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Special sponsor 20th annual Susan G. Komen Detroit Race for the Cure

Billing:

To ensure efficient claims processing from Community Care Associates, Inc., (CCA)., include on claims the following information.  Claims for Professional or Ancillary Services (Physicians, X-rays, Anesthesia, ETC.) should be submitted on a HCFA-1500 and provide  the following data: EDI claim submission Payer ID 17096.

1.) Insured Policy Number- (REQUIRED FIELD)
2.) Patient's Name
3.) Patient's Date of Birth
4.) Insured Name
5.) Insured Policy or Group Number
6.) If condition is related to accident or injury (box 10 on HCFA-1500)
7.) If there is another Health Benefit Plan ( box 11D on HCFA-1500)
8.) Authorized Signature for information release (box 12 on HCFA-1500)
9.) Authorized Signature for benefit assignement
10.) Diagnosis (REQUIRED)

Services for Emergency Room, Inpatient (Facility), Outpatient Surgery(Facility), ETC., should be submitted on an UB-92 Form and provide the following data:

1.) Insured Policy Number- (REQUIRED FIELD)
2.) Patient's Name
3.) Patient's Date of Birth
4.) Insured Name
5.) Insured Policy or Group Number
6.) Diagnosis (REQUIRED)
7.) Dates of Service (REQUIRED)

If you have any claims questions please call Claims Dept. at 313-961-3100 ext 723 - 724
Non-Contracted Providers medical claim providers must submit their claims to.

Community Care Associates Inc.

Attn: Claims Department

P.O.BOX. 44230

Detroit, MI 48244

Joint Venture Hospital Laboratory Contracted Providers must submit their claims directly to JVHL, via electronic submission or paper filing.

http://www.jvhl.org/

11.) Dates of Service (REQUIRED)
12.) Place of Service (REQUIRED)
13.) Type of Service (REQUIRED)
14.) HCPCS/CPT Code (PROCEDURE) (REQUIRED)
15.) Charges or Billed Amount (REQUIRED)
16.) Units or Days
17.) Provider Tax I.D. Number (REQUIRED)
18.) Pateint's Account Number
19.) Signature of Physician
20.) Name and Address of Facility
21.) Physicians Billing Name and Address (REQUIRED)

8.) Rev Code (REQUIRED)
9.) Description of Service ( Lab, Room& Board ETC)
10.) HCPCS/CPT Code (PROCEDURE) (REQUIRED)
11.) Charges or Billed Amount (REQUIRED)
12.) Units or Days
13.) Provider Tax I.D. Number (REQUIRED)
14.) Pateint's Control Number
15.) Name and Address of Facility

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