CMS 1500 claim form billing instruction
CMS-1500 Complete review
CMS - 1500 form has 33 Fields and it has some uni
Claim Form
The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims.
The top right margin of the claim form should NOT contain:
any type of adhesive-backed label
printing or headings (including the Medicare carrier address)
ink, markers, whiteout, etc.
Please print legibly or type all information. Claims may also be computer-prepared.
CMS - 1500 form has 33 Fields and it has some uni
Claim Form
The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims.
The top right margin of the claim form should NOT contain:
any type of adhesive-backed label
printing or headings (including the Medicare carrier address)
ink, markers, whiteout, etc.
Please print legibly or type all information. Claims may also be computer-prepared.
BLOCK 1
Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Completion of this field is required for all claims.
Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Completion of this field is required for all claims.
BLOCK 1A INSURED'S I.D. NUMBER (For Program in Block 1)
Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
Completion of this field is required for all claims.
Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
Completion of this field is required for all claims.
BLOCK 2 PATIENT'S NAME
Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.
Completion of this field is required for all claims.
Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.
Completion of this field is required for all claims.
BLOCK 3 PATIENT'S BIRTH DATE AND SEX
Enter the patient's birth date (MMDDCCYY) and sex.
Completion of this field is required for all claims.
Enter the patient's birth date (MMDDCCYY) and sex.
Completion of this field is required for all claims.
BLOCK 4 INSURED'S NAME
If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word "SAME". If there is no insurance primary to Medicare, leave blank.
Completion of this field is conditional for insurance information.
If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word "SAME". If there is no insurance primary to Medicare, leave blank.
Completion of this field is conditional for insurance information.
BLOCK 5 PATIENT'S ADDRESS
Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.
Completion of this field is required for all claims; address and telephone must be indicated.
Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and telephone number. If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.
Completion of this field is required for all claims; address and telephone must be indicated.
BLOCK 6 PATIENT RELATIONSHIP TO INSURED
Check the appropriate box for patient's relationship to the insured when block 4 is completed.
Completion of this field is conditional for insurance information when block 4 is completed.
Check the appropriate box for patient's relationship to the insured when block 4 is completed.
Completion of this field is conditional for insurance information when block 4 is completed.
BLOCK 7 INSURED'S ADDRESS
Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this block only when blocks 4 and 11 are completed.
Completion of this field is conditional for insurance information when blocks 4 and 11 are completed.
Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this block only when blocks 4 and 11 are completed.
Completion of this field is conditional for insurance information when blocks 4 and 11 are completed.
BLOCK 8 PATIENT STATUS
Check the appropriate box for the patient's marital status and whether employed or a student.
Check the appropriate box for the patient's marital status and whether employed or a student.
HCFA BOX BLOCK 9 OTHER INSURED'S NAME
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank.
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank.
BLOCK 9A OTHER INSURED'S POLICY OR GROUP NUMBER
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.
BLOCK 9B OTHER INSURED'S DATE OF BIRTH
Enter the Medigap enrollee's birth date (MMDDCCYY) and sex.
Enter the Medigap enrollee's birth date (MMDDCCYY) and sex.
BLOCK 9C EMPLOYER'S NAME OR SCHOOL NAME
Disregard "employer's name or school name" which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured's Medigap identification card. For example:
1257 Anywhere Street Baltimore, MD 21204
is shown as "1257 Anywhere St MD 21204."
Note: If a carrier assigned unique identifier of a Medigap insurer appears in block 9D, block 9C may be left blank.
Disregard "employer's name or school name" which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured's Medigap identification card. For example:
1257 Anywhere Street Baltimore, MD 21204
is shown as "1257 Anywhere St MD 21204."
Note: If a carrier assigned unique identifier of a Medigap insurer appears in block 9D, block 9C may be left blank.
BLOCK 9D INSURANCE PLAN NAME OR PROGRAM NAME
Enter the name of the Medigap insured's insurance company or the Medigap insurer's unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in block 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.
Completion of fields 9A-D are conditional for insurance information related to Medigap.
