Not Required Not Required 11c. Insurance Plan Name or Program Name 11d. Date of current illness, injury, pregnancy LMP Other Date — enter applicable qualifier and accident date when box 10b or 10c is checked Not required Name of Referring Provider or Other Source box 17b required 17a.
Not required 17b. NPI of Referring Provider from 17 Hospitalization Dates Related to Current Services Additional Claim Information Prior Authorization Number 24a. Place of service 24c. Required Enter the revenue code which identifies the specific service provided. List revenue codes in ascending order. These codes are listed in Appendix Q, under the Appendices drop-down section on the Billing Manuals web page , for valid dialysis revenue codes.
A revenue code must appear only once per date of service. Complete with as many codes necessary to identify conditions related to this bill. Required Enter the revenue code description or abbreviated description. Example: 42 REV. Use approved modifiers listed in this section for hospital based transportation services. Complete for laboratory, radiology, physical therapy, occupational therapy, and hospital based transportation.
The only valid modifier for OP radiology is TC. With the exception of outpatient lab and hospital- based transportation, outpatient radiology services can be billed with other outpatient services. Combine the units in FL 46 Units to report multiple services. Each date of service must fall within the date span entered in the "Statement Covers Period" field FL 6. Required Enter a unit value on each line completed. Use whole numbers only.
Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers e. For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL Required Enter the total charge for each line item.
Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges. Conditional Enter incurred charges that are not payable by the Health First Colorado.
Each column requires a grand total on line Non-covered charges cannot be billed for outpatient hospital laboratory or hospital based transportation services. Required Enter the payment source code followed by name of each payer organization from which the provider might expect payment. At least one line must indicate Health First Colorado. Source Payment Codes. Required Enter the NPI number assigned to the billing provider.
Payment is made to the enrolled provider or agency that is assigned this number. Conditional Complete when there are Medicare or third-party payments. Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments. Required Enter the member's name on the Health First Colorado line. Enter the policyholder's last name, first name, and middle initial. Required Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
Conditional Complete when there is third party coverage. Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card. Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried. Conditional Complete when the service requires a PAR.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 Insured Name. Submitted information is not entered into the claim processing system. Optional Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay.
Do not add extra zeros to the diagnosis code. Optional Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E". Conditional Enter the ICDCM procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Apply the following criteria to determine the principle procedure: The principal procedure is not performed for diagnostic or exploratory purposes.
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them. Enter demonstration ID number "30" for all national emphysema treatment trial claims. Diagnostic and Purchased 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 "no purchased tests are included on the claim. When billing for multiple purchased diagnostic tests, each test must be submitted on a separate CMS Form. NOTE : This is a required field when billing for diagnostic tests subject to purchase price limitations.
Prior Authorization Number This is a required field for the purposes outlined below. Post Market Approval number should also be placed here when applicable. NOTE: Item 23 can contain only one condition. Any additional conditions should be reported on a separate CMS Form.
Service Line The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.
When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position Report the NDC quantity in positions 17 through 24 of the same red shaded portion.
There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space fill the remaining positions e. UN2 or F Date of Service This is a required field. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G.
Return as unprocessable if a date of service extends more than 1 day and a valid "to" date is not present. Place of Service This is a required field. Enter the appropriate 2-digit place of service code s from the list provided in Section Identify the location, using a place of service code, for each item used or service performed. NOTE: When a service is rendered to a hospital inpatient, use the "inpatient hospital" code.
Enter only one place of service code per CMS Form, unless the second place of service code is 12 patient's home. Procedures, Services, or Supplies Code This is a required field. The CMS Form has the ability to capture up to four modifiers. 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 description in item 19 if a coherent description can be given within the confines of that box.
Otherwise, an attachment must be submitted with the claim. Noridian will return as unprocessable if an "unlisted procedure code" or a "not otherwise classified" NOC code is indicated in item 24D, but an accompanying narrative is not present in item 19 or on an attachment.
Do not place extra narrative after, under, or above the procedure code. Pricing modifiers should be placed in the first modifier position. Procedure codes should not be placed in the first modifier position.
Be sure to distinguish between zeros and the letter "O". Hyphens or any other separators should not be used between procedure codes and modifiers.
Only uppercase characters should be used for procedure codes and modifiers. Diagnosis Code Reference Number This is a required field. Charge Amount Enter the charge for each listed service.
Include the cents with dollar amounts. Do not use dollar signs, decimals, dashes, commas, or lines. Negative dollar amounts are not allowed. 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.
Some services require that the actual number or quantity billed be clearly indicated on the claim form e. When multiple services are provided, enter the actual number provided. For anesthesia, show the elapsed time minutes in item 24 G. Convert hours into minutes and enter the total minutes required for this procedure e. One hour and 10 minutes would be reported as For instructions on submitting units for oxygen claims, see Chapter 20, Section Do not place zeros before or after the number of units e.
Indicate only whole numbers, e. NOTE: This field should contain at least 1 day or unit. The carrier should program their system to automatically default "1" unit when the information in this field is missing to avoid returning as unprocessable. Leave blank. Not required by Medicare. Entering information in this item may cause delays in claims processing. Enter the rendering provider's PIN in the shaded portion.
In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion.
Enter the rendering provider's NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion.
Information must be submitted within the confines of this box. Do not enter provider names, UPIN numbers, or state postal codes in this item. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.
Do not enter hyphens or spaces. Medicare providers are not required to complete this item for crossover purposes since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim.
However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Patient's Account Number This field is optional to assist the provider in patient identification.
Enter the patient's account number assigned by the provider's of service or supplier's accounting system. As a service, any account numbers entered here will be returned to the provider.
Accept Assignment? This is a required field, even if you are a participating provider. Check the appropriate box with an X to indicate whether the provider of service or supplier accepts assignment of Medicare benefits or not. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.
Total charges for services on claim Enter the total charges for the services i. Do not mark as continued or the claim will be rejected as unprocessable; each CMS Form should have its own total. Total amount the patient paid on the covered services only Enter the total amount the patient paid on the covered services only. Do not include the amount paid by the primary insurance, co-insurance, deductibles, account balance, or payments on previous claims in this item.
NOTE: If any dollar amount is entered here, part or all of the payment will go directly to the patient, even if you are a participating provider.
Signature of Provider of Service or Supplier This is a required field. In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item NOTE: This is a required field, however the claim can be processed if the following is true.
Noridian is unable to process claims without the required signature and date listed in item If left blank, the claim will be rejected as unprocessable. The signature and date must be completely within the confines of this box. Additional acceptable signatures include: Signature stamp and computer generated signature. Name and Address of Facility Where Services Were Rendered Enter the name, address, and ZIP code of the facility if the services were furnished in a physician's office, hospital, clinic, laboratory, or facility other than the patient's home.
Only one name, address, and ZIP code may be entered in the box. If additional entries are needed, separate claim forms shall be submitted. A PO Box is not acceptable.
Do not include telephone numbers, commas, periods, or other punctuation in the address e. Main Street,
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