PURPOSE: This rule is intended to standardize the forms used in the billing and reimbursement of health care services, reduce the number of forms utilized and increase efficiency in the reimbursement of health care services through standardization in accordance with section 374.184, RSMo.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law.

1. (1) Definitions.

   1. (A) CDT-2 Codes means the current dental terminology prescribed by the American Dental Association (ADA).
   2. (B) CPT-4 Codes means the current procedural terminology published by the American Medical Association (AMA).
   3. (C) HCFA means the Health Care Financing Administration of the United States Department of Health and Human Services.
   4. (D) HCFA Form 1450/UB-92 Form (see 13 CSR 70-3.100) means the health insurance claim form published by HCFA for use by institutional care practitioners.
   5. (E) HCFA Form 1500 (see 13 CSR 70- 3.100) means the health insurance claim form published by HCFA for use by health care practitioners.

   6. (F) HCPCS means HCFA’s Common Procedure Coding System that is based upon the AMA’s Physician Current Procedural Terminology, Fourth Edition (CPT-4).

      1. 1. HCPCS Level 1 Codes means the

AMA’s CPT-4 Codes.

1. 2. HCPCS Level 2 Codes means the

codes for physicians and nonphysician services that are not included in CPT-4.

1. 3. HCPCS Level 3 Codes means the

codes for physicians and nonphysician services that are not included in CPT-4 or HCPC Level 2 Codes but which are approved by HCFA.

1. (G) Health care practitioner shall include, but not be limited to, the following persons who provided health care services under the authority of a license or certificate of Missouri.

   1. 1. A chiropractor licensed under Chap-

ter 331, RSMo;

1. 2. A corporation or partnership of health

care practitioners defined in this section;

1. 3. A dentist licensed under Chapter 332,

RSMo;

1. 4. A nurse licensed under Chapter 335,

RSMo;

1. 5. An ophthalmologist licensed under

Chapter 334, RSMo;

1. 6. An optometrist licensed under Chap-

ter 336, RSMo;

1. 7. A physician or physical therapist

licensed under Chapter 334, RSMo;

1. 8. A podiatrist licensed under Chapter

330, RSMo;

1. 9. A psychologist licensed under Chap-

ter 337, RSMo;

1. 10. A speech pathologist or clinical

audiologist licensed under Chapter 345, RSMo; and

1. 11. A home health care provider

licensed under Chapter 197, RSMo;

1. (H) ICD-9-CM Codes means the disease codes in the International Classification of Diseases, Ninth Revision, clinical modifications published by the United States Department of Health and Human Services.

2. (I) Institutional care practitioner means—

   1. 1. A hospice licensed under Chapter

197, RSMo;

1. 2. A hospital licensed under Chapter

197, RSMo; and

1. 3. A skilled nursing facility, extended

care facility, intermediate care facility, convalescent nursing home and personal care facility licensed under Chapter 344, RSMo.

1. (J) Insurer means an insurance company, health services corporation fraternal benefit society, health maintenance organization, third-party administrator and any other entity processing claims or reimbursing the costs of health care expenses.
2. (K) J500 Form Series means the uniform dental claim forms approved by the ADA for use by dentists and includes the J510, J511 and J512 versions of the form.
3. (L) Medicare means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965.
4. (M) Medical Assistance or Medicaid means Title XIX of the federal Social Security Act (42 U.S.C. 1936).
5. (N) Revenue Code means the codes established for use by institutional care practitioners by the National Uniform Billing Committee.

1. (2) Applicability and Scope.

   1. (A) Except as otherwise specifically provided, the requirements of this rule apply to insurers, health care practitioners and institutional care practitioners.
   2. (B) Nothing in this rule shall prevent an insurer from requesting additional information that is not contained on the forms required under this rule to determine eligibility of the claim for payment if required under the terms of the policy or certificate issued to the claimant. The health care practitioner, the institutional care practitioner or other claimant may charge reasonable fees for copying the additional information requested by the insurer. The state Medicaid program under the Division of Medical Services shall be exempt from subsection (2)(B) so long as they comply with the timely processing deadlines set forth by HCFA.
   3. (C) Nothing in this rule shall prohibit an insurer, health care practitioner or institutional care provider from modifying the uniform billing document where both insurer and provider believe those modifications will streamline claims processing procedures, so long as the modifications are specified in a written contract between the health care provider and the insurer.

2. (3) Requirements for Use of HCFA Form 1500.

