and are billed with a miscellaneous procedure code require a manufacturers invoice (shipping and handling are not covered).
- Claims for patients with primary commercial insurance coverage require a copy of the primary carrier explanation of payment or denial.
- All respite and home care efforts require a summary of activities provided to or for the member for each day and/or time-period being billed. Nursing duty notes are acceptable.
Appendix A
MIF Claims Requirements for 1500 Professional Form: claims received with missing required elements will be rejected
Field # | Field Name | Instruction | Formatting Requirement | Description |
---|---|---|---|---|
1 | Carrier Type | Optional | Type of Insurance | |
1a | Insured´s ID Number | Required | 12 alpha numeric | Insured´s MIF ID Number - Enter the member´s MIF number as it appears on the ID card. |
2 | Patient´s Name | Required | Enter the member´s name as is indicated on the ID card. | |
3 | Patient´s Date of Birth/Sex | Required | MMDDYYYY F or M or U | Patient´s Birth date - Enter member´s date of birth and check the box for male or female. |
4 | Insured´s Name | Optional | Insured´s Name | |
5 | Patient´s Address | Required | Patient´s Address - Enter member´s complete address and telephone number. | |
6 | Patient´s Relationship to Insured | Optional | Patient´s Relationship to Insured | |
7 | Insured Address | Optional | Insured Address | |
8 | Reserved | DO NOT USE | ||
9 | Other Insured´s Name | Required (if box 11d is Yes) | Other Insured´s Information Name | |
9a | Other Insured´s Policy or Group Number | Required (if box 11d is Yes) | Other Insured´s Information Policy/Group Number | |
9b | Reserved | DO NOT USE | ||
9c | Reserved | DO NOT USE | ||
9d | Insurance Plan Name or Program Name if Applicable | Required (if box 11d is Yes) | Other Insured´s Information Employer/School Name, Insurance Plan/Program Name | |
10 | Is Patient´s Condition Related to: | |||
10a | Employment | Required (if applicable) | Check Yes or No | |
10b | Auto Accident | Required (if applicable) | Check Yes or No | |
10c | Other Accident | Required (if applicable) | Check Yes or No | |
10d | Reserved | DO NOT USE | ||
11 | Insured´s Policy Group or FECA Number | Required (if applicable) | Insured´s Information - Policy/Group Number | |
11a | Insured´s Date of Birth | Required (if applicable) | MMDDYYYY | Insured´s Date of Birth |
11b | Other Claim ID designated by NUCC | Required (if applicable) | ||
11c | Insurance Plan Name or Program Name | Required (if applicable) | Insured´s Information - Plan/Program Name | |
11d | Is there Another Health Benefit Plan | Required | Check Yes or No | |
12 | Patient´s or Authorized Person´s Signature (Medical Records/Information Release) and Date | Required | Signature and Date | |
13 | Insured´s or Authorized Person´s Signature (Assignment of Benefits) | Required | Insured´s or Authorized Person´s Signature | |
14 | Date of Current Illness, Injury, Pregnancy, Qualifier | Optional | MMDDYY or MMDDCCYY | Date of Current - Illness (First Symptom) OR Injury OR Pregnancy (LMP) - Enter the date of onset of the member´s illness, the date of accident/injury or the date of the last menstrual period. |
15 | Qualifier, First Date of Onset of Same/Similar Illness | Optional | If patient had same or similar illness give first date | |
16 | Dates Unable to Work in Current Occupation | Optional | MMDDYY or MMDDCCYY | Dates Patient Unable to Work in Current Occupation |
17 | Qualifier/Name of Referring Physician | Required (if applicable) | Name of Referring Provider or Other Source - Enter the full name of the Referring Provider. A referring/ordering provider is one who requests services for a member, such as provider consultation, diagnostic laboratory or radiological tests, physical or other therapies, pharmaceuticals or durable medical equipment. | |
17a | Legacy Referring | Required (if applicable) | ID Number of Referring Physician - Enter State Medical License number. | |
17b | Referring Physician NPI# | Required (if applicable) | 10 digit number | Enter Referring Provider´s NPI number. |
18 | Qualifier/Hospitalization Dates Related to Current Services | Optional | MMDDYY or MMDDCCYY | Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank. |
19 | Additional Claim Information designated by NUCC | Optional | MMDDYY or MMDDCCYY | Reserved for Local Use - Use this area for procedures that require additional information, justification or an Emergency Certification Statement.
