Scott & White Health Plan

Field Number

Field Name

Requirement

Instructions

1a.

Insured's ID Number

TDI Requirement

Enter the Identification number found on the insured's SWHP ID card. (Must be valid SWHP 11-digit member ID)

2

Patient's Name

TDI Requirement

Enter patient's Last name, First name, Middle initial, patient generation,

(i.e., Jr., Sr.), if applicable.

3

Patient's Birth Date/ Sex

TDI Requirement

Enter patient's date of birth using an eight-digit date format (MM/DD/CCYY). Enter "X" in appropriate box to indicate patient's sex.

4

Insured's Name

TDI Requirement

Enter insured's Last name, First name, Middle initial, patient generation,

(i.e., Jr., Sr.), if applicable.

5

Patient's Address/ Telephone Number

TDI Requirement

Enter patient's permanent mailing address and telephone number. Street, City, State, Zip Code.

17

Name of Referring Provider or Other Source

Not Required

Enter name (First, MI, Last name) and credentials of referring, ordering or supervising provider.

17b

NPI

Conditional - Required if there is a physician listed in field 17.

Enter the 10-digit NPI number of the referring, ordering or supervising provider.

21 (1-4)

Diagnosis or Nature of Illness or Injury

TDI Requirement

Enter the ICD-9-CM Codes. The primary diagnosis should be first, followed by other diagnoses.

Enter up to 4 ICD-9-CM Codes.

24a

Date (s) of Service: From and To

TDI Requirement

Enter the dates of service using an eight-digit date format MM/DD/CCYY).

24b

Place of service

TDI Requirement

Enter the appropriate 2 digit Place of Service code. (must be valid industry standard codes)

24d

Procedures, Services or Supplies

TDI Requirement

Enter the CPT or HCPCS code for the procedures, service or suppliers and enter a modifier, if applicable. (must be valid industry standard codes)

24e

Diagnosis Code (pointer)

TDI Requirement

Enter one ICD-9-CM diagnosis code for each procedure performed. Enter only one code per line of service.  (must be valid industry standard codes)

24f

Charges

TDI Requirement

Enter charge for each line of service. (This should be original charge not the balance due or patient liability. Do not include discounts)

24g

Days or Units

TDI Requirement

Enter the number of days or units

24j

Rendering Provider NPI

Enter performing provider 10-digit NPI number.

25

Federal Tax ID Number

TDI Requirement

Enter the provider of service's Federal Tax ID number. Place an "X" in the appropriate box or SSN or EIN.

28

Total Charge

TDI Requirement

Enter total charges. This should total all charges in 24f.

31

Signature of Physician or Supplier

TDI Requirement

The claim must be signed by the physician/supplier or an authorized representative. The form must also be dated using an eight-digit date format (MM/DD/CCYY).

32

Service Facility Location

SWHP Requested 

Enter location where services were rendered. According to Texas state law, this field is required if the services were performed somewhere other than the patient's home.

33

Billing Provider Information and Phone number

TDI Requirement

Enter provider's or supplier's information that is requesting to be paid for services rendered.

33a

NPI Number

TDI Requirement

Enter the 10-digit NPI number of the billing provider

Field Number

Field Name

Requirement

Instructions

1

Billing Provider Name Address, and Telephone Number

TDI Requirement

Enter the billing name, street address, city, state, zip code and telephone number of the billing provider submitting the claim. Note: this should be the facility address

2

Pay To Name and Address

Conditional  - Required if applicable

Enter the name, street address, city, state, and zip code where the provider submitting the claims intends payment to be sent. Note: This is required when information is different from the billing provider's information in form locator 1.

3a

Patient Control Number

TDI Requirement

Enter the patient's unique alphanumeric control number assigned to the patient by the provider

4

Type of Bill

TDI Requirement

Enter the appropriate code that indicates the specific type of bill such as inpatient, outpatient, late charges, etc. (This code will be used to determine place of service)

5

Federal Tax ID Number

TDI Requirement

Enter the provider's Federal Tax Identification number.

6

Statement Covers Period

(From /Through)

TDI Requirement

Enter the beginning and ending service dates of the period included on the bill using a six-digit date format (MMDDYY). For example: 010107.