Enter the name of the Medigap insured's insurance company or the Medigap insurer's unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in block 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.
Completion of fields 9A-D are conditional for insurance information related to Medigap.
BLOCK 10A THROUGH 10C IS PATIENT'S CONDITION RELATED TO:
Check "YES" or "NO" to indicate whether employment, auto accident or other accident (i.e., liability suit) involvement applies to one or more of the services described in block 24. Enter the state postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in block 11.
Completion of fields 10A-C are required for all claims; "Yes" or "No" must be indicated.
Check "YES" or "NO" to indicate whether employment, auto accident or other accident (i.e., liability suit) involvement applies to one or more of the services described in block 24. Enter the state postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in block 11.
Completion of fields 10A-C are required for all claims; "Yes" or "No" must be indicated.
BLOCK 10D RESERVED FOR LOCAL USE
Use this block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by "MCD".
Use this block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient's Medicaid number preceded by "MCD".
BLOCK 11 INSURED'S POLICY, GROUP OR FECA NUMBER
When submitting paper or electronic claims, block 11 must be completed. By completing this information, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Claim without this information will be returned or rejected.
Note: If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to blocks 11a-11c.
If there is no insurance primary to Medicare, enter the word "NONE" in block 11 and proceed to block 12.
If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to block 11b.
Completion of block 11 (i.e., insured's policy/group number or "NONE") is required on all claims.
Completion of blocks 11B-C are conditional for insurance information primary to Medicare.
Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to another insurance include:
Group Health Plan Coverage: - Working Aged; - Disability (Large Group Health Plan); and - End Stage Renal Disease.
No Fault and/or other Liability;
Work-Related Illness/Injury: - Workers' Compensation; - Black Lung; and - Veterans Benefits.
Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.
When submitting paper or electronic claims, block 11 must be completed. By completing this information, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Claim without this information will be returned or rejected.
Note: If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to blocks 11a-11c.
If there is no insurance primary to Medicare, enter the word "NONE" in block 11 and proceed to block 12.
If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to block 11b.
Completion of block 11 (i.e., insured's policy/group number or "NONE") is required on all claims.
Completion of blocks 11B-C are conditional for insurance information primary to Medicare.
Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to another insurance include:
Group Health Plan Coverage: - Working Aged; - Disability (Large Group Health Plan); and - End Stage Renal Disease.
No Fault and/or other Liability;
Work-Related Illness/Injury: - Workers' Compensation; - Black Lung; and - Veterans Benefits.
Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.
BLOCK 11A INSURED'S DATE OF BIRTH
Enter the insured's birth date (MMDDCCYY) and sex, if different from block 3.
BLOCK 11B EMPLOYER'S NAME OR SCHOOL NAME
Enter the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter the six - digit retirement date (MMDDYY) preceded by the word "RETIRED."
Completion of this field is conditional when the beneficiary has insurance primary to Medicare.
Enter the insured's birth date (MMDDCCYY) and sex, if different from block 3.
BLOCK 11B EMPLOYER'S NAME OR SCHOOL NAME
Enter the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter the six - digit retirement date (MMDDYY) preceded by the word "RETIRED."
Completion of this field is conditional when the beneficiary has insurance primary to Medicare.
BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME
Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB.
Completion of this field is conditional for insurance information primary to Medicare.
Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB.
Completion of this field is conditional for insurance information primary to Medicare.
BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN
Leave blank. Not required by Medicare.
Leave blank. Not required by Medicare.
CMS 1500 - BLOCK 12 PATIENT OR AUTHORIZED PERSON'S SIGNATURE
The patient or an authorized representative must sign and enter the six - digit date (MMDDYY) for this block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by: "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign the form. The signature on file authorization is effective indefinitely unless patient or the patient's representative revokes the arrangement.
The patient's signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.
Signature By Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.
Signature on File Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary's behalf.
The patient or an authorized representative must sign and enter the six - digit date (MMDDYY) for this block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by: "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign the form. The signature on file authorization is effective indefinitely unless patient or the patient's representative revokes the arrangement.
The patient's signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.
Signature By Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.