|
20 | Outside Laboratory | Optional | Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory. | |
21 | Diagnosis or Nature of Illness or Injury | Required | 10 digit Alpha Numeric | Enter all letters and/or numbers of the ICD-10 code for each diagnosis, including fourth and fifth digits if present. The first diagnosis listed in section 21.1 indicates the primary reason for the service provided |
22 | Resubmission Code: | Required for correction or voiding of a claim only | Enter: 7 for a corrected claim 8 for a voided claim AND Original Reference Code: Enter the Claim ID number of the claim you are requesting to correct or void. Both Data elements above are required. | |
23 | Prior Authorization Number | Required (if applicable) | Enter prior authorization or referral number. | |
24a | Date of Service, From and To | Required | MMDDYY or MMDDYYYY | Enter the date the service was rendered in the "from" and "to" boxes in the MMDDYY format. If services were provided on only one date, they will be indicated only in the "from" column. If the services were provided on multiple dates (i.e., DME rental, hemodialysis management, radiation therapy, etc), the range of dates and number of services should be indicated. "To" date should never be greater than the date the claim is received by the Health Plan. |
24b | Place of Service | Required | 2 digit number | Enter one code indicating where the service was rendered. |
24c | Emergency Service | Optional | Check box and attach required documentation. | |
24d | Procedures, Services or Supply Code including modifiers if applicable NDC numbers | Required | Enter the applicable CPT and/or HCPCS National codes in this section. Modifiers, when applicable, are listed to the right of the primary code under the column marked "modifier". If the item is a medical supply, enter the two-digit manufacturer code in the modifier area after the five-digit medical supply code. Reminder : Payment modifiers should be in first position. | |
24e | Diagnosis Pointer | Required | Enter the diagnosis code number from box 21 that applies to the procedure code indicated in 24D. | |
24f | Charges | Required | Enter the charge for service in dollar amount format. If the item is a taxable medical supply, include the applicable state and county sales tax. | |
24g | Days or Units | Required | Enter the number of medical visits or procedures, units of anesthesia time, oxygen volume, items or units of service, etc. Do not enter a decimal point or leading zeroes. Do not leave blank as units should be at least 1. | |
24h | EPSDT Family Plan | Optional | Enter code "1" or "2" if the services rendered are related to family planning (FP). Enter code "3" if the services rendered are Child Health and Disability Prevention (CHDP) screening related | |
24i | ID Qualifier | Optional | Enter "X" if billing for emergency services. | |
24j | Provider ID Number Taxonomy Rendering Provider NPI Number | Optional Required | 10 alpha numeric 10 digit number | Enter the Rendering Provider´s NPI number |
25 | Federal Tax ID Number | Required | 9 digit number | Enter the Federal Tax ID for the billing provider. |
26 | Patient´s Account Number | Required | Length 20 max. | Enter the patient´s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated. |
27 | Accept Assignment | Required | Check Yes or No | |
28 | Total Charge | Required | Enter the total for all services in dollar and cents. Do not include decimals. Do not leave blank. | |
29 | Amount Paid | Required (if applicable) | Enter the amount of payment received from the Other Health Coverage or member. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. | |
30 | Reserved | DO NOT USE | ||
31 | Signature of Practitioner or Supplier and Date | Required | The claims must be signed and dated by the provider or a representative assigned by the provider in black pen. An original signature is preferred. Stamps are also acceptable. Initials and other facsimiles are not acceptable. | |
32 | Service Facility Location/Location where services were rendered | Required | Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number of the facility where services were rendered, if other than home or office. | |
32a | Service Facility NPI if different from Billing Provider NPI | Required (if applicable) | 10 digit number | Enter the NPI of the facility where the services were rendered. |
32b | Other ID | Optional | Enter the provider number for an atypical service facility. | |
33 | Billing Provider/Supplier´s Name, Address, & Telephone Number as it appears on your W-9 | Required | Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number. | |
