Triad Healthcare Inc. Provider Website

Forms & Instructions

Claim Submission Guidelines

The following information is provided to you and your staff to aid in the process of submitting a Health Insurance Claim Form (HCFA 1500) to Triad Healthcare Inc.

Please reference the patients plan information prior to submitting claims to ensure Triad Healthcare inc. accepts claims directly.

Please note: Claims for Oxford patients should continue to be sent directly to Oxford Health Plans

Claims can be mailed to:
Triad Healthcare Inc.
Claims Department
PO BOX 904
80 Spring Lane
Plainville, CT 06062 - 0904

The information requested in these data fields is required and must be legibly provided on a HCFA 1500 Form. If any required field on this form is omitted, or otherwise illegible, you will receive notice that you have failed to follow the proper procedure for filing a claim. Such notice shall be provided to you within statutory time frames and shall include a description of the failure and the proper procedures to follow in order to rectify and re-submit the request.

All claims must include the following information in order to be considered clean and processed in a timely manner. All claim submissions received by Triad Healthcare Inc. will be reviewed in accordance with a pre-certification (ICP/EOC). Only those services that have been approved in advance will be reimbursed. Claims for services rendered on the same date, or duplicates, will be adjudicated based upon the authorization generated during the pre-certification process.

Required Fields

Field# Description 1 Check off one - Medicare/Medicaid/CHAMPUS/CHAMPVA/Group Health Plan/FECA/other 1a Insured's ID Number 2 Patient's Name 3 Patient's DOB/Gender 4 Insured's Name 5 Patient's Address/City/State/Zip Code/Phone# 6 Patient Relationship to Insured (Self/Spouse/Child/Other) 8 Patient Status - Check either- Single/Married/Other/Employed/FT/PT 9,9a-d* Other Insured's Name/Other Insured's Policy #/ DOB/Gender/Employer's Name/Insurance Plan 10a-c Is the patient's condition related to: Employment, Auto or Other? Place? 11 Insured's Policy Group or FECA Number 11d Is there another Health Benefit Plan? 12 Patient's or authorized person's signature 13 Insured's or authorized person's signature 21 Diagnosis Codes 24a Date of Service 24b Place of Service 24d Procedure Codes 24e Diagnosis Code 24f Charge Amounts 24g Days or Units 24k Rendering Provider's ID as assigned by payer 25 Federal Tax ID Number, SSN/EIN 26 Patient's Account # 27 Accept Assignments 28 Total Charge 29 Amount Paid 30 Balance Due 31 Signature of Physician or supplier and Date 32 Name and Address of Facility where services were rendered 33 Physician's, Supplier's Billing Name, Address, Zip code & Phone #

* Please note field 9,9a-d are only required when field 11d is filled out as YES

Please note: Triad Healthcare Inc. will accept the revised (8/05) CMS 1500 claim form starting on 10/1/06. Required fields - 24J (shaded area) Rendering Provider's ID as assigned by payer 24J (white area) Rendering Provider's NPI if one has been assigned. All other CMS-1500 fields are required per HCFA-1500 requirements above.