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Paper Claims Billing Manual

The Paper Claims Billing Manual, produced by Gainwell Technologies, is designed to offer guidance and assistance to providers submitting claims for reimbursement to the Mississippi Division of Medicaid (DOM). The Paper Claims Billing Manual includes detailed information specific to the submission of paper claims which includes Centers for Medicare and Medicaid (CMS)-1500, Dental, and UB-04 claims. This manual must be used in conjunction with the General Policy and DOM’s Provider Specific Administrative Code. DOM policy is located at Administrative Code and Mississippi Medicaid State Plan.



Section 1 – Introduction

Section 2 – Mississippi DOM
2.1 Fiscal Agent

2.2 Telephone Contact

2.3 Mailing Contact Information

Section 3 – Adjusting and Voiding Claims

3.1 Completing the Adjustment/Void Request Claim (CMS-1500, UB-04, ADA 2012)

Section 4 – CMS-1500 Claim Form Instructions

4.1 Provider Types

4.2 MESA Web Portal Reminder

4.3 Paper Claim Guidelines

4.4 Paper Claims with Attachments

4.5 Electronic CMS-1500 Claims

4.6 Claim Mailing Address

4.7 CMS-1500 Claim Form Instructions (Version 02/12)

4.8 Filing Medicare Crossover Claims on the CMS-1500

Section 5 – UB-04 Claim Form Version CMS-1450

5.1 Provider Types

5.2 Web Portal Reminder

5.3 Paper Claim Guidelines

5.4 Multi-Page Paper Claims

5.5 Paper Claims with Attachments

5.6 Electronic UB-04 Claims

5.7 Claim Mailing Address

5.8 UB-04 Claim Form Instructions – Institutional Claims

5.9 Filing Medicare Part, A Crossover Claims on the UB-40

Section 6 – Dental Claim Form Instructions (Version 2012 American Dental Association)

6.1 Provider Types

6.2 Electronic Dental Claims

6.3 Paper Dental Claims Guidelines

6.4 Multi-Page Paper Claims

6.5 Paper Claims with Attachments

6.6 Claim Mailing Address

6.7 2012 ADA  American Dental Association Dental Claim Form