33A | Billing Provider/Supplier´s NPI Number | Required | 10 digit number | Enter the billing provider´s NPI. |
33b | Other ID | Optional | Used for atypical providers only. Enter the provider number for the billing provider. |
Appendix B
MIF Claims Requirements for UB Institutional Forms: claims received with missing required elements will be rejected
Field # | Field Name | Instruction | Formatting Requirement | Description |
---|---|---|---|---|
1 | Provider Name, Address, and Phone | Required | Do not use P.O. boxes | Enter the provider name, address and zip code and telephone number this section. |
2 | Pay-to Name, address and Secondary Identification Fields | Required (If different than 1) | Enter the provider name, address and zip code and telephone number this section. | |
3a | Patient Control Number | Required | Length 20 max. | This number is reflected on the Explanation of Benefits for reconciling payments if populated. |
3b | Medical/Health Record Number | Optional | This number will not be reflected on EOB if populated. | |
4 | Type of Bill | Required | 4 digit code | Enter the appropriate four-character type of bill code. |
5 | Federal Tax Number Pay-to-provider ≠ Billing Provider | Required | 9 digit number. | Enter the Federal Tax ID for the billing facility. |
6 | Statement Covers Period (From-Through) | Required | MMDDYY | Enter the "From" and "Through" dates of services covered on the claim if claim is for inpatient services. |
7 | Not Used | DO NOT USE | ||
8a | Patient´s Name | Required | Enter patient´s name in 8b | |
8b | Patient Identifier | Required | Enter patient´s last name, first name and middle initial if known. | |
9a-e | Patient´s Address, State, and Zip Code | Required | Enter Patient Address | |
10 | Patient´s Date of Birth | Required | MMDDYYYY | Enter the patient´s date of birth in an eight digit format, Month, Date, Year (MMDDYYYY) format. |
11 | Patient´s Sex | Required | F or M | Use the capital letter "M" for male, or "F" for female. |
12 | Admission Date | Required (if applicable) | MMDDYY | Enter in a six-digit format (MMDDYY), enter the date of hospital admission. |
13 | Admission Hour | Required (if applicable) | Military Standard Time (00-23) | Enter hour of patient´s admission. |
14 | Type of Admission | Required | Single digit code: 1-9 | Enter the numeric code indicating the necessity for admission to the hospital. 1 - Emergency 2 - Elective |
15 | Source of Admission | Required | Single code: 1-9; A-Z | If the patient was transferred from another facility, enter the numeric code indicating the source of transfer. 1 - Non-Healthcare Facility Point of Origin 2 - Clinic 4 - Transfer from a Hospital (Different Facility) 5 - Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) 6 - Transfer from Another Healthcare Facility 7 - Emergency Room 8 - Court/Law Enforcement 9 - Information Not Available B - Transfer from Another Healthcare Facility C - Readmission to the same Home Health Agency D - Transfer from one distinct unit of the hospital to another distinct unit of the same hospital resulting in a separate claim to the payer E - Transfer from Ambulatory Surgery Center F - Transfer from Hospice and is under a hospice plan of care or enrolled in a hospice program |
16 | Discharge Hour | Required (if applicable) | Military Standard Time (00-23) | Enter the discharge hour. For Inpatient only. |
17 | Patient Status | Required | Enter Patient Discharge Status | |
18-28 | Condition Codes If Applicable Type of Admission | Required (if applicable) | ||
29 | Accident State | Optional | 2 alpha abbreviation | If visit or stay is related to an accident, enter in which state accident occurred. |
30 | Not Used | DO NOT USE | ||
31-34 | Occurrence Codes and Dates | Required (if applicable) | MMDDYYYY | Enter the codes and associated dates that define the significant even related to the claim. Occurrence Codes covered by SFHP: 01 - Auto Accident 02 - No Fault Insurance Involvement - Including Auto Accident/Other 03 - Accident/Tort Liability 04 - Employment Related 05 - Other Accident 06 - Crime Victim |
35-36 | Occurrence Span Codes and Dates | Required (if applicable) | MMDDYYYY | Enter Occurrence Span Codes and Dates |
37 | Not Used | DO NOT USE | ||
38 | Responsible Party Name and Address | Required (if applicable) | Enter the name and address of the party responsible for payment if different from name in box 50 | |
39-41 | Value Codes and Amounts | Required (if applicable) | Enter Value Codes and Amounts | |
42 | Revenue Code | Required | 4 digit code | Enter the four-digit revenue code for the services provided, e.g. room and board, obstetrics, etc. |