   1. (A) Health care practitioners, other than dentists, shall use the HCFA Form 1500 and instructions provided by HCFA for use of the HCFA Form 1500 when filing claims with insurers for professional services. Health care providers that bill patients directly shall provide a properly completed HCFA Form 1500 in addition to any other explanatory information used to bill the patient when requested by the patient.

   2. (B) Insurers may not require health care practitioners to use any coding system for the initial filing of claims for health care services other than the following:

      1. 1. HCPCS Codes;
      2. 2. ICD-9-CM Codes; and
      3. 3. For anesthesia services, HCPCS

Level 1 Codes.

1. (C) Insurers may not require health care practitioners to use any other descriptor with a code or to furnish additional information with the initial submission of a HCFA Form 1500 except under the following circumstances:

   1. 1. When the procedure code used

describes a treatment or service that is not otherwise classified; or

1. 2. When the procedure code is followed

by the CPT-4 modifier 22, 52 or 99, health care practitioners may use item 19 of the HCFA Form 1500 to explain multiple modifiers.

1. (D) Health care practitioners may use Box 19 of the HCFA Form 1500 to indicate the form is an amended version of a form previously submitted to the insurer by inserting the word, amended, in the space provided.
2. (E) Health care practitioners billing for services based on the amount of time involved shall define on line 19 the time interval in item 24 G of the HCFA Form 1500. If not defined, units will be assumed to be days of treatment.
3. (F) Health care practitioners shall provide the unique physician identification number, as assigned by HCFA, in box 17a.
4. (G) Health care practitioners shall provide the federal tax identification number or Social Security number to complete Item 25 of the HCFA Form 1500.

1. (4) Requirements for Use of HCFA Form 1450.

   1. (A) Institutional care practitioners shall use the HCFA Form 1450 and instructions provided by HCFA for use of the HCFA Form 1450 when filing claims with insurers for health care services. Institutional care providers that bill patients directly shall provide a properly completed HCFA Form 1450 in addition to any other explanation information used to bill the patient when requested by the patient.

   2. (B) Insurers may not require institutional care practitioners to use any coding system for the initial filing of claims for health care services other than the following:

      1. 1. ICD-9-CM Codes;
      2. 2. Revenue Codes;
      3. 3. HCPCS Level 1 Codes;
      4. 4. HCPCS Level 2 Codes;
      5. 5. HCPCS Level 3 Codes; and 20 CSR 400-8
      6. 6. If charges include direct service fur-

nished by a health care practitioner, the information outlined in section (3) of this rule.

1. (C) Hospitals may use the HCFA Form 1500 to supplement an HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with insurers for professional medical services.

1. (5) Requirements for Use of J500 Form Series.

   1. (A) Dentists shall use the J500 Form Series and instructions provided by the ADA for use of the J500 Form Series for filing claims with insurers for professional services. Dentists that bill patients directly shall provide a properly completed form in addition to any other form used to bill the patient when requested by the patient, unless the services provided are reimbursable under other health coverage of the patient, in which case, the dentist shall use the HCFA Form 1500.
   2. (B) Insurers may not require a dentist to use any code other than the CDT-1 Codes for the initial filing of claims for dental care services, unless the use of supplemental codes are defined and permitted in a written contract between the insurer and dentist.

2. (6) General Provisions.

   1. (A) Health care practitioners and institutional care practitioners shall file claims in a manner consistent with the requirements of this rule. Claims filed in paper form shall be printed on eight and one-half by eleven-inch (8 1/2 × 11") paper.
   2. (B) Insurers shall accept forms submitted in compliance with this rule for the processing of claims.

   3. (C) Health care practitioners, institutional care practitioners and insurers shall—

      1. 1. Use and accept the most current edi-

tions of the HCFA Form 1500, HCFA Form 1450, UB-92 Form or J512 Form and most current instructions for these forms in the billing of patients or their representatives and filing claims with insurers; and

1. 2. Modify their billing and claim reim-

bursement practices to encompass the coding changes for all billings and claim filing by ninety (90) days after the effective date of the changes by the developers of the forms, codes and procedures required under this rule.

1. (7) This rule shall become effective on January 1, 1995.
2. (8) Separability. If any provision of this rule or its application to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of the provision to other persons or circumstances shall not be affected. FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION Division 400—Life, Annuities and Health

AUTHORITY: section 374.184, RSMo (1994).* Original rule filed Nov. 29, 1993, effective Jan. 1, 1995. Amended: Filed Oct. 15, 1996, effective June 30, 1997.

*Original authority 1992. FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION Division 400—Life, Annuities and Health