Medical Indemnity Fund

  • Guidance is also available in Portable Document Format (PDF)

MIF Claim Submission Guidance - Provider Claims

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).

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.

  • 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 03840-0784
      Note: Photographs and faxes of claims are not acceptable and will not be processed.
  • 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.
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.
  • This section may be used for an unlisted procedure code when explanation is required and clinical review isrequired.
  • If modifier "-99" multiple modifiers is entered in section 24d, they should be itemized in this section. All applicable modifiers for each line item should be listed.
  • Claims for "By Report" codes and complicated procedures should be detailed in this section if spacepermits.
  • All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.
  • Anesthesia start and stop times.
  • Itemizationof miscellaneous supplies, etc.
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.
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)