Submission

As always, if you have questions about which form to use or about submitting a bill, don't hesitate to call us at 800.285.8525 or email your question to providerquestions@saif.com.

Choosing the right form

Your profession and the type of service you provide to an injured worker will determine which form you need to submit to SAIF.

• If you are a professional medical provider, use form CMS-1500.
• If you are a hospital provider, use the UB form.
• For dental, pharmacy, and all other providers, go to the "Other providers" section below.

Other providers

If you are not a professional provider (physician, physician assistant, authorized nurse practitioner, chiropractor, podiatrist, or naturopath) or a hospital provider, follow these instructions for billing us.

• Dental billings: Use the ADA dental claim form. Purchase the form through www.adacatalog.org, or view a sample form.
• Pharmacy billings: use the current NCPDP form
• Other ancillary providers: use the CMS-1500 form or UB-04 form. Call or email us if you are unsure which form to use.

 

CMS-1500 tips

• All forms must contain a Tax Identification Number (TIN) or Social Security Number or they will be returned.
• Payments will only be sent to the address entered in Box 33.
• Be sure to complete all highlighted areas to ensure speedy processing.
• Please print clearly inside the boxes using black or dark blue ink. (Black or dark blue ink is required for automated entry.)
• When rebilling, print REBILL clearly at the top of the form.
• Use HCPCS instead of CPT 99070.
• If you are billing for chart note copies, please include the number of copies provided in the "Days and Units" field on the CMS-1500 (formerly HCFA).
• If you are billing for report services, conference or record review, please include the same date of service on the CMS-1500 as appears on the corresponding document.
• Please complete CMS-1500 Box 32 if different than Box 33.
• Identify the rendering provider in Box 31 on CMS-1500.*
• Use valid codes (ICD-9, CPT, HCPCS, CDT, etc).
• Use appropriate units.
• When faxing a bill on the new CMS-1500, please be aware that the text on the shaded lines in Field 24 may not come through on the fax. The shading overshadows the printing, leaving it unreadable in some cases.

Modifiers

Bill for services with the correct modifiers. For example:

• Ambulatory Surgical Center, modifier SG should be billed only for ASC services (not x-rays, injections, etc.).
• Physician assistants and authorized nurse practitioners should bill modifier 81.
• Multiple surgeries should bill modifier 51.
• Bilateral surgeries should bill modifier 50.
• Use bill modifier 26 for CPT codes according to the Federal Register (26 indicates a professional component).

UB form tips

• All forms must contain a Tax Identification Number (TIN) or they will be returned.
• Payments will only be sent to the address entered on the form.
• Be sure to complete all highlighted areas to ensure speedy processing.
• Please print clearly inside the boxes using black or dark blue ink (Black or dark blue ink is required for automated entry). When rebilling, print REBILL clearly at the top of the form.
• More helpful billing tips.

 

Additional submission tips

 

Getting your bill processed quickly

• Use SAIF's claim number. If you have Business Online access, log in and go to Claim Profile.
• Attach legible documentation or chart notes to support the charges billed.
• Line up information on forms in the correct boxes.
• To re-bill for services previously billed but not yet paid, or for bills submitted and paid, resubmit the bill to us and clearly indicate "re-bill" on the invoice.
• Be sure to include the name of the provider rendering the service on your billing.
• Make sure the date of service on the bill matches the date of service on the supporting documentation.
• Do not submit "statement" billings that include multiple workers on the same document.
• Include the appropriate units or days.

IMPORTANT: If your bill does not contain your Taxpayer ID Number (TIN), it will be returned for correction and resubmission.

 

Disallowed bills

If your bill is not submitted with the correct information, it will be disallowed. You may resubmit your billing with the proper documentation after disallowance. Examples of bills without correct information:

• Hospital bills containing services for compensable and non-compensable conditions. For example: worker admitted to the hospital for treatment of a compensable knee condition and also has surgical treatment for an unrelated hernia repair.
• Bills not submitted on a CMS-1500 or UB-04 form.
• Bills without a UB itemization.
• Bills without a rendering provider of service listed.
• Invalid or incorrectly assigned place of service codes.
• Services rendered by authorized nurse practitioners and physician assistants without a modifier "81."
• Requests for review of disallowed bills must be submitted within 90 days of the date the original bill was processed.

If you need additional information, please contact us at providerquestions@saif.com. Thank you for making your bill submission as complete as possible. We appreciate it.