Signature on File Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary's behalf.
BLOCK 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE
The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.
BLOCK 14 DATE OF CURRENT ILLNESS
the six - digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six - digit date (MMDDYY) of the initiation of the course of treatment and enter the six - digit date (MMDDYY) x-ray date in block 19
.Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.Completion of this field is required for all chiropractic services; conditional for other services.
the six - digit date (MMDDYY) of current illness, injury, or pregnancy. For chiropractic services, enter the six - digit date (MMDDYY) of the initiation of the course of treatment and enter the six - digit date (MMDDYY) x-ray date in block 19
.Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.Completion of this field is required for all chiropractic services; conditional for other services.
BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS
blank. Not required by Medicare.
blank. Not required by Medicare.
BLOCK 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
the six - digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage.Completion of this field is conditional for disability information.
the six - digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage.Completion of this field is conditional for disability information.
BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Referring Physician - A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician - A physician who orders nonphysician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.All claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician's name and Unique Physician Identification Number (UPIN) and National provider number (NPI)
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Referring Physician - A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician - A physician who orders nonphysician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.All claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician's name and Unique Physician Identification Number (UPIN) and National provider number (NPI)
BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
Enter the six - digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Completion of this field is conditional for medical services related to hospitalization.
Enter the six - digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Completion of this field is conditional for medical services related to hospitalization.
BLOCK 19 RESERVED FOR LOCAL USE
BLOCK 20 OUTSIDE LAB
Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the "YES" block is checked. A "YES" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "NO" check indicates that "no purchased tests are included on the claim". When "YES" is annotated, block 32 must be completed.
Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the "YES" block is checked. A "YES" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "NO" check indicates that "no purchased tests are included on the claim". When "YES" is annotated, block 32 must be completed.
BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Enter the patient's diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.
All narrative diagnosis codes must be submitted on an attachment.
Enter the patient's diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.
All narrative diagnosis codes must be submitted on an attachment.
BLOCK 22 MEDICAID RESUBMISSION
Leave blank. Not required by Medicare.
Leave blank. Not required by Medicare.
BLOCK 23 PRIOR AUTHORIZATION NUMBER
Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
Enter the Investigational Device Exemption (IDE) number for those clinical trial procedures requiring IDE approval.
For paper claims only, enter the ten - digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.
Completion of this field is conditional the situations above
Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.
Enter the Investigational Device Exemption (IDE) number for those clinical trial procedures requiring IDE approval.
For paper claims only, enter the ten - digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services. Only one CLIA number may be reported per claim.
Completion of this field is conditional the situations above
CMS 1500 - BLOCK 24A DATES OF SERVICE
Enter the six or eight - digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.
Completion of this field is required for all claims; all lines of service.
BLOCK 24B PLACE OF SERVICE
Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed.
BLOCK 24C TYPE OF SERVICE
Not required by Medicare. Leave blank.
BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES
Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative.
BLOCK 24E DIAGNOSIS CODE
Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21.
BLOCK 24F ($) CHARGES
Enter the charge for each listed service.
Completion of this field is required for all claims (all lines of service).
BLOCK 24G DAYS OR UNITS
Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Completion of this field is required for all claims; (all lines of service).
BLOCK 24H EPSDT FAMILY PLANNING
Leave blank. Not required by Medicare.
BLOCK 24I EMG
Leave blank. Not required by Medicare.
BLOCK 24J COB
Leave blank. Not required by Medicare.
BLOCK 24K RESERVED FOR LOCAL USE
Enter the carrier assigned Provider Identification Number (PIN) and NPI number of the rendering physician.
BLOCK 25 FEDERAL TAX ID NUMBER
Enter your provider of service and (or) supplier Federal Tax Employer Identification Number (EIN) or Social Security Number. The participating provider of service and (or) supplier federal tax identification number is required for a mandated Medigap transfer.
Completion of this field is conditional for Medigap transfers.
BLOCK 26 PATIENT'S ACCOUNT NUMBER
Enter the patient's account number assigned by the provider of service and (or) supplier's accounting system. This is an optional field to enhance patient information.
