Revised and Restated Paper Claim Submission Requirements

Revised guidelines for submitting paper claims to Tufts Health Plan will be effective November 16, 2009.

Under these revised guidelines, Tufts Health Plan will no longer waive requirements for completing mandatory fields on paper claim forms. Those fields are noted in the detailed specifications for submitting UB-04 and CMS-1500 claims in the Tufts Health Plan provider manuals.

Submitted forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

For all commercial and Tufts Health Plan Medicare Preferred paper claims:

• Diagnosis codes must be entered in priority order (primary, secondary condition) for proper adjudication. Up to 4 diagnosis codes will be accepted on the CMS-1500 form, but consistent with our current policy, only the first code will be used for claim processing.
• Providers should submit industry-standard codes on all paper claims.
• Paper claims will be rejected and returned to the submitter if required information is missing or invalid. Common omissions and errors include but are not limited to the following:
  • Illegible claim forms
  • Member ID number
  • Date of service or admission date
  • Physician’s signature (CMS-1500 Box 31)

For specific information on claim submission requirements, refer to the Claim Requirements chapter of the Tufts Health Plan Commercial and Tufts Medicare Preferred provider manuals at tuftshealthplan.com.


October 9, 2009
Updated October 12, 2009