Provider Connection

“Clean Claim” Defined

Revised: April 2014

A clean claim is defined by Medicare as a claim which has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment.

The elements for a clean claim have been required for some time, beginning January 1, 2012 medical bills will be denied if elements are missing that are necessary to process for payment. The required elements must be complete, legible and accurate. The following elements are required to meet the test for “Clean Claim” status for MSF:

CMS-1500 and  the new CMS-1500 form (NUCC – 2/2012 (See the CMS website for form information:

Box # Description


1a Required Insured’s ID number will be the full 12 digit claim number of the injured worker. “NOTE: the claim number may be entered anywhere on the CMS 1500 form to be accepted”.
2 Required Injured Employee’s name
3 Required Injured employee’s date of birth/sex
5 Required Injured employee’s address
10  “Is patient’s condition related to…?
11 Claim number may also be entered here
12 The patient (injured employee) or authorized representative must sign/date the form unless there is a signature on file, then “Signature on file” is sufficient
14 Required Accident/Injury Date (exception – DME)
17a Referring Provider Taxonomy (if applicable) – input ZZ in first box and 10-character taxonomy code without spaces in the second box
17b Referring provider NPI# (if applicable), input 10-character NPI number. Required if 17a is populated.
21 Required ICD diagnosis code(s) Note: for Vocational Rehabilitation, this box is optional; enter 959.9 for dates of service through 9-30-2015 and T14.90 for dates of service after 10-1-2015.
24A Required Date(s) of service
24B Required Place of service code (this field is optional for Voc Rehab, MSF PPO contracted home health, and MCM services and other MSF PPO contracted vendors or on non CMS 1500 bills).
24D Required Procedures, Services or Supplies – enter appropriate CPT, HCPCS or contracted code(s). If using an unlisted code etc, also enter description.
24E ICD code or number or letter from Box 21
24F Required Service charge/fee billed for each line item/code
24G Required # Days or unit(s) – enter the number of units for each line item/code
24I ID Qualifier – ‘Blank’ and preprinted ‘NPI’ spaces. Blank space should be populated with ZZ for taxonomy code listed in 24J.
24J Required – if applicable (some exceptions would be Vocational Rehabilitation; ambulance, ambulatory surgery centers, DME and Home Infusion Therapy, labs, MRI centers, non medical providers and MCM, POS 12, etc.) Rendering provider ID# – If top space is ‘blank’, 24I is populated with ZZ then enter 10-digit taxonomy code in 24J (top space) note: MSF# no longer valid. Bottom line, enter the NPI number in the corresponding space after preprinted ‘NPI’ in 24I.
25 Required Federal Tax ID number – enter the tax ID or SS# of the billing entity
28 Required Total Charges
31 Signature of Physician or supplier, including degrees or credentials
32 Required – if applicable (exceptions would be Ambulance, POS 12,DME and Voc Rehab). Name and address of facility where services were rendered (cannot be PO Box)
32a Required – if applicable (exceptions would be Ambulance, POS 12,MCM, non-medical providers and Voc Rehab). Service Facility Location NPI – enter 10-character NPI number
32b Service Facility Location Taxonomy – input ZZ and 10-character taxonomy code without spaces
33 Required Physician’s, suppliers billing name, address, and zip code.
33a Requiredif applicable (exceptions would be MCM, non-medical providers, POS 12, DME and Voc Rehab). Billing Provider NPI # – input 10-character NPI number
33b Billing Provider Taxonomy – input ZZ and 10-character taxonomy code without spaces

UB04 (See the CMS website for form information:

Form Locator Description
1 Required Billing provider name, and physical address.
2 Required – if applicable Pay to address if different than field 1.
4 Required Type of bill –enter the three or 4 digit code that indicates the type of bill you are submitting.
5 Required Federal Tax Number
6 Required Statement covers period – enter the beginning and ending service date(s) of the period covered by the bill.
8 Required Patient name – enter last name, first name and middle initial.
9a-d Required Patient address
10 Required Date of birth
11 Required Sex (“M” for male, “F” for female or “U” for unknown.
12 Admission/start of care date – enter the date the member was admitted for inpatient care, or the date of the outpatient service.
13 Admission hour – Enter the two-digit hour during which the patient was admitted for care.
14 Admission Type – enter the code indicating the priority of this admission/visit.
15 Source of Admission – enter the appropriate source of admission code
16 Discharge hour – enter the code that indicates the discharge hour of the member from inpatient care.
17 Required Patient discharge status – enter the appropriate patient discharge status code
42 Required Revenue code(s) – enter the 4 digit Revenue code beside each service described in column 43.
43 Required Description – enter a brief description that corresponds to the revenue code in column 42.
44 Required HCPCS/Rates – for outpatient services, enter the CPT/HCPCS code. On inpatient bills, enter the accommodation rate
45 Required for Out Patient Claims – Service date – enter the date on which each service was rendered.
46 Required Units of service
47 Required Total Charges – the sum of the total charges for the billing period for each revenue code (FL42)
Line 23 Required Total Charges – Enter the claim total.
56 Required Billing Provider NPI – input 10-characer NPI number.
57 Billing Provider Taxonomy – input ZZ and 10-character taxonomy code without spaces
58 Required Insured’s name
60 Required May enter the patient’s claim number here
67A-Q Required Principal diagnosis code and present on admission and any other diagnosis
69 Admitting Diagnosis
74 Required – if applicable Principal procedure code – situational.
76 Required Attending Provider NPI – input 10-character NPI number
77 Operating Provider NPI – input 10-character NPI number
78-79 Other Provider’s NPI – input 10-character NPI number
81a Billing Provider Taxonomy – input B3 in the first box and 10-character taxonomy code without spaces in second box.

