10A NCAC 27A .0303 clean claim format requirements
(a) A provider of a service that is payable from funds administered by an LME shall submit a claim for payment to the authorizing LME. The provider shall submit the claim in one of the formats listed as follows:
(1) HIPAA compliant 837;
(3) the standardized billing format provided by the DMH/DD/SAS; or
(4) a single web based direct data entry system.
The provider shall complete each element contained in the selected format.
(b) The billing format provided by the DMH/DD/SAS shall contain standardized elements including:
(1) date of claim;
(2) provider information including:
(A) name; and
(3) client information including:
(B) identification number;
(C) target population code; and
(D) ICD-9 diagnosis code.
(4) service information including:
(C) units delivered;
(D) billing code; and
(E) authorization number.
History Note: Authority G.S. 122C-112.1(a)(32); S.L. 2006-142;
Eff. May 1, 2008;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 25, 2016.