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Questions About Claim Forms

To receive reimbursement for covered services from a non-participating provider, you should submit a standard HCFA-1500 health insurance claim form to GHI. Click here to download forms and obtain addresses.

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For fastest reimbursement, please file claims promptly after receiving services. However, GHI has extended its claims filing period to 12 months after the date services were rendered for PPO (including Medicare) claims.

For HMO, FHP, CHP and Medicaid, the claim filing period is 90 days.

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Yes, you can view summaries of the GHI's Claim Coding Policies.

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Edits will be based upon the following guidelines. Some specific examples are highlighted below:

• Correct Coding Initiative (CCI) : The Correct Coding Initiative is a compilation of edits in the following categories:
  • Comprehensive/Component procedures: - e.g., right heart catheterization (93501) billed with right and left heart catheterization (93526). 93501 is considered to be part of 93526.
  • Mutually Exclusive procedures: Procedures that are similar to each other are not allowed to be billed in the same operative session, e.g., complex repair of trunk 1.1cm to 2.5cm (13100) and 2.6cm to 7.5cm (13101). It is not necessary to repair multiple wounds of the trunk in the same repair classification.

• Multiple Procedure Policies: Multiple surgery occurs when the same physician performs two or more surgical procedures that are subject to multiple surgery rules on the same day, at the same time or different operative sessions. The major service or procedure is billed normally but each additional procedure subject to the multiple surgery rule must be identified by adding the -51 modifier. For example, procedures 56605 (biopsy of vulva or perineum; one lesion) and 57454 (colposcopy with biopsy) are performed on the same date of service (DOS). The appropriate way to bill these procedures would be:

  Line 1 - 57454
  Line 2 - 56605-51

  57454 should be billed without modifier -51 to indicate that it is the primary procedure and 56605 should be billed with modifier -51 to represent a secondary procedure.

• American Medical Association (AMA) Policies : The AMA's CPT-4 code Manual is a systematic listing and coding of procedures and services performed by physicians. The purpose of the terminology manual is to provide a uniform language that will accurately describe medical, surgical and diagnostic services and will provide an effective means for reliable nationwide communication among physicians, patients, and third parties. An example of an AMA policy is usage of preventive medicine evaluation and management codes. The physician reporting these codes on a claim must identify the code that is specific to the patient's age. This service would be subject to an age edit based on CPT-4 code definition as outlined by the AMA. For example, a newborn who sees a pediatrician for preventive medicine service should be reported as:  99381=Initial preventive medicine E/M of an individual etc., age under one (1) year.


• Specialty Academy Guideline Policies : Academy guidelines are designed to provide accurate and authoritative information specific to the specialty and are used as a tool in understanding specialty-specific procedure explanations to translate them into correct CPT codes. Example, in the specialty of Ophthalmology, an Ophthalmologist would code a condition of Corneal abscess (ICD-9 code 370.55) to the procedure of multiple punctures of anterior cornea, e.g., for corneal erosion, tattoo (CPT-4 code 65600).


• Local Medicare Policies : Where there are no defined national CMS policies, local Medicare carriers may develop policies. Additionally, local Medicare carriers may develop policies, which can be adapted from state-to-state.

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The claim coding review program will not change applicable fee schedules. Only the coding edits have been modified.

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Please refer to the CMS Web site at: www.CMS.gov

In addition, The Correct Coding Initiative can be obtained from:

Administer Federal (NTIS) P.O. Box 50469 Indianapolis, IN 46250-0469 or by calling: 703-605-6060 or toll-free 800-363-2068

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The AMA guidelines can be obtained directly from the CPT-4 code manual, by visiting their Web site at www.ama-assn.org, or by contacting them directly at:

515 N. State Street Chicago, IL 60610 or by calling: 800-621-8225.

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Because there are numerous Medicare Intermediaries that develop local Medicare policies, please visit www.CMS.gov for a listing of the policies, by state.

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Physicians and practitioners should refer to the policies and guidelines that our outlined by each specialty academy and/or specialty society.

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