43 | Revenue Description | Required (if applicable) | Enter the description of the particular revenue code in box 42 or HCPCS code in box 44. Include NDC/UPN Codes here, when applicable. | |
44 | CPT/HCPCS only | Required (if applicable) | Enter the applicable HCPCS codes and modifiers. For outpatient billing do not bill a combination of HCPCS and Revenue codes on the same claim form. When billing for professional services, use CMS 1500 form. | |
45 | Service Dates | Required | MMDDYYYY | Enter the service date in MMDDYY format for outpatient billing. |
46 | Units of Service | Required | Enter the actual number of times a single procedure or item was performed or provided for the date of service. | |
47 | Total Charges | Required | Enter Total Charges (By Rev. Code) | |
48 | Non-covered Charges | Optional | Enter Non-Covered Charges | |
n/a | Creation Date | Required | ||
n/a | Totals | Required | ||
49 | Not Used | DO NOT USE | ||
50a-c | Payer Name | Required | ||
51a-c | National Health Plan Identifier | Optional | Enter Health Plan ID | |
52a-c | Release of Information Certification Indicator | Required | Check Yes or No | |
53a-c | Assignment of Benefits Certification Indicator | Required | Check Yes or No | |
54a-c | Prior Payments | Required if Applicable | Enter any prior payments received from Other Coverage in full dollar amount. | |
55a-c | Estimated Amount | Optional | Enter Estimated Amount Due | |
56 | National Provider ID (NPI) | Required | 10 digit number | Enter NPI number |
57a-c | Other Provider ID | Optional | 10 digit number | Enter Other Provider IDs |
58a-c | Insured´s Name | Required | Enter the mother´s name if billing for an infant using the mother´s ID. If any other circumstance, leave blank. | |
59a-c | Patient´s Relationship to Insured | Required | Enter "03" (child) if billing for an infant using the mother´s Identification Number | |
60a-c | Insured´s Unique ID | Required | 12 alpha numeric | Enter the patient´s 12-digit MIF ID number as it appears in the member´s ID card. |
61a-c | Insurance Group Name | Optional | Enter Insured Group Name | |
62a-c | Insurance Group Number | Optional | Enter Insured Group Number | |
63a-c | Treatment Authorization Code | Optional | Enter any authorizations numbers in this section. It is not necessary to attach a copy of the authorization to the claim. Member information from the authorization must match the claim. | |
64 | Document Control Number (DCN) | Required for correction or voiding of a claim only | When the Type of Bill in box 4 ends in a 7 or an 8 enter the Claim ID number of the claim you are requesting to correct or void. This can be found on your Remittance Advice | |
65 | Employer Name | Optional | Enter Employer Name | |
66 | Diagnosis and Procedure Code Qualifier ICD Indicator: | Required | 10 digit alpha numeric | Enter: 0—ICD-10-CM Diagnosis |
67 | Principle Diagnosis Code | Required | 10 digit alpha numeric | Enter all letters and/or numbers of the ICD-9 or 10 CM code for the primary diagnosis including the fourth and fifth digit if present |
67A-Q | Other Diagnosis Code (including POA Codes) | Required (if applicable) | 10 digit alpha numeric | Enter all letters and/or numbers of the secondary ICD-9 or 10 CM code including fourth and fifth digits if present. |
68 | Not Used | DO NOT USE | ||
69 | Admitting Diagnosis | Required (if applicable) | 10 digit alpha numeric | Enter Admitting Diagnosis Code |
70A-C | Patient´s Reason for Visit | Required (if applicable) | 10 digit alpha numeric | Enter Patient´s Reason for Visit Code |
71 | Prospective Payment System (PPS) Code | Optional | Enter PPS Code | |
72 | External Cause of Injury (ECI) Code | Optional | 10 digit alpha numeric | Enter External Cause of Injury Code |
73 | Not Used | DO NOT USE | ||
74 | Principle Procedure Codes and Date | Required (if applicable) | MMDDYYYY | Enter Principal Procedure Code/Date |
74a-e | Other Procedure Codes and Dates | Required (if applicable) | MMDDYYYY | Enter Other Procedure Code/Date |
75 | Not Used | DO NOT USE | ||
76 | Attending Provider Name and Identifiers (including NPI) | Required (if applicable) | 10 digit number | Enter Attending Name/ ID-Qualifier 1G |
77 | Operating Provider Name and Identifiers (including NPI) | Required (if applicable) | 10 digit number | Enter Operating ID |
78-79 | Other Provider Name and Identifiers (including NPI) | Required (if applicable) | 10 digit number | Enter Other ID |
80 | Remarks | Optional | Enter Remarks | |
81a-d | Code to Code Field | Optional | Enter Code-Code Field/Qualifiers |
NY_DOH_MIF@pcgus.com * 1-855-NYMIF33 (1-855-696-4333)