8b

Patient Name

SWHP Requirement

Enter the patient's last name, first name and middle initial.

9

Patient Address

TDI Requirement

Enter the patient's complete mailing address (fields 9a - 9e), including street address (9a), city (9b), state (9c), zip code (9d) and country code (9e), if applicable to the claim.

10

Patient's Birth Date

TDI Requirement

Enter the patient's date of birth using an eight-digit date format (MMDDYYYY).

For example: 01281970.

17

Patient's Discharge Status

TDI Requirement

Enter the appropriate two-digit code indicating the patient's discharge status.

Note: Required on all inpatient, observation, or emergency room care claims

18 - 28

Condition Codes

Conditional - Required if applicable

Enter the appropriate two-digit condition code or codes if applicable to the patient's condition.

42

Revenue Code

TDI Requirement

Enter the applicable Revenue Code for the services rendered. (must be valid industry standard codes)

43

Revenue Code Description

TDI Requirement

Enter the standard abbreviated description of the related revenue code categories included on this bill.

44

HCPCS/Rates/HIPPS Code

Conditional - Required for outpatient claims

Enter the applicable HCPCS (CPT)/HIPPS rate code for the service line item if the claim was for ancillary outpatient services and accommodation rates. Also report HCPCS modifiers when a modifier clarifies or improves the reporting accuracy. (must be valid industry standard codes)

45.

Service Date (MMDDYY)

Required for outpatient claims

Enter the applicable six-digit format (MMDDYY) for the service line item if the claim was for outpatient services, SNF\PPS assessment date, or needed to report the creation date for line 23.

(Note: Line 23 - Creation Date is Required for all claims.)

46

Service Units

TDI Requirement

Enter the number of units provided for the service line item. (Units must be ≥ 1)

47

Total Charges

TDI Requirement

Enter the total charges using Revenue Code 0001. Total charges include both covered and non-covered services. (Total must equal sum of all service lines)

48

Non-Covered Charges

Conditional  - Required if applicable

Enter any non-covered charges as it pertains to related Revenue Code.

56

National Provider Identifier (NPI)

TDI Requirement

Enter the billing provider's 10-digit NPI number.

60

Insured's Unique Identifier (Insured's ID)

SWHP Requirement

Enter the insured's identification number (60a). If applicable, enter the other insured's identification number when other payers are known to be involved

(60b and 60c). (Must be valid SWHP 11-digit member ID)

67

Principal Diagnosis Code and Present on Admission Indicator

TDI Requirement

Enter the principal diagnosis code for the patient's condition.

67a - 67q

Other Diagnosis Codes

Conditional - Required if applicable.

Enter additional diagnosis codes if more than one diagnosis code applies to claim.

69

Admitting Diagnosis Code

TDI Requirement

Enter the diagnosis code for the patient's condition upon an inpatient admission.

71

Prospective Payment System Code (PPS)

SWHP - Requirement  where applicable

Enter the DRG based on software for inpatient claims when required under contract grouper with a payer.

74

Principal Procedure Code and Date (MMDDYY)

Conditional - Required if applicable

Enter the principal procedure code and date using a six-digit format (MMDDYY) if the patient has undergone an inpatient procedure.

Note: Required on inpatient claims.

74a - e

Other Procedure Codes and Dates (MMDDYY)

Conditional - Required if  applicable

Enter the other procedure codes and dates using a six-digit format (MMDDYY) if the patient has undergone additional inpatient procedure.

Note: Required on inpatient claims.

76

Attending Provider Name and Identifiers

TDI Requirement

Enter the attending provider's 10-digit NPI number and last name and first name. Enter secondary identifier qualifiers and numbers as needed.

*Situational: Not required for non-scheduled transportation claims.

77

Operating Name and Identifiers

Conditional

Enter the operating provider's 10-digit NPI number, Identification qualifier, Identification number, last name and first name. Enter secondary identifier qualifiers and numbers as needed.

78 - 79

Other Provider Names and Identifiers

Conditional

Enter any other provider's 10-digit NPI number, Identification qualifier, Identification number, last name and first name. Enter secondary identifier qualifiers and numbers as needed.