ADA Dental Form

Box 3 Required Primary payer informatio; Include injured worker’s complete 12 digit claim number (may also put this in Box 15)
Box 4-11 Other coverage – leave blank if no other coverage
Box 17 Employer Name
Box 20 Required Name and address of injured employee
Box 21 Required Injured employee date of birth
Box 22 Required Injured employee gender
Box 24 Required Procedure date of service
Box 27 Required Tooth number – enter tooth number (if applicable) or range of teeth using a hyphen
Box 28 Designate tooth surface(s)
Box 29 Required Procedure code – enter the appropriate dental code
Box 30 Required Description of procedure
Box 31 Required Fee – enter corresponding fee for each procedure listed in column 29
Box 33 Required Total fees
Box 48 Required Billing entity name and address
Box 49 Required Billing provider NPI – input 10-character NPI number. If not present, the bill will be denied for this omission.
Box 51 Required Federal tax identification number
Box 53 Required Rendering dentist’s signature
Box 54 Required Rendering dentist NPI – input 10-character NPI number
Box 56 Required Rendering dentist address, city and zip code
Box 57 Rendering dentist phone number – not required

In addition, documentation to support services rendered where reimbursement is being requested is required per ARM 24.29.1401A (9) and 24.29.1513.

Gentle Reminders

Implants – when requesting outlier reimbursement for implants an invoice is required with the bill, purchase orders are NOT sufficient.

Time documentation is still needed for codes where time is an element.

When remitting a refund to MSF, please submit with a copy of the EOR.

Radiology – documentation must support the CPT code billed (# views etc) if not submitting actual radiology report (in the clinical setting). Facilities must provide actual radiology report.

Laceration documentation – Documentation must include laceration measurement(s) when billing for repairs.

Lockhart Lien still applies when an injured worker is represented by an attorney who is exercising the lien.

To verify if a provider has been designated as treating physician, please contact the MSF Claim Examiner assigned to the claim.

MO Modifier no longer applicable so please do NOT use.

back to Provider Connection

Bill Status – 1-866-274-7464

Main Phone Number 406-495-5000 or 800-332-6102

Main Fax  406-495-5020

Medical Team – 406-495-5011

Submit your Claims and/or Correspondence To
Montana State Fund
PO Box 4759
Helena, MT  59604

RMS (Bill Status)
Phone  866-274-7464

For questions about information in this bulletin, call 800-332-6102 and ask for a member of the Medical Team.
For questions about Advanced Nurse Review contact Kym Vonada at 406-495-5389.

Medical Team

Michele Fairclough
Medical Team Leader

Justin Kennedy
Nurse Manager

Shannon Hadley
Provider Relations Specialist

Kym Vonada
Medical Auditor

Annalyn Stewart
Medical Payment Auditor

Sheryl Semans
Pharmacy Liaison

Susan Bomar
Medical Payment Auditor

Cindy Gallus
Medical Customer Service Liaison

Sherri Sprenger
Medical Customer Service Liaison

Shannon Mergenthaler
Medical Customer Service Liaison

Maggie Pentecost
Medical Customer Service Liaison

Jamie Statton
Medical Customer Service Liaison

Website Information

Montana State Fund

Department of LaborDepartment of Labor and Industry (DLI) website.
The website includes the Facility and Non-Facility Fee Schedule information as well as the Administrative Rules of Montana (ARM) and the instruction set for the Non-Facility Fee Schedule. Historical fee schedule information can also be found on this website.

If you have questions regarding the fee schedules call 406-444-6530 and someone will direct you to a DLI representative. For NPI information click here National Plan and Provider Enumeration System (NPPES)