BLOCK 27 ACCEPT ASSIGNMENT
Check the appropriate block to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in block 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.
BLOCK 28 TOTAL CHARGE
Enter the total charges of all services reported on the claim (i.e., total of all charges from block 24f).
Completion of this field is required for all claims.
BLOCK 29 AMOUNT PAID
Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges.
Completion of this field (i.e., amount paid or "$0.00") is required for all claims.
BLOCK 30 BALANCE DUE
Leave blank. Not required by Medicare.
BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED
Enter the name and address including the ZIP code of the facility where the services were furnished. When the name and address of the facility where the services were furnished is the same as the biller's name and address shown in block 33, enter the word "SAME". we Need to provide NPI number of the location.
BLOCK 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
Enter the physician's individual/group or or supplier's billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.
Individual Provider
Enter the carrier assigned PIN# and NPI for the performing physician or supplier who is not a member of a group practice.
Group Practices
Enter the carrier assigned GRP# and NPI for the group.Complete either the PIN# or GRP# field, not both.
Completion of this field is required for all claims.
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Enter the six or eight - digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.
Completion of this field is required for all claims; all lines of service.
BLOCK 24B PLACE OF SERVICE
Enter the appropriate place of service code from the list provided below. Identify the location where the item is used or the service is performed.
BLOCK 24C TYPE OF SERVICE
Not required by Medicare. Leave blank.
BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES
Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative.
BLOCK 24E DIAGNOSIS CODE
Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21.
BLOCK 24F ($) CHARGES
Enter the charge for each listed service.
Completion of this field is required for all claims (all lines of service).
BLOCK 24G DAYS OR UNITS
Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Completion of this field is required for all claims; (all lines of service).
BLOCK 24H EPSDT FAMILY PLANNING
Leave blank. Not required by Medicare.
BLOCK 24I EMG
Leave blank. Not required by Medicare.
BLOCK 24J COB
Leave blank. Not required by Medicare.
BLOCK 24K RESERVED FOR LOCAL USE
Enter the carrier assigned Provider Identification Number (PIN) and NPI number of the rendering physician.
BLOCK 25 FEDERAL TAX ID NUMBER
Enter your provider of service and (or) supplier Federal Tax Employer Identification Number (EIN) or Social Security Number. The participating provider of service and (or) supplier federal tax identification number is required for a mandated Medigap transfer.
Completion of this field is conditional for Medigap transfers.
BLOCK 26 PATIENT'S ACCOUNT NUMBER
Enter the patient's account number assigned by the provider of service and (or) supplier's accounting system. This is an optional field to enhance patient information.
BLOCK 27 ACCEPT ASSIGNMENT
Check the appropriate block to indicate whether the provider of service and (or) supplier accepts assignment of Medicare benefits. If MEDIGAP is indicated in block 9 and MEDIGAP payment authorization is given in block 13, the provider of service and (or) supplier must also be a Medicare participating provider of service and (or) supplier and must accept assignment of Medicare benefits for all covered charges for all patients.
BLOCK 28 TOTAL CHARGE
Enter the total charges of all services reported on the claim (i.e., total of all charges from block 24f).
Completion of this field is required for all claims.
BLOCK 29 AMOUNT PAID
Enter the total amount the patient paid on covered services only. The total amount should not exceed the total charges.
Completion of this field (i.e., amount paid or "$0.00") is required for all claims.
BLOCK 30 BALANCE DUE
Leave blank. Not required by Medicare.
BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED
Enter the name and address including the ZIP code of the facility where the services were furnished. When the name and address of the facility where the services were furnished is the same as the biller's name and address shown in block 33, enter the word "SAME". we Need to provide NPI number of the location.
BLOCK 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
Enter the physician's individual/group or or supplier's billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.
Individual Provider
Enter the carrier assigned PIN# and NPI for the performing physician or supplier who is not a member of a group practice.
Group Practices
Enter the carrier assigned GRP# and NPI for the group.Complete either the PIN# or GRP# field, not both.
Completion of this field is required for all claims.
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