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July 13, 2022Revised 05.04.23

Invoice Claim Filing Instructions

Claim Submission: Part A

  • Include the name of the drug, radiopharmaceutical, supply, or skin substitute and the exact dosage administered/amount used must appear in the Documentation Field (NOTE: see information under Part B below for more information).
    • Electronic Media Claims (EMC): report this information in Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7.
    • Paper claims (if you are approved to submit paper claims): report this information in Form Locator 80 on the UB-04 form.

Claim Submission: Part B

  • The name of the drug, radiopharmaceutical, supply, or skin substitute and the exact dosage administered/used must appear in the Documentation Field.
    • For electronic claims, report invoice information in the Electronic Documentation Field Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level).
    • If you are approved to submit paper claims, report this information in Item 19 of the CMS-1500 claim form and provide a copy of the actual invoice.
  • If the submitted charge matches the actual invoice cost, add note "Actual Invoice Cost" in the Documentation Field. You are not required to submit invoice information with the claim; however, it must be available if requested. (Note: the actual invoice price must be included and in dollars and cents with the decimal.)
  • If the submitting charge does not match the actual invoice cost, the following information must be included in the Documentation Field, using these abbreviations:
    • Des = Description/Name of agent (e.g., Des=TC99m MDP)
    • QS = Quantity shipped (e.g., QS=100 mci)
    • TA = Total amount charged for quantity shipped in dollars and cents with the decimal (e.g., TA=$57.40)
    • UP = Unit Price in dollars and cents with the decimal (e.g., UP = $0.57 per mci) (Optional)
    • DG = Dosage administered/amount used (e.g., DG=25 mci)
  • In lieu of submitting the invoice information, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail Details on the PWK Segment Process.
  • Claims requiring invoice submitted without the above information or the actual invoice may be denied or delayed.

Reviewed: 12.11.23

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