Common use of Billing Address Clause in Contracts

Billing Address. This address is used for submitting all claims to HealthChoice for processing and appears in box 33 of the CMS-1500 claim form or box 2 on the UB-04. If box 2 is not used by the facility, the billing address appears in Box 1 of the UB-04. Claims will be paid exclusively to the billing address. Each address must have a corresponding phone number, email address, fax number and contact person. Insurance Certificate/Face Sheet must have name of the applicant listed as the insured. The insurance limits must be at the levels required in the contract and must indicate clearly the coverage type(s) stated in the contract. Product liability coverage in lieu of professional/medical liability is acceptable for DME only. W-9 forms must be signed and list only the Tax ID number for each location listed on the application which will be used on claim forms Please return entire application packet with the new information. Network Facility Application Requirements Thank you for your interest in the HealthChoice Provider Network. Please complete the attached Application and submit with the required attachments listed below. Complete all sections of the application. If an area of inquiry is not applicable to the facility, please indicate. If you need additional space to provide complete answers, attach additional sheets of paper and clearly indicate the item to which each sheet applies.