Requirements for Non-Network Provider Claims

The following are tips on completing your claim form. Following the tips may, in most cases, help expedite the processing and payment of your claim.

• Fill in all the Requested Information: Any bill/claim submitted to us requires your full name, address, ID number (usually your SSN) and your Employer’s name and full address. Please provide the patient’s full name, full address, DOB, gender, and relationship to the insured member. 
• Use the 1500 Claim Form: We would prefer all claims to be submitted on the 1500 Claim form. For detailed information on this form, visit http://www.nuss.org
• Provide Additional Insurance Information: If patient has medical coverage through any other  insurance, we request that you please submit the Name and full address of the insurance company, along with phone number, group number etc. 
• Verify Patient Name and Covered Individual Have the Same Last Name: If patient has a different last name and/or over 19 years of age, we will request additional information be submitted in order to complete the processing of your claim.  

Assignment of Benefits: If signed, the member is authorizing the insurance company to pay his/her benefits directly to the Provider of service. If you do not wish payment to go directly to the provider, please leave this line blank. If left blank, payment will automatically be paid to the member. 

The following Provider billing information must be completed and can be obtained from your provider or the facility where you received treatment:

 

1. Diagnosis - Ensure to use the appropriate ICD 10 code “0” and DSM 5 diagnosis code
2. Date(s) of service (break-down of charges per day for facility based treatment)
3. Place of service (office or facility)
4. CPT code (description of services rendered by the Provider- procedure code that you can get from your provider)
5. Amount charged (breakdown of charges per day for facilities; or cost of each visit for providers)
6. Provider Name & Address (actual provider who rendered the service and address of where the service was rendered)
7. Provider Tax ID or Social Security #, and Provider’s license level (MFCC, PHD, MD, etc.)
8. Providers NPI number

Copy completed claim form for your records. Please send claim to the address listed on liveandworkwell.com. If you have any questions, do not hesitate to contact Member Services at the number listed on the back of your insurance card.